pancreatic diseases

Question 1

case 1: hx gallstones 1 day hx of sev. epigastric pain radiates to mid-upper back
N/V, diaphoretic, have a fever
T=100.7F P=108 RR=18
BP=100/48
questions?

Answer 1

GERD, ulcers, taking PPIs? better/worse with food?
peritoneal signs (radiation to back) MI 

ask if similar presentation to past gallstone attacks

Question 2

Acute Pancreatitis

Answer 2

Most cases are related to the biliary tract (often a passed gallstone) or heavy alcohol intake
Generally there is some insult to the ampulla of Vater causing obstruction and reflux of bile into the pancreatic ducts causing damage and inflammation to the cells of the pancreas

Question 3

other considerations for acute pancreatitis

Answer 3

ERCP procedure itself can cause pancreatitis

Medications, viruses, autoimmune, high cholesterol also are considerations

Question 4

acute pancreatitis acronym

Answer 4

GET SMASHED

gallstones
etOH
trauma

steroids
mumps
autoimmune
scorpion venom
hypothermia hyperlipidemia
ERCP
drugs: azathioprine, thiazides, na valproate, tetracycline

Question 5

pancreatitis clinical findings

Answer 5

Most pts have epigastric abdominal pain
Often abrupt onset, radiates to the back, worse when laying flat
Better when laying in the fetal position or leaning forward

N/V, often fever, may have mild jaundice, tender abdomen
Possible history of a heavy meal or heavy alcohol consumption prior to the attack

Question 6

pancreatitis labs

Answer 6

Elevations in amylase and lipase (more specific)
Generally 3x the upper limits of normal within 24 hours of symptoms
Return to normal is variable
Lipase remains elevated longer than amylase and is slightly more accurate for the diagnosis of acute pancreatitis

Elevated WBC count (can be pure inflammation)
Hyperglycemia (pancreas isn’t functioning properly) (may become DM)
Hyperbilirubinemia and/or elevated LFTs may be present as well
High crea is associated with progression to pancreatic necrosis

Question 7

?? can independently be associated with a greater mortality rate

Answer 7

Presence of a systemic inflammatory response syndrome (SIRS) or sepsis

Question 8

?? is widely used to determine the severity of acute alcoholic pancreatitis

Answer 8

Ranson’s criteria

Sensitivity of predicting a severe course as accurate as 60-80% based on these criteria

each factor worth a point
more than 3 positives: pancreatitis is likely
less than 3: pancreatitis unlikely
the greater, higher mortality: 4-6: 50% mortality
close to all positive: almost 100% mortality

Question 9

Ranson’s criteria

Answer 9

Blood glucose  > 200 mg/dL
Age in years > 55 years
Serum LDH > 350 IU/L
Serum AST > 250 IU/L
White blood cell count > 16000 cells/mm3
Within 48 hours:
Serum calcium less than 8.0 mg/dL
Hematocrit fall > 10%
Oxygen: PaO2 below 60mmHg
BUN rise more than 5 mg/dL
base deficit more than 4 mEq/L
Sequestration of fluids > 6 L

mnemonic GALAW AND CHOBBS: Glucose, Age, LDH, AST and Whites; Calcium, Hematocrit, Oxygen, BUN, Base, Sequestration.
-the more risk factors you have to more severe of a case it is
if increase in score: increase in morbidity/mortality

Question 10

pancreatitis imaging

Answer 10

Plain radiographs may show calcified gallstones
A “sentinel loop”
Segment of air-filled small intestine usually in the LUQ
“Colon cutoff sign”:
Gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation

Question 11

pancreatitis U/S

Answer 11

can be helpful for identifying gallstones/cholecystitis but generally not helpful for pancreatitis given overlying bowel gas

Question 12

CT can help to identify an ??

Answer 12

enlarged or inflamed pancreas

Can also show necrosis, pseudocyst, or other complications

Question 13

Pancreatitis EponymsPresent in 1-2% of cases…

Answer 13

Cullen’s sign
Grey Turner’s sign

may present together
imply pancreatic necrosis, higher risk of death
need volume resuscitation

Question 14

Mild pancreatitis tx

Answer 14

most will subside over a few days
Bowel rest, bed rest, pain control
Fluid resuscitation
Classically meperidine has been given for pain preferentially over morphine due to risk of?
(Now thought to be an acceptable alternative and is often preferred)

Slowly resume p.o. diet when pain free (after “gut rest”), bowel sounds are present, and labs are improving
can go home when eating again

Question 15

Severe pancreatitis tx

Answer 15

Large amounts of IVF resuscitation due to volume loss in necrotizing disease
Treatment of sepsis and evolving multi-organ dysfunction
Calcium replacement if hypocalcemic
Enteral feeding via nasojejunostomy preferred
Parenteral nutrition (TPN) in those with ileus

Question 16

?? considered the drug of choice for necrotizing pancreatitis involving more than 30% of the pancreas

Answer 16

Carbapenems (imipenem)

Antifungals a consideration as well (yeast is in gut, higher risk for candida if on TPN, higher blood glucose)

Question 17

pancreatitis complications: Intravascular volume depletion due to leakage of fluids in the pancreatic bed and ileus can cause ??

Answer 17

acute renal insufficiency/ATN

Could last 1-2 weeks and in some cases patients require hemodialysis

Question 18

pancreatitis complications: Pancreatic necrosis and fluid collections (pseudocysts)

Answer 18

can be acute or chronic and can be sterile or infected
This complication occurs in 5-10% of cases and is a frequent predictor of mortality
An infected pseudocyst can form a pancreatic abscess
Often associated with splenic vein thrombosis and L sided pleural effusions as well

about 50% mortality, not good candidate for sx, can only effectively drain thru tubes

Question 19

other possible pancreatitis complications

Answer 19

Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes

Question 20

slide 18

Answer 20

pseudocyst on right

Question 21

tx of pancreatitis complications

Answer 21

Surgery should follow all severe cases especially with nercocosis/pseudocyst:
Some mild cases with stones may need a cholecystectomy or cholecystotomy
Necrosectomy may improve survival but patient must be good candidates:
If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well:
Risk for infection, fistula formation

Mortality: 25% and if there is multiorgan failure present, 50%

Question 22

case 2: chronic alcohol use presents to the ER with a c/o intermittent epigastric pain, weight loss, and diarrhea
labs/imaging

Answer 22

Patient has mild elevation in amylase and lipase
Serum alkaline phosphatase and bilirubin are slightly elevated
Patient uses the restroom and returns to tell you his stool looked “oily”
CT scan demonstrated diffuse pancreatic calcifications (chronic!) and some ductal dilation

Question 23

slide 23

Answer 23

chronic pancreatitis: calcifications

Question 24

chronic pancreatitis Characterized by ??

Answer 24

persistent or intermittent epigastric pain, steatorrhea, weight loss, and up to 30% of affected patients have calcifications of their pancreas on CT

Question 25

nearly 80% chronic pancreatitis due to

Answer 25

chronic alcoholism

BUT The risk of pancreatitis in heavy drinkers is only 5-10%
Smoking can accelerate this risk

Question 26

Mnemonic for predisposing factors of chronic pancreatitis:

Answer 26

T – toxic metabolic
I – idiopathic
G – genetic
A – autoimmune
R – recurrent and severe acute pancreatitis
O - obstructive

Question 27

?? which increases levels of serum calcium can lead to increased calcium deposition in the pancreas and be a cause

Answer 27

Hyperparathyroidism

Question 28

Elevated levels of IgG and certain autoantibodies can be the hallmarks of autoimmune pancreatitis

Answer 28

autoimmune pancreatitis

Question 29

Between 10-30% of all cases of chronic pancreatitis are ??

80% of adults develop ?? within 25 years after the onset of chronic pancreatitis

Answer 29

idiopathic

diabetes

Question 30

CP presentation

Answer 30

epigastric and LUQ pain
Anorexia N/V, constipation acutely (steatorrhea is a later finding)
Abdominal exam may reveal LUQ tenderness over the pancreas
Attacks can last a few hours or possibly 2+ weeks

Question 31

?? is the most sensitive test and can show dilated ducts, intraductal stones, strictures, pseudocyst development

Answer 31

ERCP

Question 32

medical management of chronic pancreatitis

Answer 32

Low fat diet
Abstinence from all alcohol
Use NSAIDs, tramadol, acetaminophen (avoid opioids)

Question 33

Steatorrhea is treated with pancreatic supplements at mealtimes:

Answer 33

Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze

Question 34

Autoimmune pancreatitis is treated with ??

Answer 34

steroids

Prednisone 40mg/d for 1-2mo followed by a taper

Question 35

CP Surgical Treatment

Answer 35

If there is underlying biliary tract disease, surgical treatment is advised
Must reestablish free flow of bile into the duodenum
Possible endoscopic drainage of pancreatic pseudocysts
Distal bile duct obstruction can be relieved with stenting

Question 36

considered as a last resort ??

Answer 36

In severe cases, subtotal or total pancreatectomy is considered as a last resort

Results in diabetes mellitus and pancreatic insufficiency

Question 37

Prognosis is best in patients with ??

Answer 37

recurrent acute pancreatitis caused by stones or sphincter of Oddi stenosis which can be remedied

Question 38

Endoscopic Pseudocyst Drainage

Answer 38

listen 28 min
slide 29
creating a fistula to drain into the gut

Question 39

ramsey criteria

Answer 39

each factor worth 1 pt (look up)