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CSI- Winter > Pancreatic Diseases > Flashcards

Pancreatic Diseases Flashcards

1
Q

Case: A 46yo man with a h/o gallstones presents to the ER with a 1 day history of severe epigastric pain which radiates to his mid-upper back
Patient reports nausea and vomited en route to the hospital
He is diaphoretic and believes he has a fever but has not taken his temp.
Epigastric pain, mid-upper back
History of GRED, ulcers, taking PPIs, peritoneal signs….

A

Acute Pancreatitis

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2
Q

Most cases of acute pancreatitis are related to

A

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

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3
Q

_______ itself can cause pancreatitis

A

ERCP procedure

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4
Q

Acute pancreatitis may also be caused by

A

Medications, viruses, autoimmune, high cholesterol also are considerations

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5
Q

GET SMASHED

thinks that cause pancreatitis

A 
Gallstones 
Ethanol 
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hypothermia/Hyperlipidemia 
ERCP 
Drugs- azathioprine, thiazines, sodium valproate, tetracycline
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6
Q

Big blues to think acute pancreatitis

A

History of gallstones or heavy drinking

Trauma directly to pancreas (insult to gut, kid going over handlebars)

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7
Q

Signs and symptoms of acute pancreatitis

A
  • Most patients 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)
  • *Nausea and vomiting are usually present**
  • Possible history of a heavy meal or heavy alcohol consumption prior to the attack
  • Abdomen is generally tender on exam
  • Fever is often present
  • Mild jaundice may be seen
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8
Q

Pancreatitis may also be caused by obstruction of

A

ampula of vader from stone, etc.

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9
Q

Lab findings for pancreatitis

A
  • *LIPASE is most specific and stays high for longer**
  • Elevations in amylase and lipase
  • Generally 3x the upper limits of normal within 24 hours of symptoms
  • Return to normal is variable
  • Elevated WBC count- not always infection, can be inflammation
  • Hyperglycemia (pancreas isn’t functioning properly- isn’t producing insulin properly)
  • Hyperbilirubinemia and/or elevated LFTs may be present as well
  • High creat is associated with progression to pancreatic necrosis
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10
Q

Severity of pancreatitis depends on

A

Presence of a systemic inflammatory response syndrome (SIRS) or sepsis can independently be associated with a greater mortality rate

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11
Q

_______ is widely used to determine the severity of acute alcoholic pancreatitis
Sensitivity of predicting a severe course as accurate as 60-80% based on these criteria

A

Ranson’s criteria

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12
Q

Ranson’s Criteria

A

At admission or diagnosis:

  • Age over 55
  • WBC count over 16,000
  • Blood glucose over 200
  • Serum lactic dehydrogenase (LDH) over 350
  • Serum AST over 250

During initial 48 hrs

  • Hematocrit fall greater 10% points
  • Blood urea nitrogen rise over 5 mg/dl
  • Arterial PO2 below 60mmHg
  • Serum calcium below 8 mg/dl
  • Base deficit > 4
  • Estimated fluid sequestration over 6000 ml

*more you have=higher risk of mortality

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13
Q

“Sentinel Loop” and “Colon cutoff Sign” seen in xray

A

-“sentinel loop” is a segment of air-filled small intestine usually in the LUQ (Air filled small bowel; air filled loops towards stomach- google image)

-“Colon cutoff sign” is a gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation
(cutoff right where pancreas is, showing potential acute inflam- google image)
-Plain radiographs may show calcified gallstones

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14
Q

Ultrasound helpful?

A

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

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15
Q

CT helpful?

A
  • CT can help to identify and enlarged or inflamed pancreas

- Can also show necrosis, pseudocyst, or other complications

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16
Q

Physical signs that present in 1-2% of pancreatitis cases

A 
Cullen sign (bruising around umbilicus) 
Grey Turner's sign (bruising along side, flank)

-usually present together, correlate high with pancreatic necrosis

17
Q

Treatment for mild pancreatitis

A

-Most cases are mild and 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–> Morphine may cause spasm of sphincter of odi (now people don’t think this but may still be test answer- older way of thinking)
Now thought to be an acceptable alternative and is often preferred
-Slowly resume p.o. diet when pain free, bowel sounds are present, and labs are improving
-Even eating a little food/drinking/hard candy will cause pancreas to think your eating and it will start contracting causing severe pain
-Must do FULL gut rest

18
Q

Treatment for severe pancreatitis

A
  • 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
19
Q

Drug of choice for necrotizing pancreatitis

A

Carbapenems (imipenem) considered the drug of choice for necrotizing pancreatitis involving >30% of the pancreas (more than 1/3)
-Antifungals a consideration as well, if sick for longer, higher blood glucose (pancreas isn’t working), want to prevent yeast/candida

20
Q

Complications of acute pancreatitis

A
  1. Intravascular volume depletion due to leakage of fluids in the pancreatic bed and ileus can cause acute renal insufficiency/ATN (could last 1-2 weeks and in some cases patients require hemodialysis)
  2. Pancreatic necrosis and fluid collections (pseudocysts) 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
  3. Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes may also occur
21
Q

______ should follow all severe cases especially with nercocosis/pseudocyst

A

Surgery

-Some mild cases with stones may need a cholecystectomy or cholecystotomy

22
Q

________ may improve survival but patient must be good candidates

A

Necrosectomy

-If possible delay until patient is stable and necrosis has organized

23
Q

Internal or external drainage of pseudocysts a consideration as well, but risk for _________

A

infection and fistula formation

-Mortality rates in the most severe cases are 25% and if there is multiorgan failure present, 50%

24
Q

Case: A 65yo man with a h/o chronic alcohol use presents to the ER with a c/o intermittent epigastric pain, weight loss, and diarrhea. Frequent, watery diarrhea, green-yellow color, prefers to drink liquids, not much solid food; no recent travel. “Oily stools” seen and CT scan demonstrated diffuse pancreatic calcifications (chronic irritation) and some ductal dilation.

A

Think chronic pancreatitis

**Think alcoholics (smoking accelerates process)

25
Q

Labs with chronic pancreatitis will show

A
  • mild elevation in amylase and lipase

- Serum alkaline phosphatase and bilirubin are slightly elevated

26
Q

Chronic pancreatitis is characterized by

A
  1. persistent or intermittent epigastric pain
  2. steatorrhea
  3. weight loss
  4. up to 30% of affected patients have calcifications of their pancreas on CT
  5. Nearly 80% of cases due to chronic alcoholism
27
Q

Mnemonic for predisposing factors to chronic pancreatitis

A 
T – toxic metabolic
I – idiopathic (10-30% of cases) 
G – genetic
A – autoimmune
R – recurrent and severe acute pancreatitis
O - obstructive
28
Q

Another preexisting disease that can cause chronic pancreatitis is

A

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

29
Q

Hallmarks of autoimmune pancreatitis

A

Elevated levels of IgG and certain autoantibodies

30
Q

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

A

diabetes

31
Q

S/S of chronic pancreatitis

A
  • Patients generally present with 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
  • Pts think they are having GERD
32
Q

Most sensitive test for chronic pancreatitis

A

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

33
Q

Medical management for chronic pancreatitis

A
  • Low fat diet
  • Abstinence from all alcohol
  • Use NSAIDs, tramadol, acetaminophen (avoid opioids)
34
Q

Steatorrhea is treated with

A

pancreatic supplements at mealtimes

Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze- all are capsules filled with pancreatic enzymes

35
Q

Autoimmune pancreatitis is treated with

A

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

36
Q

Surgical treatment is advised for chronic pancreatitis when

A

there is underlying biliary tract disease

  • Must reestablish free flow of bile into the duodenum
  • Possible endoscopic drainage of pancreatic pseudocysts
  • Distal bile duct obstruction can be relieved with stenting
37
Q

In severe cases, _________ is considered as a last resort

A

subtotal or total pancreatectomy

-Results in diabetes mellitus and pancreatic insufficiency

38
Q

Prognosis is best in patients with

A

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

CSI- Winter (44 decks)

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