Pancreatic Diseases Flashcards
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….
Acute Pancreatitis
Most cases of acute pancreatitis 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
_______ itself can cause pancreatitis
ERCP procedure
Acute pancreatitis may also be caused by
Medications, viruses, autoimmune, high cholesterol also are considerations
GET SMASHED
thinks that cause pancreatitis
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hypothermia/Hyperlipidemia ERCP Drugs- azathioprine, thiazines, sodium valproate, tetracycline
Big blues to think acute pancreatitis
History of gallstones or heavy drinking
Trauma directly to pancreas (insult to gut, kid going over handlebars)
Signs and symptoms of acute pancreatitis
- 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
Pancreatitis may also be caused by obstruction of
ampula of vader from stone, etc.
Lab findings for pancreatitis
- *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
Severity of pancreatitis depends on
Presence of a systemic inflammatory response syndrome (SIRS) or sepsis can independently be associated with a greater mortality rate
_______ 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
Ranson’s criteria
Ranson’s Criteria
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
“Sentinel Loop” and “Colon cutoff Sign” seen in xray
-“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
Ultrasound helpful?
Ultrasound can be helpful for identifying gallstones/cholecystitis but generally not helpful for pancreatitis given overlying bowel gas
CT helpful?
- CT can help to identify and enlarged or inflamed pancreas
- Can also show necrosis, pseudocyst, or other complications
Physical signs that present in 1-2% of pancreatitis cases
Cullen sign (bruising around umbilicus) Grey Turner's sign (bruising along side, flank)
-usually present together, correlate high with pancreatic necrosis
Treatment for mild pancreatitis
-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
Treatment for severe pancreatitis
- 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
Drug of choice for necrotizing pancreatitis
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
Complications of acute pancreatitis
- 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)
- 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 - Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes may also occur
______ should follow all severe cases especially with nercocosis/pseudocyst
Surgery
-Some mild cases with stones may need a cholecystectomy or cholecystotomy
________ may improve survival but patient must be good candidates
Necrosectomy
-If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well, but risk for _________
infection and fistula formation
-Mortality rates in the most severe cases are 25% and if there is multiorgan failure present, 50%
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.
Think chronic pancreatitis
**Think alcoholics (smoking accelerates process)
Labs with chronic pancreatitis will show
- mild elevation in amylase and lipase
- Serum alkaline phosphatase and bilirubin are slightly elevated
Chronic pancreatitis is characterized by
- persistent or intermittent epigastric pain
- steatorrhea
- weight loss
- up to 30% of affected patients have calcifications of their pancreas on CT
- Nearly 80% of cases due to chronic alcoholism
Mnemonic for predisposing factors to chronic pancreatitis
T – toxic metabolic I – idiopathic (10-30% of cases) G – genetic A – autoimmune R – recurrent and severe acute pancreatitis O - obstructive
Another preexisting disease that can cause chronic pancreatitis is
Hyperparathyroidism- which increases levels of serum calcium can lead to increased calcium deposition in the pancreas and be a cause
Hallmarks of autoimmune pancreatitis
Elevated levels of IgG and certain autoantibodies
80% of adults develop _____ within 25 years after the onset of chronic pancreatitis
diabetes
S/S of chronic pancreatitis
- 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
Most sensitive test for chronic pancreatitis
ERCP is the most sensitive test and can show dilated ducts, intraductal stones, strictures, pseudocyst development
Medical management for chronic pancreatitis
- Low fat diet
- Abstinence from all alcohol
- Use NSAIDs, tramadol, acetaminophen (avoid opioids)
Steatorrhea is treated with
pancreatic supplements at mealtimes
Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze- all are capsules filled with pancreatic enzymes
Autoimmune pancreatitis is treated with
steroids (Prednisone 40mg/d for 1-2mo followed by a taper)
Surgical treatment is advised for chronic pancreatitis when
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
In severe cases, _________ is considered as a last resort
subtotal or total pancreatectomy
-Results in diabetes mellitus and pancreatic insufficiency
Prognosis is best in patients with
recurrent acute pancreatitis caused by stones or sphincter of Oddi stenosis which can be remedied
