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GI II: Test 2 > Pancreatic Diseases/Abdominal Pain > Flashcards

Pancreatic Diseases/Abdominal Pain Flashcards

1
Q

criteria for pancreatitis?

A

2/3 criteria:

Characteristic Abdominal pain: epigastric pain going to back

Amylase or lipase > 3 times normal

Characteristic findings on CT

causes of pancreatitis? 
CMV.
autoimmune. 
lipids.
thiazide.
****alcohol.
*****gallstones.
pancreas divisum.
** obesity.
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2
Q

What is one of the worse prognosis for pancreatitis?

A

Obesity.

Central obesity is a metabolically active organ associated with Barret’s epithelium, adenocarcinoma of the esophagus and, especially in diabetics, pancreatic cancer.

Obesity also makes acute pancreatitis worse by causing local circulatory changes in peripancreatic fat and produces hypoxia by limiting respiration.

BMI > 30 kg/m2 = poor prognosis

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3
Q

best test for pancreatitis?

A

**# 1 = Lipase

# 2. Amylase: (less specific) also elevated in bowel problems, ectopic production, lung, fallopian tube and salivary gland secretion, ** macroamylasemia (low urinary amylase - normal serum lipase), renal insufficiency, trauma
- amylase is not that specific

**3. ALT>150 IU/L suggests gallstones as cause for biliary pancreatitis!!!

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4
Q

what causes acute pancreatitis?

A

Main causes:

    • alcohol
    • gallstones
  • drugs - they can cause anything: sulfa, tetracycline
  • obesity

Other causes:

  • metabolic: hyperlipidemia (types I, IV, V)
  • AI disease: IgG4 related diseases
  • genetics: SPINK1 gene, PRSS1 gene
  • hypercalcemia: drives conversion of trypsinogen to trypsin
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5
Q

Cullen’s sign

A

blood around the umbilicus = hemorrhagic poor prognosis pancreatitis = intraperiteonal bleeding

  • hemorrhage in part due to trypsin activation of elastase –> vascular damage and hemorrhage
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6
Q

Grey Turner’s

A

bleeding around the flank = hemorrhagic poor prognosis pancreatitis = intraperiteonal bleeding

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7
Q

Ranson Score criteria

A

worse prognosis for pancreatitis

(score of 3 or more = bad!) At admission - Age, WBC, Glucose, LDH, AST. At 48 hours includes BUN and 5 other criteria.

** if you have to follow one test for pancreatitis, then follow BUN to see if its worsening!

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8
Q

HAPS score

A

Harmless Acute Pancreatitis Score (“HAPS”) score

(absence of rebound tenderness, normal hemacrit, and normal creatinine) ** predicts a nonsevere course.

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9
Q

APACHE II

A

(score of 8 or more = bad!) used to access severity of pancreatitis

Rectal temp, mean arterial pressure, HR, RR, FiO2, arterial pH, Na, K, Cr, Hct, WBC. Score of 8 = necrosis

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10
Q

BISAP score

A

used to assess pancreatitis

  • BUN > 25 mg/dL,
  • Impaired mental status,
  • SIRS, (indicates shock)
  • Age > 60,
  • Pleural effusion

– score of 3 or more = bad sign.

(Obesity should also be considered as a point - BISOAP.)

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11
Q

other markers for pancreatitis?

A

CRP >150 = sign of pancreatic necrosis

creatinine >1.8 = marker for necrosis

calcium - decreased with albumin extravasation or saponification (the pancreas is digesting itself and needs calcium to activate trypsin)

hemacrit >44% at admission and at 24 hours = sign of necrosis

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12
Q

Clinical presentation of acute pancreatitis?

A

AMYLASE

Acute abdominal pain to the back

Mid-abdominal staining (Cullen’s and Grey Turner signs)

Yellow (jaundice –stones or cancer)

Lipase elevated, Left sided pleural effusion or atelectasis (on left side b/c pancreas is over there)

Amylase (>1000) - poorer test

Sentinel loop and colon cut off signs - distended loop of bowel is seen near the site of injured viscus or inflamed organ

Emesis and nausea

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13
Q

imaging for pancreatitis?

A

first test for suspected gall stones is US

CT scan shouldn’t be done on first day unless you doubt ddx/ or if its really severe: should be done on 3rd/4th day if its milder

can use CT severity index to determine prognosis of pt. – this is better index to determine severity and mortality

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14
Q

necrotizing pancreatitis

A

indicates a 50% chance of infection (abscess) and 30% chance of mortality from MOF (multi-organ failure)

Complications of Acute Pancreatitis and Prediction of Severity.

  1. RANSOM (> 3) and APACHE II (> 8) scores.
  2. MOD (lipotoxicity and GI bacterial products) – BP < 90, pO2 < 60 (ARDS), Cr > 2 (ATN), GI bleed
  3. Systemic complications: DIC (Platelets < 100,000, Fibrinogen < 1g/L, FSP > 80 ug/mL), hypocalcemia with Ca < 7.5 mg/dL (muscle spasms).
  4. Local complications:
    a. Infected fluid collections or pancreatic necrosis within 1-3 weeks(abscess) – often complicated by splenic vein thrombosis (gastric varices) and left pleural effusions.

b. Pseudocyst – more than 4-6 weeks - if over 6 cm = surgery? Watch for pain, rupture, hemorrhage or abscess.
c. Ascites.
d. Chronic Pancreatitis.

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15
Q

what do you see on CT w/ chronic pancreatitis?

A

see calcifcations on the pancreas - seen as white spots

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16
Q

causes of chronic pancreatitis?

A

** recurrent acute pancreatitis: most often due to alcohol!

acohol, smoking, surgery, hyperparathyroidism, obstructions, AI, CF, SPINK1/PRSS1 mutations

17
Q

sx of chronic pancreatitis?

A

(chronic pancreatitis “shows up” with vitamin deficiency)

  1. Calcification, Cancer
  2. Pain
  3. Steatorrhea and osmotic diarrhea
  4. Weight loss
  5. Vitamin deficiency (maldigestion of proteins
    and fat - no absorption of ADEK)
  6. Diabetes (may be brittle with loss of insulin and glucagon)
18
Q

how to make ddx of chronic pancreatitis?

A
  1. Xray – diffuse speckled calcification
  2. US or CT – ductal dilation, calcification and cystic lesions
  3. ERCP – **most sensitive and specific
  4. MRI with cholangiopancreatography

Other Tests:

  1. 24 hour fecal fat > 10 g/day = + test.
  2. Secretin/cholecystokinin secretion test (with tube in distal duodenum and assay for HCO3, trypsin, lipase, etc.). - not often done
19
Q

D-Xylose test?

A

indicates small intestine malabsorption

25 gm is taken by mouth. If less than 4 gm shows
up in a 5 hr urine collection, this indicates mucosal malabsorption
(xylose not absorbed) or bacterial overgrowth (xylose fermented or
“eaten” by the bugs, so none absorbed).

** In pancreatic insufficiency, d- xylose absorption (which requires no
enzyme activity) is not effected, so that the urine shows adequate
d-Xylose to be present.

20
Q

Tx for chronic pancreatitis?

A
  1. Pain- (worry about drug addiction)
  2. Low fat diet
  3. 36,000 units of lipase/meal with H2 blocker (pancrelipase/Creon)
  4. Surgical ductal decompression for pain relief prednisone or azathioprine
  5. Watch for cancer
21
Q

pneumatosis intestinalis

A

= air in bowel wall on CXR

benign causes: COPD, scleroderma, Crohns, Corticosteroids

Lifethreatening causes: mesenteric vascular ischemia

22
Q

LUQ pain?

A

may be due to splenomegally: malaria, leukemia, etc.

23
Q

complication of acute pancreatitis?

A
  1. Local complications:
    a. Infected fluid collections or pancreatic necrosis within 1-3 weeks(abscess) – often complicated by splenic vein thrombosis (gastric varices) and left pleural effusions.
    b. Pseudocyst – more than 4-6 weeks - if over 6 cm = surgery? Watch for pain, rupture, hemorrhage or abscess.
    c. Ascites.
    d. Chronic Pancreatitis.

Other complications?

  • ATN
  • necrotizing pancreatitis w/ MOF
  • ARDS: seen in 3-7 days
  • SIRS
  • hypocalcemia
  • infected pancreatic necrosis (abscess) - often complicated by splenic vv. thrombosis (causing gastric varices) and left pleural effusions
24
Q

what Ab do you give for infected necrosis of pancreas?

A

imipenem

25
Q

how to differentiate steatorrhea from pancreas or from SI?

A

do the Secretin test and fecal elastase test (if positive then it is pancreatic cause)

Levels of fecal elastase lower than 200 μg / g of stool indicate an exocrine insufficiency

Do D-xylose test to find if its the SI

26
Q

Familial Mediterranean fever

A

present w/ arthritis, pleuritis, epiodic fever, hot ankle rash, abdominal pain and tenderness

  • d/t malfunctioning pyrin gene that results in amyloid AA formation and WBC mobbing tissues!

** they have chronic amyloid AA production – can hit kidney – most pts. die of kidney failure due to amyloidosis
presents as acute abdominal pain

AMYLOID PROTEIN HITS THE KIDNEYS AND CAUSES DEATH!!!!

27
Q

go back over atypical ab. pain slides?

A

do i need to know anything else???

GI II: Test 2 (6 decks)

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