Pancreatic Diseases/Abdominal Pain Flashcards
criteria for pancreatitis?
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.
What is one of the worse prognosis for pancreatitis?
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
best test for pancreatitis?
**# 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!!!
what causes acute pancreatitis?
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
Cullen’s sign
blood around the umbilicus = hemorrhagic poor prognosis pancreatitis = intraperiteonal bleeding
- hemorrhage in part due to trypsin activation of elastase –> vascular damage and hemorrhage
Grey Turner’s
bleeding around the flank = hemorrhagic poor prognosis pancreatitis = intraperiteonal bleeding
Ranson Score criteria
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!
HAPS score
Harmless Acute Pancreatitis Score (“HAPS”) score
(absence of rebound tenderness, normal hemacrit, and normal creatinine) ** predicts a nonsevere course.
APACHE II
(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
BISAP score
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.)
other markers for pancreatitis?
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
Clinical presentation of acute pancreatitis?
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
imaging for pancreatitis?
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
necrotizing pancreatitis
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.
- RANSOM (> 3) and APACHE II (> 8) scores.
- MOD (lipotoxicity and GI bacterial products) – BP < 90, pO2 < 60 (ARDS), Cr > 2 (ATN), GI bleed
- Systemic complications: DIC (Platelets < 100,000, Fibrinogen < 1g/L, FSP > 80 ug/mL), hypocalcemia with Ca < 7.5 mg/dL (muscle spasms).
- 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.
what do you see on CT w/ chronic pancreatitis?
see calcifcations on the pancreas - seen as white spots
causes of chronic pancreatitis?
** recurrent acute pancreatitis: most often due to alcohol!
acohol, smoking, surgery, hyperparathyroidism, obstructions, AI, CF, SPINK1/PRSS1 mutations
sx of chronic pancreatitis?
(chronic pancreatitis “shows up” with vitamin deficiency)
- Calcification, Cancer
- Pain
- Steatorrhea and osmotic diarrhea
- Weight loss
- Vitamin deficiency (maldigestion of proteins
and fat - no absorption of ADEK) - Diabetes (may be brittle with loss of insulin and glucagon)
how to make ddx of chronic pancreatitis?
- Xray – diffuse speckled calcification
- US or CT – ductal dilation, calcification and cystic lesions
- ERCP – **most sensitive and specific
- MRI with cholangiopancreatography
Other Tests:
- 24 hour fecal fat > 10 g/day = + test.
- Secretin/cholecystokinin secretion test (with tube in distal duodenum and assay for HCO3, trypsin, lipase, etc.). - not often done
D-Xylose test?
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.
Tx for chronic pancreatitis?
- Pain- (worry about drug addiction)
- Low fat diet
- 36,000 units of lipase/meal with H2 blocker (pancrelipase/Creon)
- Surgical ductal decompression for pain relief prednisone or azathioprine
- Watch for cancer
pneumatosis intestinalis
= air in bowel wall on CXR
benign causes: COPD, scleroderma, Crohns, Corticosteroids
Lifethreatening causes: mesenteric vascular ischemia
LUQ pain?
may be due to splenomegally: malaria, leukemia, etc.
complication of acute pancreatitis?
- 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
what Ab do you give for infected necrosis of pancreas?
imipenem
