pancreatic disorders Flashcards
What is the exocrine function of the pancreas
digestion
*secretes bicarb and digestive enzymes
What is the pancreas endocrine function
glucose homeostasis
What are the most common triggers of acute pancreatitis
gallstones and alcohol intake
*hypertriglyceridemia and ACEi are also common
What helps diagnosis of acute pancreatitis
serum amylase and Lipase
clinical presentation
imaging
What is the treatment for actor pancreatitis
IV fluids
analgesics
nutritional support
What toxins can cause acute pancreatitis
scorpion bites
organophosphate poisoning
What level of alcohol intake can lead to acute pancreatitis
> 4-7 drinks/day in men
3drinks/day in women
**generally from binge drinking rather than chronic
What is the patient presentation with acute pancreatitis
severe, upper abdominal pain with radiation (boring) to back with frequent N/V
diaphoretic and ill appearing
semi- comatose
What is grey turner sign and what is it associated with
ecchymoses of the flanks
acute pancreatitis
What is Cullen sign and what is it associated with
ecchymosis of the umbilical region
acute pancreatitis
What may help reduce some pain with acute pancreatitis
Sitting up ad leaning forward
What is the presentation difference between gallstone and alcohol pancreatitis
Gallstone occurs suddenly
alcohol occurs over a few days
What is the top differential dx is acute pancreatitis
perforated gastric/duodenal ulcer
*also r/o inferior wall MI
When is genetic testing recommended with acute pancreatitis
if <30y/o
When should a pancreatic tumor be highly considered with acute pancreatitis
> 40y/o
When should TG be considered as the cause of acute pancreatitis
> 1000mg/dl
What is the dx criteria for acute pancreatitis
Abdominal pain consistent with acute pancreatitis
serum lipase >3x upper limit of normal
Findings consistent on imagining
*need 2 of the 3
What lab work gives the best evaluation of acute pancreatitis
Rising BUN or rising Hct
What lab is most specific for pancreatitis
Lipase
How long do labs stay elevated with acute pancreatitis
Increase the first day and return to normal in 3-7 days
When may labs remain normal with acute pancreatitis
Destruction of acinar tissue in previous episodes
When may labs remain normal
If there is an elevated anion gap with acute pancreatitis, what is it indicative of
metabolic acidosis & shock
What is the imaging study of choice with pancreatitis
CTA
what risk factors predict a severe course of acute pancreatitis
systemic inflammatory response syndrome (SIRS)
AMS
comorbid health problems
BMI > 30
hypovolemia markers
What is the Ranson criteria
cumbersome, takes 48 hours
could negative predictive value of acute pancreatitis
What is the APACHE II score
good negative predictive value of acute pancreatitis
*complex & cumbersome
What is BISAP and what is it used for
Bedside index of severity in acute pancreatitis
calculated during first 24 hours
good positive predictor value of severe case M&M
What is the Balthazar score
CT severity index score based on the degree of necrosis and fluid presence for acute pancreatitis
What are the types of acute pancreatitis
Interstitial
Necrotizing
What is mild acute pancreatitis
Inflammation confined to pancreas and close vicinity, no organ failure or systemic/local complications
What is mild acute pancreatitis
Local or systemic complications but no organ failure
What is severe acute pancreatitis
Peristent single or multi organ failure and 1 or more local complications
When is the most important stage in management of acute pancreatitis
in the first 12-24 hours
-fluid resuscitation
-analgesia
- nutritional support
What is the foundation of acute pancreatitis management
early & aggressive fluid resuscitation
*monitor BUN, Hct, and urine output Q4-6 hours in first 24 hours to adjust fluid rate
What is included in lactated ringers
Sodium, chloride, lactate, potassium, calcium
If there is no response to immediate management of acute pancreatitis, what is it indicative of
high likelihood of MODS/SIRS
How long does someone with acute pancreatitis need to stay NPO
until abdominal pain, n/v, appetite, ileum improve/resolve
If a patients acute pancreatitis is from gallstones, how do you manage their treatment
Cholecystectomy
If a patients acute pancreatitis is from cholangitis/billiary obstruction, how do you manage their treatment
ERCP w/n 24 hours of presentation
If a patients acute pancreatitis is from hypertriglyceridemia, how do you manage their treatment
bring down and maintain <500mg/dl
*apheresis and insulin drip +/- glucose
What is a pancreatic pseudocyst
Pancreatic and peri pancreatic collections of enzyme rich fluid +/- necrotic material
*most resolve spontaneously
What will be seen on imaging with acute pancreatic necrosis
gas bubbles on imaging/CT-guided percutaneous aspiration
When is surgery done for acute pancreatitis
if the organ has deteriorated despite abx
What criteria makes the dx for SIRS
Temp >38.3 or <36
HR >90bpm
RR>20
WBC> 12,000 or <4000
What are the 2 major risk factors for chronic pancreatitis
alcohol and smoking
What is the predominant symptoms of chronic pancreatitis
abdominal pain
What is the treatment for chronic pancreatitis
pain control and mngmt of pancreatic insufficiency
What is chronic pancreatitis
Persistent inflammation due to permanent structural damage
What is the hallmark of chronic pancreatitis
Fibrosis caused by inflammation and recurrent pancreatic injury
What are the primary manifestations of chronic pancreatitis
abdominal pain and pancreatic insufficiency
What is steatorrhea
high fat stool
What are signs of pancreatic insufficiency
flatulence
abdominal distention
steatorrhea
undernutrition
weight loss
fatigue
What is needed for diagnosis of chronic pancreatitis
Clinical assessment
imaging
pancreatic function tests
How may chronic pancreatitis look on KUB
Calcified
How may chronic pancreatitis appear on US
Atrophy with dilated main pancreatic duct with intraductsal calculi
What imaging modality is frequently used for chronic pancreatitis diagnosis
MRI
What type of pancreatic function tests are there
Direct (enzyme secretion)
Indirect (fat malabsorption)
When is direct pancreatic function tests Most useful
in earlier stages when imaging isn’t diagnostic
What is administered for diet pancreatic function test
IV CCK and then IV secretin for bicarb production
How do you treat chronic pancreatitis
Smoking/ETOH cessation
pain control
pancreatic enzyme supplements
What is used for indirect pancreatic function tests
Serum Trypsinogen
Steatorrhea
How do you give pancreatic enzyme replacement
25k - 50k IU lipase per meal and half dose with snacks along with PPI/H2 blocker to prevent enzyme breakdown
Who may present with unopposed and prolonged hypoglycemia
pancreatogenic diabetes
What is exocrine pancreatic insufficiency (EPI)
Reduction in pancreatic enzyme activity
*mainly lipase
What are the 2 primary causes of EPI
chronic pancreatitis in adults
CF in children
How much pancreatic function is typically lost before EPI occurs
> 90%
How do you treat / manage EPI
Monitor body weight / BMI
Screen for nutritional deficiency
referral to dietician
address any causes
What is the mainstay treatment of exocrine pancreatic function
pancreatic enzyme replacement therapy (PERT)
What type of malabsorption happens first in EPI
Fat before carb/protein
