1. ICU admission score only - Not pancreatitis specific - Not recalculated during hospitalization 2. Calculated from patient's age & 12 routine physiological measurements - PaO2 - Temperature (rectal) - Mean arterial pressure - pH arterial - Heart rate - Respiratory rate - Sodium - Potassium - Creatinine - Hematocrit - White blood cell count - Glasgow Coma Scale

Pancreatic Disorders Flashcards by Maggie Gambee

What is acute pancreatitis?

Inflammation of pancreas that occurs suddenly & usually resolves in a few days w/ treatment
Can be life-threatening w/severe complications

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Causes of Acute Pancreatitis

Gallstones
Chronic, heavy alcohol use
Abdominal trauma
Medications 
Infections
Tumors
Genetic abnormalities

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Acute Pancreatitis: Etiology Theory

Develops when pancreatic enzyme outflow is obstructed, causing leakage of enzymes into pancreatic tissue
Leaked enzymes become activated leading to “autodigestion” of pancreatic tissue

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Clinical Manifestations : Acute pancreatitis

Fever
Leukocytosis
N/V may occur (↑ w/ paralytic ileus) 
Abd Pain
CBD obstruction (edema/stone)

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Advanced Clinical Manifestations : Acute pancreatitis

Abdominal distention
a. Bowel hypomotility & accumulation of fluids in peritoneal cavity
Hypotension & shock
a. Plasma volume lost as enzymes released into circulation increase vascular permeability & dilate vessels
Hypovolemia
Azotemia
Acute tubular necrosis (renal failure)
Myocardial insufficiency

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Severe Clinical Manifestations: Acute pancreatitis

Small % of pts develop tachypnea & hypoxemia 2° to pulmonary edema, atelectasis, or pleural effusions caused by circulating pancreatic enzymes
Multiple organ failure accounts for most deaths

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Diagnostic Studies : Acute pancreatitis

Serum Lipase ↑ 4-8 hr (nl 8-14 days)
Serum Amylase ↑ 6-24 hr (nl 3-4 days)
Trypsin-activated peptide (TAP); urine Trypsinogen & Carboxypeptidase B
- All elevated (not widely available tests)
↑ CRP
CBC
a. Leukocytosis
b. Hb/Hct may be ↑ 2° to 3rd space fluid loss
CMP
a. ↑ Serum Bilirubin 15-25% of cases 2° to pancreatic edema compressing CBD
b. ↓ Serum Calcium
c. +/- glucose
(-) ETOH → USN & possibly Endoscopic Retrograde Cholangiopancreatography (ERCP)

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What are the Severity of Dz classification systems?

Ranson criteria
- Used fornon-gallstone & gallstone pancreatitis, but parameters differ
- Mortality increases w/ number of (+) signs
Glasgow Prognosis Score
APACHE III

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Ranson Criteria : Non-gallstone pancreatitis parameters

1. At admission:
Age > 55 years
White blood cellcount > 16,000 cells/mm3
Blood glucose> 200 mg/dL
SerumAST> 250 IU/L
SerumLDH> 350 IU/L

2. Within 48 hours:
Serum calcium < 8.0 mg/dL
Hctfall > 10% 
PaO2< 60 mmHg
BUN↑ by ≥ 5 mg/dL after IV fluid hydration
Base deficit > 4 mEq/L
Sequestration of fluids > 6 L

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Ranson Criteria: Gallstone pancreatitis parameters

1. At admission:
Age in years > 70 years
White blood cell count > 18,000 cells/mm3
Serum glucose> 220 mg/dL
SerumAST> 250 IU/L
SerumLDH > 400 IU/L

2. Within 48 hours:
Serum calcium < 8.0 mg/dL
Hct fall > 10%
PaO2< 60 mmHg
BUN↑ by ≥ 2 or more mg/dL after IV fluid hydration
Base deficit  > 5 mEq/L
Sequestration of fluids > 4 L

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More Ranson Criteria

1. Criteria at time of admission:
Age > 55 (1 point)
Glucose > 200 (1 point)
WBC > 16,000 (1 point)
AST > 250 (1 point)
LDH > 350 (1 point)

2. Criteria that may develop over 1st  48 hr:
BUN rises more than 5 mg/dL (1 point)
Base deficit > 4 (1 point)
Hct drops 10% or > (1 point)
PO2 < 60 (1 point)
Calcium < 8 (1 point)
Fluid sequestration > 6L (1 point)
 
Scoring
 ≥ 3 = acute severe pancreatitis              
 < 3 = acute mild pancreatitis
 0-2 points: Mortality = 1% 
 3-4 points: Mortality = 16% 
 5-6 points: Mortality =  40% 
 7-11 points: Mortality ≈100

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Glasgow Prognosis Score (PANCREAS ACRONYM)

PaO2 < 60mm Hg
Age > 55 yr 
Neutrophils: (WBC >15,000) 
Calcium < 8.0mg/dL 
Renal function:  	 		      (BUN > 49mg/dL)
Enzymes: (AST > 200 IU/L or  	   	           LDH > 600 IU/L)
Albumin < 32 gm/L
Sugar: (Glucose >200 mg/dL)

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APACHE III Score

ICU admission score only
- Not pancreatitis specific
- Not recalculated during hospitalization
Calculated from patient’s age & 12 routinephysiologicalmeasurements
- PaO2
- Temperature (rectal)
- Mean arterial pressure
- pH arterial
- Heart rate
- Respiratory rate
- Sodium
- Potassium
- Creatinine
- Hematocrit
- White blood cell count
- Glasgow Coma Scale

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Treatment: Acute pancreatitis

Goal →stop autodigestion & prevent systemic complications
a. NPO to “rest” pancreas
b. Continuous gastric suction
c. Narcotic medication for severe pain
d. IV fluids essential to restore blood volume & prevent hypovolemia
e. TPN to reverse the catabolic state
f. PPI to↓ gastric acid production
Monitor closely for complications
a. Pancreatic pseudocyst
→ infection, hemorrhage, obstruction & rupture
b. Renal failure
c. Pleural effusion
d. Hypocalcemia
e. Pancreatic abscess

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What is chronic pancreatitis?

Inflammation of pancreas that does not heal or improve
a. Worsens over time → permanent damage
Irreversible damage to pancreas
a. Assoc. w/ recurrent inflammation, fibrosis, & injury to the exocrine & endocrine tissues, causing episodes of pain

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Causes: Chronic Pancreatitis

Most common cause of chronic pancreatitis is many years of heavy alcohol use
Can be triggered by 1 acute attack that damages the pancreatic duct → causes pancreas inflammation → scar tissue develops & slow pancreas destruction
Other causes
- Cholelithiasis
- PUD
- Hyperparathyroidism/Hypercalcemia
- Hyperlipidemia/Hypertriglyceridemia
- ERCP
- Hereditary disorders (Cystic Fibrosis)
- Smoking ↑ risk w/ ETOH abuse

Signs & Sx’s : Chronic Pancreatitis

Epigastric or diffuse abdominal pain
a. +/- radiates through to back
b. +/- postprandial
Steatorrhea
Loss of appetite
Weight loss
Nausea
Vomiting
Diabetes
Malabsorption sx’s
a. Diarrhea, bloating, pain
b. Pancreatic calcification
c. Steatorrhea
d. DM

Physical Exam: Chronic Pancreatitis

Evaluate for pallor, jaundice

Rarely, a tender fullness or mass may be palpated in epigastrium

Diagnostic Studies : Chronic Pancreatitis

Lab testing – most helpful during acute or advanced disease
a. ↑ Alk phos/bilirubin if significant duct obstruction
b. Serum amylase & lipase – normal to slightly ↑
c. Serum Trypsin <10 ng/mL in advanced Dz
d. Secretin-Caerulein test (SCT)
- Gold Standard for pancreatic function
e. Fecal testing
- Quantitative fecal fat
- Chymotrypsin
- Pancreatic elastase 1

Pancreatic Calcification*
2. Imaging
a. Ultrasound (Endoscopic USN prn)
b. CT scan
c. ERCP (most sensitive)
d. MRCP

Secretin-Caerulein Test

Combination of caerulein & secretin bolus given via gastrofiberscope
a. Stimulate pancreatic exocrine secretion
b. Measurement of duodenal juice
Safe, reliable, & effective mean for the purpose of testing pancreatic function

What is the classic triad of Chronic Pancreatitis?

Pancreatic calc
Steatorrhea
DM

Treatment: Chronic pancreatitis

May require hospitalization:
Pain management
IV hydration
Nutritional support – NG tube feedings may be necessary for several weeks for weight loss
Synthetic pancreatic enzymes
a. Taken w/ every meal to help food digestion & regain weight

Management: Chronic Pancreatitis

Low fat diet
Avoid ETOH
Smoking cessation
Pain meds (avoid opiates if possible)
Pancreatic supplements
a. Containing Lipase, Amylase, Protease
b. (Pancreaze, Creon, Ultresa, Zenpep)
Surgery if indicated
a. Resect pseudocyst, abscess, fistula, or fixed obstruction
Corticosteroids for autoimmune Dz
Insulin for DM

Complications : Chronic Pancreatitis

Opioid addiction
Brittle DM
Pseudocyst
Abscess
CBD stricture
Steatorrhea
Malnutrition
PUD
CA risk
- 4% after 20 yr of Dz
- 19% after age 50

Pancreatic Insufficiency: Malabsorption

Inadequate metabolism of dietary substances due to defects in digestion, absorption, or transport Interferes w/ nutrient absorption in small intestine Results from mucosal disruption caused by - Gastric or intestinal resection - Vascular disorders - Intestinal Dz - Pancreatic insufficiency

Pancreatic Insufficiency: Causes

Chronic pancreatitis Pancreatic carcinoma Pancreatic resection Cystic Fibrosis

Pancreatic Insufficiency: Diagnostic Studies

``` Diagnosis made by pancreatic function testing (PFT) -Fecal fat -Fecal elastase -Secretin-caerulein test (SCT) (Gold standard) ``` Management includes enzyme replacement & fat soluble vitamin therapy

Pancreatic Cancer: Risk Factors

``` ETOH abuse Tobacco use Increased age Obesity Long standing Hx of DM (1° in women) Chronic pancreatitis Heredity ```

Pancreatic Cancer: Signs & Sx’s

``` Painless jaundice** Epigastric pain Weight loss Anorexia Pruritus Nausea/Vomiting Palpable liver Clay colored stools Courvoisier’s Sign***** -Nontender, enlarged GB w/ jaundice Trousseau Sign Virchow’s Node Blumer’s Shelf Sister Mary Joseph Nodule ```

Diagnostic Studies: Pancreatic Cancer

``` CT , MRI, USN, ERCP, MRCP, PET scan CBC CMP (Alk Phos, GGT,AST, ALT) Amylase, Lipase CA 19-9 antigen to follow (not for screening) CEA ```

Treatment: Pancreatic Cancer

1. Whipple Procedure (surgery) a. Factors that define inoperability - Vascular encasement - Liver Mets - Peritoneal implants - Distal lymph node mets Surgery + chemotherapy & external beam radiation - 40% 2-yr survival - 25% 5-yr survival

Insulinoma

Rare pancreatic beta cell tumor that hypersecretes insulin (Hyperinsulinism) Whipples Triad Low serum glucose (<50 mg/dL) CNS symptoms of hypoglycemia Eating carbohydrates relieves symptoms Treatment Surgical resection

Gastrinomas (AKA Zollinger-Ellison Syndrome)

Z-E syndrome caused by a gastrin-producing tumor usually located in the pancreas, duodenal wall, or lymph nodes Gastric acid hypersecretion by parietal cells & gastric/peptic ulcerations result Sx’s-pain, chronic diarrhea, steatorrhea, weight loss, hematemesis Diagnosis -fasting serum gastrin levels x 3(normal < 100 pg/ml) or Secretin stim test, MRI to R/O tumor Treatment -PPI & surgical resection

Vipoma

1. Malignant pancreatic islet cell tumor secreting vasoactive intestinal peptide (VIP)→ a. Syndrome of extreme Watery Diarrhea, Hypokalemia, and Achlorhydria* (WDHA syndrome) - *Production of gastric acid in the stomach is absent or low Diagnosis-serum VIP levels Tumor is localized w/ CT & endoscopic USN Treatment -Surgical resection

Glucagonoma

Rare malignant islet cell tumor originating from alpha-2 cells that secrete glucagon Causes hyperglycemia & characteristic skin rash - Found on shin, face, & groin - Necrolytic migratory erythema Diagnosis is by ↑ glucagon levels & imaging studies -Tumor localized w/ CT & endoscopic USN Treatment Surgical resection