Pancreatitis Flashcards
1
Q
- leading cause of acute pancreatitis
- second most common
A
- Gallstones
- alcohol
2
Q
- pancreas blood supply maintained
- which is generally self-limited
A
nterstitial pancreatitis
3
Q
- pancreas blood supply interrupted
- the extent of necrosis may correlate with the severity of the
attack and its systemic complications
A
Necrotizing pancreatitis
4
Q
- accepted pathogenic
- proteolytic enzymes (e.g., trypsinogen, chymotrypsinogen,
proelastase, and lipolytic enzymes such as phospholipase A2) are activated in the pancreas acinar cell rather than in the intestinal lumen
A
Autodigestion
5
Q
Factors that facilitate premature
activation of trypsin
A
- Endotoxins
- Exotoxins
- viral infection
- Ischemia
- oxidative stress
- lysosomal calcium
- direct trauma
6
Q
- characterized by intrapancreatic digestive enzyme activation and acinar cell injury
- Trypsin activation
A
Initial phase
7
Q
activation, chemoattraction, and sequestration of leukocytes
and macrophages in the pancreasenhanced intrapancreatic inflammatory reaction
A
Second phase
8
Q
due to the effects of activated proteolytic enzymes and
cytokines, released by the inflamed pancreas, on distant
organs
A
Third phase
9
Q
Genetic variants associated with susceptibility to pancreatitis
A
- cationic trypsinogen gene (PRSS1)
- pancreatic secretory trypsin inhibitor (SP/NKz)
- the cystic fibrosis transmembrane conductance regulator
gene (CFTR) - the chymotrypsin C gene (CTRC)
- the calcium-sensing receptor (CASR)
10
Q
- major symptom
- mild discomfort to severe, constant, and incapacitating distress
- steady and boring in character, is located in the epigastrium and periumbilical region, and may radiate to the back, chest, flanks, and lower abdomen
A
Abdominal pain
11
Q
- A faint blue discoloration around the umbilicus
- Due to hemoperitoneum
A
Cullen’s sign
12
Q
Symptoms of Pnacreatitis
A
- Abdominal pain
- Nausea/ vomiting
- Abdominal distention
- distressed and anxious
- Low-grade fever, tachycardia, and hypotension
- hypovolemic Shock
- Jaundice (rare)
- Erythematous skin nodules
- basilar rales, atelectasis, and pleural effusion (left sided)
- Abdominal tenderness and muscle rigidity
- Diminished or absent bowel sounds
13
Q
- a blue-red-purple or green-brown discoloration of the
flanks - tissue catabolism of hemoglobin from severe necrotizing pancreatitis with hemorrhage
A
Turner’s sign
14
Q
- Return to normal after 3-7 days
- acidemia (arterial pH $7.32)
A
Serum amylase
15
Q
- Preferred test
- nocorrelation between the severity of pancreatitis and the degree of serum lipase and amylase elevations
- remain elevated for 7-14 days
A
Serum Lipase
16
Q
LABORATORY DATA OF PANCREATITIS
- Leukocytosis
- Hemoconcentration- Hematocrit
- BUN
- glycemia
- calcemia
- bilirubinemia
- Serum alkaline phosphatase and aspartate aminotransferase levels
- triglyceridemia
- Hypoxemia
- ECG -
A
- Leukocytosis -15,000—20,000 leukocytes/uUL)
- Hemoconcentration- Hematocrit of >44%
- BUN >22mq/dl
- Hypoglycemia
- Hypocalcemia
- Hyperbilirubinemia (serum bilirubin >4.0 mg/dL)
- Serum alkaline phosphatase and aspartate aminotransferase levels are also transiently elevated
- Hypertriglyceridemia
- Hypoxemia (arterial PO2 <60 mm Hg
- ECG - ST-segment and T-wave abnormalities
17
Q
- initial diagnostic imaging modality
- most useful to evaluate for gallstone disease and the
pancreatic head
A
Abdominal ultrasound
18
Q
CT scan
Revised Atlanta Criteria of pancreatitis
A
1) necrotizing pancreatitis
2) acute pancreatic fluid collection
3) pancreatic pseudocyst
4) acute necrotic collection (ANC)
C) walled-off necrosis (WON)
19
Q
DIAGNOSIS Criteria of pancreatitis
A
two of the three criteria
- (1) typical abdominal pain in the epigastrium that may
radiate to the back - (2) threefold or greater elevation in serum lipase and/or
amylase, an - (3) confirmatory findings of acute pancreatitis on crosssectional abdominal imaging
20
Q
- lasts 1-2 weeks
- severity is defined by clinical parameters rather than morphologic findings.
- Organ failure is defined as a score of 2 or more for one of these three organ systems using the modified Marshall scoring system.
- respiratory, cardiovascular, and renal
- Persistent organ failure (>48 h) is the most important clinical finding in regard to severity of the acute pancreatitis episode
A
Early phase of acute pancreatitis
21
Q
- > 2 weeks
- characterized by a protracted course of illness
- require imaging to evaluate for local complications
- persistent organ failure- important clinical parameter of severity
- may require supportive measures- renal dialysis, ventilator support, supplemental nutrition via the nasojejunal or parenteral route
- necrotizing pancreatitis- radiographic feature of greatest importance
A
Late phase
22
Q
Severity Classifications
- without local complications or organ failure
- self-limited and subsides spontaneously
- within 3-7 days after treatment is instituted
- Oralintake resumed ifthe patient is hungry, has normal
bowel function, and is without nausea and vomiting - aclear or full liquid diet has been recommended for the initial meal
- a low-fat solid diet
A
Mild acute pancreatitis
23
Q
Severity Classifications
- characterized by transient organ failure
- (resolves in <48h
- local or systemic complications in the absence of persistent organ failure
- may develop a local complication such as a fluid collection that requires a prolonged hospitalization >1 week
A
Moderately severe acute pancreatitis
24
Q
Severity Classifications
- is characterized by persistent organ failure (>48 h)
- Organ failure can be single or multiple
- CT scan or MRI should be obtained to assess for necrosis
and/or complications - management is dictated by clinical symptoms, evidence
of infection, maturity of fluid collection, and clinical stability of the patient - Prophylactic antibiotics are not recommended
A
Severe acute pancreatitis
25
Q
Types of Pancreatitis
- 90-95% of admissions for acute pancreatitis
- characterized by diffuse gland enlargement, homogenous contrast enhancement, and mild inflammatory changes or peripancreatic stranding
- Symptoms resolve with a week of hospitalization
A
Interstitial pancreatitis
26
Q
Types of Pancreatitis
- 5-10% of acute pancreatitis admissions
- does not evolve until several days of hospitalization
- characterized by lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or presence of findings of peripancreatic necrosis.
A
Necrotizing pancreatitis
27
Q
ACUTE PANCREATITIS MANAGEMENT
A
- Fluid Resuscitation
- lactated Ringer’s or normal saline
- initially bolused at 15-20 mL/kg (1050-1400 mL),
- followed by 2-3 mL/kg per hour (200-250 mL/h), to maintain urine output >0.5 mL/kg per hour.
- targeted resuscitation strategy with measurement of hematocrit and BUN every 8-12 h
- A rise in hematocrit or BUN- repeat volume challenge with a 2-L crystalloid bolus followed by increasing the fluid rate by 1.5 mg/kg per hour
- The patient is made NPO to rest the pancreas and is
given intravenous narcotic analgesics to control abdominal pain and supplemental oxygen (2 L) via nasal cannula
28
Q
Markers of Severity At Admission or within 24hr
SIRS—defined by presence of 2 or more criteria:
- Core temperature <
- Heart rate
- Respirations: or Pco2
- White blood cell count
- APACHE
- Hemoconcentration ()
- Admission BUN
- BISAP Score
- (B) BUN
- (I) mental status
- (s) sirs:
- (A) Age
- (P) Pleural
- Organ (Modified Marshall Score)
- Cardiovascular: systolic BP: , heart rate:
- Pulmonary: Pao2
- Renal: serum creatinine
A
SIRS—defined by presence of 2 or more criteria:
- Core temperature <36° or >38°C
- Heart rate >90 beats/min
- Respirations >20/min or Peo, <32 mmHg
- White blood cell count >12,000/pL, <4000/yL, or 10% bands
- APACHE II
- Hemoconcentration (hematocrit >44%)
- Admission BUN (>22 mg/dL)
- BISAP Score
- (B) BUN >25 mg/dL
- (I) Impaired mental status
- (s) sirs: >/=2 of 4 present
- (A) Age >60 years
- (P) Pleural effusion
- Organ failure (Modified Marshall Score)
- Cardiovascular: systolic BP <90 mmHg, heart rate >130 BPM
- Pulmonary: Pao2 <60 mm Hg
- Renal: serum creatinine >2.0 mg
29
Q
- ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within
24-48 h of admission - increased risk of recurrence
- cholecystectomy during the same admission or within 4—
6 weeks of discharge. - non surgical candidates — endoscopic biliary sphincterotomy before discharge
A
GALLSTONE PANCREATITIS
30
Q
- Serum triglycerides >1000 mg/dL
- insulin, heparin, or plasmapheresis
- Outpatient therapies: control of diabetes if present, lipidlowering agents, weight loss, and avoidance of drugs that elevate lipid levels.
A
HYPERTRIGLYCERIDEMIA
31
Q
Nutritional Therapy for Pancreatitis
A
- low-fat solid diet after the abdominal pain has resolved
- Enteral nutrition should be considered 2-3 days after
admission in subjects with more severe pancreatitis
instead of total parenteral nutrition (TPN) - Enteral feeding
+ maintains gut barrier integrity
+ limits bacterial translocation
+ less expensive
+ has fewer complications than TPN
32
Q
Complications of Acute Pancreatitis
A
- Local Necrosis (Sterile, Infected)
- Walled-off necrosis
- Pancreatic fluid collections
- Pancreatic pseudocyst
- Disruption of main pancreatic duct
- Thrombosis of blood vessels (splenic vein, portal vein)
- Pancreatic enteric fistula
- Bowel infarction
- Obstructive jaundice
