Pancreatitis Flashcards
Acute Pancreatic H&P
Acute onset
Upper abdominal pain or epigastric pain
Pain may radiate to back
Severe and constant
+ Nausea/Vomiting
Improved with leaning forward
Fever, chills, sweats
Chronic Pancreatic H&P
Less abrupt onset
Improved with leaning forward
Upper and chronic abdominal pain
Steatorrhea
Weight loss
Diabetes
Fever, chills, sweats
Pancreatic Cancer
Nonspecific
Upper abdominal pain
New onset diabetes
Weight loss and anorexia
Nausea and vomiting
Fever, chills, sweats
If mets to the liver…
Jaundice
Dark urine
Light colored stools
Pancreatic PE
+ abdominal distension
- bowel sounds
+ tenderness on examination
Cullen’s sign-periumbilical bruising
Grey Turner’s sign-bruising of the flank
Dyspnea due to diaphragmatic inflammation
Pleural effusions
ARDS
Scleral icterus and/or jaundice
Hepatomegaly
Differentials Include:
Peptic ulcer disease
GI Perforation
Cholecystitis, cholangitis, choledocholithiasis
Intestinal obstruction
Mesenteric ischemia
Hepatitis
Cardiac
Pancreatic Causes
Alcohol Use – 25-35%
Gallstones – 40-70%
Hypertriglyceridemia 1-14%
Post ERCP
Family History and/or autoimmune diseases
Hypercalcemia
Medication History - < 5%
ACE inhibitors
Diuretics
Azathioprine
Sulfa drugs
Etiology of Acute Pancreatitis: Mechanical
-Gallstones
-Biliary sludge
-ascariasis-roundworm
-periampullary diverticulum
-pancreatic or periampullary cancer
-ampullary stenosis
-duodenal stricture or obstruction
Etiology of Acute Pancreatitis: Toxic
-Ethonal
-methanol
-scorpion venom
-organophosphate poisoning
Etiology of Acute Pancreatitis: Metabolic
-Hyperlipidemia (types I, IV, V)
-Hypercalcemia
Etiology of Acute Pancreatitis: Infection
-Viruses-mumps, coxsacks, hep B, CMV, varicella-zoster, HSV, HIV
-Bacteria-mycoplasma, legionella, leptospira, salmonella
-Fungi-aspergillus
-Parasites-toxoplasma, cryptospordium, ascaris
Etiology of Acute Pancreatitis: Vascular
-Ischemia
-Atheroembolism
-Vasculitis (polyarteritis nodosa, SLE)
Amylase
-Breaks down carbohydrates
-Rises in 6-12 hours after onset of pancreatitis
-Level returns to normal w/in 3-5 days
-Short half life – 10 hours
-May miss acute diagnosis
-Level > 3 times of normal = sensitivity for the diagnosis of acute pancreatitis of 67 to 83 percent and a specificity of 85 to 98 percent
-Rarely use
Can also be elevated in
Renal failure
Renal Stones
Intestinal disease
Parotitis
Salivary disorders
Lipase
-Breaks down fats
-More sensitive and specific to pancreas
-Rises 4-8 hours onset of symptoms
-Peaks at 24 hours
-Normalizes 8-14 days
-More sensitive when compared to amylase for pancreatitis secondary to alcohol
Also elevated in
Renal failure
Acute cholecystitis
Bowel obstruction
Duodenal ulcer
Pancreatic tumors
Type II DM, DKA
HIV
Sarcoidosis
Celiac disease
Diagnostic Criteria for Acute Pancreatitis
Must meet 2/3 criteria
-Epigastric pain
-Elevation in lipase or amylase to 3x or more upper limit of normal
-Imaging findings of acute pancreatitis
No imaging needed if met criteria of epigastric pain and elevation of lipase/amylase labs
Imaging Recommendations for Acute Pancreatitis
Pain not characteristic
Amylase or Lipase < 3x normal
Routine imaging not recommended
Abdominal CT
Abdominal MRI w/ gadolinium if renal failure or contrast allergy
Management of AP
-Fluids (1.5 mL/kg/hour with a 10 mL/kg bolus in patients with hypovolemia)
-Limit fluid resuscitation to first 24-48 hours
-Pain control
-glucose
-treat underlying cause
-nutrition
-ppx abx not recommended
Pancreatitis from Hypertriglyceridemia
-Triglyceride levels > 1000 mg/dL risk factor
-Blood becomes “milky” and break down of free fatty acids by pancreatic lipases causes inflammatory response and injury
-Risk factors: Diabetes, alcohol, hypothyroidism, estrogen, propofol, olanzapine, thiazide diuretics, beta blockers, pregnancy, obesity
-Gemfibrozil 600 mg BID
-Low fat/cholesterol diet & exercise
-Apheresis/Therapeutic Plasma Exchange (TPE)
Pancreatitis from hypercalcemia
Identify and treat underlying causes
-Hyperparathyroidism
-Hyperthyroidism
-Immobility
-Medication induced – lithium, thiazide, theophylline
-CKD
-Multiple myeloma
Pancreatic Pseudocyst
Encapsulated and mature fluid collection with minimal or no necrosis
Well defined wall on imaging
Walled off pancreatic necrosis (WOPN)
Encapsulated collection of necrosis
Imaging contains thick liquid and debris
Consider drainage if symptomatic or greater than 6 cm in size
Pancreatic Insufficiency
Pancreas unable to digest food due to lack of enzymes
–Trypsin and chymotrypsin – digest protein
–Amylase – digest carbohydrates
–Lipase – digest fat
s/s
Steatorrhea
Weight loss
Fatigue
Excessive gas and abdominal distension
Anemia
Pancreatic Diabetes
30-50% of patients with chronic pancreatitis
Annual Hemoglobin A1c and fasting blood glucose for monitoring
Abdominal Compartment Syndrome: pancreatic complication
Intra-abdominal pressure > 20 mmHg with no organ failure
Tissue edema from aggressive hydration, inflammation, ascites, ileus
Serial urinary bladder pressure measurements
Increased abdominal girth
Supportive care
Surgical decompression and open abdomen
Temporary abdominal wall closure
Splenic Vein Thrombosis: Pancreatic Complication
-1-24% in patient with chronic pancreatitis
-Develops secondary to inflammatory process
-May develop gastric varices due to increased portal hypertension
-Asymptomatic presentation is common
-UGI bleed from varices
-+ascites, +splenomeagly
-? anticoagulation