pancreatitis Flashcards
pancreas
Oblong, glandular GI accessory organ measuring ~6 inches
Performs exocrine and endocrine functions
Head
Widest part of the pancreas
Found nestled in the curve of the duodenum
Divided into:
Head proper
Uncinate process
Neck
Thin section of the gland between the head and the body of the pancreas
Body
Middle part of the pancreas between the neck and the tail
Superior mesenteric artery and vein run behind this region
Tail
Thin tip of the pancreas in the left side of the abdomen, in close proximity to the hilum of the spleen
Acinar cells
exocrine
Cells in clusters located at the terminal ends of pancreatic ducts
Secrete enzyme-rich pancreatic juice into ducts
Major pancreatic ducts:
Pancreatic duct joins the common bile duct just before duodenum (ampulla of Vater)
Accessory duct (duct of Santorini) runs from the pancreas directly into the duodenum superior to the pancreatic duct
Islets of Langerhans (endocrine)
Small islands of cells scattered throughout the pancreas that produce pancreatic polypeptide, insulin, glucagon, and somatostatin
Pancreatitis
general
Inflammation of the pancreas and on occasion, adjacent tissues
Increasing incidence in the United States since 1990
♂>♀
Acute or chronic presentation
Multiple etiologies
Can be life-threatening
pancreatitis
etiology
Gallstones (40%)
Heavy alcohol consumption (30%)
Idiopathic (10-15%)
Surgical procedures of the abdomen
Endoscopic retrograde cholangiopancreatography (ERCP) in ~5% of patients – mechanical obstruction
Hypertriglyceridemia
Causes plasma viscosity which may induce ischemia in the pancreatic tissue
Medication-induced
Autoimmune pancreatitis
Infections
pancreas
Normal function of digestive enzymes
Pancreatic digestive enzymes are released by the acini cells in an inactive form (zymogen) and travel to the duodenum → activated by trypsin
Pancreatitis
patho
Pancreatic enzymes accumulate within the injured acini cells
Intra-acinar activation lead to autodigestive injury of the pancreas itself
Injury leads to activation of the complement system and the inflammatory cascade (cytokines)
Inflammation and edema of the pancreas → necrosis → death
Acute pancreatitis
mild
Inflammation confined to the pancreas and its close vicinity
No organ failure
No local or systemic complications
acute pancreatitis
moderate
Moderate
Local or systemic complications
No organ failure or only transient organ failure (resolves within 48 hours)
acute pancreatitis
severe
One or more local complications
Persistent single or multiorgan failure (>48 hours)
Mortality rate of >30%
pancreatitis
Risk Factors for Severe Disease Course
Initial assessment:
Age ≥60 years
Comorbid health problems
Obesity with BMI >30
Long-term, heavy alcohol use
Presence of systemic inflammatory response syndrome (SIRS)
Elevated BUN- number 1 indicator of high mortality
Altered mental status
pancreatitis
S/Sx
Upper abdomen/epigastric
Severe, steady, boring pain
Radiation through to the back (50%)
Onset:
Sudden → gallstone pancreatitis
Develops over days → alcoholic pancreatitis
↑ pain with coughing, vigorous movements, or deep breathing
Diminished bowl sounds
Nausea and vomiting
Fever 38.4-39°C
Jaundice
Tachycardia
Hypotensive
pancreatitis
PE findings
Patient are ill-appearing; sometimes anxious
Sitting up and/or lean forward to help reduce pain
Scleral icterus/jaundice →choledocholithiasis
Xanthomas→hypertriglyceridemia
Abdomen
Abdominal distension and absent bowel sounds with an associated ileus
Upper abdominal tenderness to palpation
Guarding, rigidity, and rebound tenderness
Hepatomegaly → alcoholic pancreatitis
Palpable mass
Inflamed pancreas
Pseudocyst: collection of leaked pancreatic fluids that forms next to the pancreas
Hemorrhagic pancreatitis
general and PE findings
1% of cases
Indicator of poor prognosis
Presentation:
Grey Turner sign
Ecchymosis of the flanks due to blood in the retroperitoneum
Cullen sign
Ecchymosis of the umbilical region due to blood in the peritoneum
pancreatitis
Dx criteria (3)
Diagnosis is established by the presence of at least 2 of the following:
Abdominal pain consistent with the disease
Serum amylase and/or lipase >3 times the upper limit of normal (within 24 hours of onset)
Characteristic findings on imaging studies (CT or MRI)
NEED CT
pancreatitis
labs
CBC
Leukocytosis (10,000-30,000 mcL)
Lipase and amylase
>3x upper limit of normal within 24 of onset
Return to normal is dependent on the severity of disease
Other labs that may be elevated:
Bilirubin
Alkaline phosphatase
ALT
Lactate dehydrogenase(LDH): ↑ in severe disease
Fasting triglycerides >1000 mg/dL
BUN & creatinine
Activated pancreatic enzymes and cytokines can enter systemic circulation resulting in acute kidney injury (prerenal azotemia)
Sustained elevated BUN correlates with mortality risk
pancreatitis
CT
CT scan of the abdomen and pelvis with contrast
Imaging test of choice to establish the diagnosis and to access for local complications
Repeat CT scan should be performed if the patient deteriorates
Necrosis, fluid collection, pseudocyst
pancreatitis
Ultrasound
Performed if gallstone pancreatitis is suspected (if CT cant find it and suspecting small stone)
pancreatitis
Chest radiograph
and potential findings
Forpatientswith pulmonary symptoms (dyspnea, tachypnea, hypoxia)
Potential findings
Pleural effusions
Diffuse, patchy infiltrates indicatingacute respiratory distress syndrome(ARDS)
pancreatitis
ERCP (endoscopic retrograde cholangiopancreatography)
Diagnostics and therapeutic
Performed to relieve bile duct obstruction
pancreatitis
Treatment – Mild to Moderate Disease
support and meds
Admission to a step-down bed
Supportive measures
Fluid resuscitation
Early, aggressive IV fluids of lactated Ringer’s 250-500 mL/hour for the first 12-24 hours
Modifications will need to be made based on underlying renal or cardiovascular comorbidities
How to measure fluid adequacy?
Improvement of BUN levels, improvement of vital signs, maintaining adequate urine output
Analgesics
IV opioids (hydromorphone 1.0mg or fentanyl 70mcg)
Antiemetics
Given as needed for nausea and vomiting
Nutritional support
Early enteral nutrition as soon as it can be tolerated
Clear liquids → oral low-residue, low-fat, soft diet
Prophylactic antibiotics are not recommended in patients with acute pancreatitis, regardless of disease severity
pancreatitis
Treatment – Moderate to Severe Disease
ICU admission
Same supportive measures on the previous slide
IV antibiotics
Used for the development of extrapancreatic infection (pneumonia, cholangitis, UTI)
pancreatitis
Sign of deterioration
Fever
↑ WBC count
Failure to improve after 7-10 days of hospitalization
Most common organisms are gram-negative bacteria
pancreatitis
Surgery
All cases of severe acute pancreatitis should receive a surgical consult
Necrosectomy
Removal of infected tissue
Cholecystectomy
Performed prior to discharge for patients with gallstone pancreatitis who spontaneously improve
Percutaneous, surgical, or endoscopic ultrasound-guided cystogastrostomy
Performed for a pseudocyst that is expanding, infected, bleeding, or at risk for rupture
KEY POINTS of acute pancreatits
There are many causes of acute pancreatitis, but the most common are gallstones and alcohol intake
Inflammation is confined to the pancreas in mild cases, but, with increasing severity, a severe systemic inflammatory response may develop, resulting in single or multiorgan failure
Once pancreatitis is diagnosed, assess risk using clinical criteria and scoring systems to triage appropriate patients to more intensive care and aggressive therapy and to help estimate prognosis
Treatment includes IV fluid resuscitation, pain control, and nutritional support
Complications, including pseudocyst and infected pancreatic necrosis, need to be identified and treated appropriately (drainage of pseudocyst, necrosectomy)
Chronic Pancreatitis
general
Persistent inflammation of the pancreas
Results
Permanent structural damage with fibrosis and ductal strictures
Decline in exocrine and endocrine function (pancreatic insufficiency)–> diabetes
chronic pancreatitis
Etiology
Heavy alcohol consumption (50%)
Pancreatic duct obstruction
Cigarette smoking
Dose-dependent risk factor
Additive risk when combined with alcohol consumption
chronic pancreatitis
Complications
Malabsorption
Occurs when lipase and protease secretions are reduced to 10% of normal
Fat malabsorption
Vitamin A, D, E, and K deficiencies
Glucose intolerance → overt diabetes mellitus (type 3c diabetes)
Formation of pseudocysts
Development of pancreatic adenocarcinoma
pancreatitis
chronic pancreatitis
S/Sx
Abdominal pain:
Epigastric region
Postprandial
Initially episodic (after meals) → continuous
Nausea and vomiting
Malabsorption without pain (10-15%)
Abdominal distention
Steatorrhea: oily, foul-smelling stools
Flatulence
Weight loss
Fatigue
Chronic pancreatitis
Dx and labs
Diagnosis is highly dependent on clinical assessment, imaging studies, and
pancreatic function tests
Lipase and amylase
Slightly elevated or normal…Why?- due to ongoing damage
Pancreatic function tests
Can detect early disease, but are expensive and invasive
high ETOH use
chronic pancreatitis
imaging studies
CT scan of the abdomen and pelvis with contrast
Exclude pancreatic cancer as a cause of pain
Detect pancreatic abnormalities
Magnetic resonance imaging with cholangiopancreatography (MRCP)
Indicated when CT findings are equivocal
chronic pancreatitis
lifestyle changes and management
Directed by a multidisciplinary team that includesgastroenterologists, surgeons (pseudocysts), endocrinologists, dieticians, and pain management specialists
Includes:
Smoking cessation
Avoidance of alcohol
Low-fat diet
Pain control – most challenging
Pancreatic enzyme supplements
Management of diabetes - insulin
Management of other complications
pancreatitis
Which of the following is the most common cause of acute pancreatitis?
A. Viral infection
B. Gallstones
C. Alcoholism
D. Smoking
B
High-pitched peristalsis or borborygmiin a patient with acute abdominal pain and distention suggests which of the following?
A. Peritonitis
B. Biliary colic
C. Bowel obstruction
D. Acute pancreatitis
C
Which of the follow elevated labs correlates most closely with increased mortality in acute pancreatitis?
A. Alkaline phosphatase
B. Lipase
C. Creatinine
D. BUN
D
