Pancreatitis Flashcards
What are the most common causes of acute pancreatitis?
obstructive causes, esp. gallstones (45%)
toxins, especially EtOH
smoking increases the risk
Describe the pathogenesis of acute pancreatitis.
granules filled with digestive enzymes are released into the interstitial space, usually triggered by obstruction or toxin
release of enzymes leads to inflammation
What is the classic presentation of acute acute pancreatitis?
epigastric pain that radiates to the back, often with vomitting
increase of 3x normal amylase along with edema around the pancreas on CT can confirm pancreatitis (early imaging can be normal
lipase is more sensitive than amylase and it stays elevated longer (levels do not correlate with severity)
What labs may cause you consider gallstone over EtOH etiology of acute pancreatitis?
higher ALT is specific for gallstones, if the bile duct is obstructed you get inflammation of the liver, also causing increase in bilirubin levels
Which lab values are the most useful in discussing patients prognosis.
score systems take into account HCT and creatinine; remember increase in HCT can be due to plasma leakage into 3rd space due to damage to vessels
increased HCT is a horrible prognostic sign and increasing creatinine usually means kidney failure
Give 2 examples of hemorrhagic complications of acute pancreatitis.
Grey-Turner’s sign (ecchymosis on patients side)
Cullen’s Sign (periubilical ecchymosis)
due to erosion into the vascular system
**additional complication: pseudocyst obstruction, can be addressed with shunt to stomach
What is the primary treatment of acute pancreatitis?
lots of IV fluids: 250-400cc/hr (there is a lot of third spacing in acute pancreatitis)
also consider enteral nutrition (decrease other complications if addressed) and possible prophylactic antibiotics
if due to obstruction- ECRP is important to remove gall stones
Describe the pathophysiology of chronic pancreatitis?
toxins lead to pancreatic juice rich and high viscous protein, precipitation of protein plugs in small ductules (inflammation and calcification)
progressive fibrosis leads to exocrine and endocrine insufficiency, chronic inflammation causes increased inter ductal pressure, and noxious stimulation of nerves
this leads to considerable heterogeneity in presentation and natural history
What is the presentation of chronic pancreatitis?
asymptomatic, pain, nausea and vomiting, labs can often be normal
pain: worse with food
malabsorption when 80%+ glands destroyed
diabetes when <10% normal exocrine function
What is the most common cause of chronic pancreatitis?
chronic alcoholism accounts for 70% of cases, prolonged and substantial abuse is generally required
chronic obstruction by tumors, trauma, pseudocyst, inflammation and fibrosis, papilla stenosis; hyperlipidemia, CF
What types of imaging can be used to confirm chronic pancreatitis?
abdominal x-ray can pick up 30% with calcifications
ultrasound picks up dilation of ducts, calcifications and changes in pancreatic parenchyma
ERCP is not often used, although it is sensitive,
endoscopic ultrasound is also effective, best imaging for looking at pancreatic tissue
What are complications of chronic pancreatitis?
pseudocyst bile duct obstruction splenic vein thrombosis pseudoaneurysms pancreatic cancer
What are the aims of treating chronic pancreatitis treatment?
pain management (narcotics)
correction of pancreatic insufficiency: enzyme replacement (lipase, amylase, protease), vitamin supplement, medium chain triglycerides
complication management
lifestyle treatments: decrease alcohol and tobacco use, small low fat meals and hydration
Describe some specialized chronic pancreatitis treatment.
endoscopy to admin celiac plexus block
surgery to dilated main pancreatic duct
ESWL- breaking down gallstones
