Pancreatitis Flashcards
What drugs affect the pancreas?
Cipro
APAP
Meropenem
Opioids
Somatostatin Tramadol Octreotide Metronidazole Pancreatic enzymes
What drugs have endocrine functions?
Insulin (beta-cells)
Glucagon (alpha-cells)
Somatostatin
What drugs have exocrine function?
Secretion of isotonic fluid
Bicarbonate (to neutralize acid)
Pancreatic enzymes to neutralize food)
Pancreatic enzymes?
Proteolytic Amylolytic Lipolytic Nucleolytic Miscellaneous
Pancreatic enzymes: proteolytic
Trypsinogen
Chymotrypsinogen
Pancreatic enzymes: Amylolytic
Amylase
Pancreatic enzymes: Lipolytic
Lipase
Phospholipase A2
Carboxylesterase lipase
Pancreatic enzymes: Nucleolytic
Ribonuclease
Pancreatic enzymes: miscellaneous
Trypsin inhibitor
Normal sequence of events for pancreatic stimulation
Cephalic (when you are hungry)
Gastric (starts to ramp up and pump out fluid)
Intestinal
What enzymes are secreted in the intestine?
Secretin
Cholecystokinin
Where are zymogens activated?
Duodenum
What enzyme activates other enzymes?
Trypsin
What is the primary cause of acute pancreatitis?
Gall stones
What toxins cause acute pancreatitis?
Alcohol
What are the causes of acute pancreatitis?
Structural Toxins Infectious Metabolic Medication Trauma Vascular
Metabolic causes of acute pancreatitis?
Genetic hypertriglyceridemia
What medications can cause acute pancreatitics
Valproic acid
GLP-1 agonists
Sulfonamides
DPP4 inhibitors
What clinical presentations is in 100% of patients with acute pancreatitis?
Abdominal pain
What are the clinical presentations of acute pancreatitis?
Ab pain
Nausea +/- vomiting
Ab distention
Fever
Hypotension
Pancreatic inflammation and/or necrosis, increased CRP
Leukocytosis, hyperglycemia, hypoalbuminemia, hyperbilirubinemia
Elevated alkaline phosphatase and liver transaminases
Dehydration
Hypocalcemia
What are the options for imaging for acute pancreatitis?
Ab Xray Ab ultrasound CT ERCP EUS
How is acute pancreatitis diagnosed?
Characteristic ab pain
Serum amylase and/or lipase >/= 3 times ULN
Imaging if needed
What are the principles for the severity and risk prediction of mild acute pancreatitis?
No organ failure
No complications
What are the principles for the severity and risk prediction of moderately severe acute pancreatitis?
Local complications AND/OR transient organ failure
What are the principles for the severity and risk prediction of severe acute pancreatitis?
Persistent organ failure
What are the complications of acute pancreatitis?
Pancreatic ascites Pseudocyst Abscess Necrosis Systemic complications
What are pancreatic ascites?
Pancreatic secretions spread throughout peritoneal cavity
What are pseudocysts?
Collecting of pancreatic juice enclosed by a wall of fibrous tissue
What causes pseudocysts?
Pancreatic juice persistently leaking from the pancreatic duct
What causes pancreatic ascites?
Increased permeability d/t inflammation
What causes abscesses in acute pancreatitis?
Follows infection of pancreatic or peripancreatic necrosis
What defines necrosis in acute pancreatitis?
Presence of 1+ diffuse or focal areas of nonviable pancreatic parenchyma may be sterile or infected
What are systemic complications of acute pancreatitis?
CV, renal, pulmonary
What are the causes of systemic complications in acute pancreatitis?
Hypovolemia
Hypotension
What are the supportive care treatments for ALL patients with acute pancreatitis?
Fluid resuscitation
Nutrition
Pain control
Antiemetics
What is used in fluid resuscitation of acute pancreatitis?
Lactated ringers or NS
Correct intra-vascular volume depletion
What is nutrition used for in acute pancreatitis?
Enteral over parenteral
Beginning within 48 hours shows benefit
How is pain controlled in pancreatitis?
IV/PCA
Continued until able to tolerate PO
Morphine (not in AKI), Dilaudid, fentanyl
What are additional cares for moderately severe and severe acute pancreatitis?
Supportive care for end organ damage
Surgical care for local complications, if minimal/no improvement
Judicious use of abx and antisecretory agents, as appropriate
What abx are used in acute pancreatitis?
Ceph
Quinalones + Flagyl
Carbapenems
Why are abx used in acute pancreatitis?
May decrease complications in necrotic pancreatitis
Prophylactic abx not warranted
Spectrum should include GI pathogens
What antisecretory agents are used in acute pancreatitis?
Octreotide
Somatostatin
What is the use of antisecretory agents in acute pancreatitis?
May inhibit pancreatic secretions
Insufficient data to support use in all patients
Routine use not in guidelines
What is the pathophysiology of acute pancreatitis?
Inflammation that leads to cellular necrosis and fibrosis
Protein plug formation that blocks interlobular and intralobular ducts
Progressive structural damage in ducts and tissues
What is the cause of the formation of a protein plug?
D/t high protein, low bicarbonate secretion
What is the clinical presentation of chronic pancreatitis?
Chronic ab pain (typically post prandial and associated with N/V)
Recurrent episodes of acute pancreatitis
Exocrine malfunction
Endocrine malfunction
What are the results of exocrine malfunction?
Steatorrhea
Malabsorption
Vitamin deficiency (ADEK, B12)
What are the results of endocrine malfunction?
Diabetes
How do we diagnose chronic pancreatitis?
Amylase and lipase are nonspecific for chronic pancreatitis
Ab CT/MRCP are sensitive but not specific for diagnosis
Fecal fat and fecal elastase 1 concentrations may be helpful
What are ways to manage pain in chronic pancreatitis?
Lifestyle modifications
What are the lifestyle modifications for chronic pancreatitis pain management?
Alcohol and smoking cessation correlate with a reduction in pain
Smaller meals, low-fat diet or elemental diets reduce pain and enzyme secretion
What are the options for chronic pancreatitis analgesia?
Antioxidants APAP NSAIDs Adjunct therapies Opioids
How are antioxidants used in chronic pancreatitis pain management?
Might be efficacious if used in combination with lifestyle medications
What concerns are there for APAP in chronic pancreatitis pain management?
With continued alcohol risk
What concerns are there for NSAIDs in chronic pancreatitis pain management?
Risk for GI bleeding
Which adjunct therapies in chronic pancreatitis pain management shows the most promise?
Pregabalin
What concerns are there for opioids in chronic pancreatitis pain management?
Development of dependence and tolerability. Opioid related ADR
How should pancreatic enzyme replacement therapy tablets be taken?
Give with acid suppression agent to increase efficacy
Take with food
How should pancreatic enzyme replacement therapy enteric coated be taken?
Microspheres can be administered with tube feedings
