pancreatitis Flashcards
rfs and pfs for acute pancreatitis
- RFs
- Smoking
- High dietary glycemic load Abdominal adiposity
- ↑ Age and obesity
- Increases changes of more severe course
- PFs
- high vegetable/fiber diet
- statins (bar simvastatin which increases it)
Assessment of Severity
- Ranson Criteria
- Sequential Organ Failure Assessment (SOFA)
- Modified Marshall scoring system
- APACHE II
- Bedside Index for Severity in Acute Pancreatitis (BISAP)
- Presence of SIRS (Systemic Inflammatory Response Syndrome) and Elevated BUN on admission with a rise in BUN w/in first 24 hours of hospitalization
- Early rise in serum levels of neutrophil gelatinase-associated lipocalin has been proposed as a marker of severe acute pancreatitis
- HAPS (“Harmless acute pancreatitis score”)
- Revised Atlanta classification (Mild, Moderate, Severe)
- CT Grade of Severity Index for Acute Pancreatitis
ranson criteria and apache II score
ranson: 1-2 (1% mortality); 3-4 (16% m); 5-6 (40%); 7-8 (100%)
physiological score + age + chronic health points = APACHE II score
RISK Factors for Severe Acute Pancreatitis with high levels of fluid accumulation
Younger age
Alcohol etiology
Higher hematocrit value
Higher serum glucose w/in 48 hrs of hospital admission
SIRS w/in 48 hrs of hospital admission
which criteria predicts a severe course complicated by necrosis, and what value corresponds to this in the criteria?
3 or more aspects of the criteria, ranson criteria, 60-80 sensitivity
Revised Atlanta Criteria
mild AP: no oran failure, no complications
moderate AP: transient organ failure < 48 hrs with +/- complications
severe: organ failure lasting longer than 48 hrs +
Tx of Mild Acute Pancreatitis
80% resolve without complications
Lots of fluids: 1/3 of a 72 hr fluid administration needs to be delivered to the patient in the first 24 hours of their presentation.
Let the pancreas rest: NPO, bed rest, NG suction for the ileus
Fluid administration prevents SIRS (systemic inflammatory response syndrome) but may induce ARDS (acute respiratory distress)
opioids for pain; when pain relieved, begin oral administration of food/liq
tx of severe pancreatitis
FFP for coagulopathy
Serum Albumin infusions to restore albumin
calcium glucoronate for hypocalcemia with tetany
I GET SMASHED
Idiopathic
Gallstone obstruction
Ethanol abuse
Trauma
Steroid abuse
Mumps
Autoimmune disorders
Scorpoion sting
Endoscopic Retrograde Colangiopancreatography (ERCP)
Hypertriglyceridemia/Hypercalcemia
SAPE
sentinel Acute Pancreatitis Event
hypothesis that a single initiating event damages the pancreas and leads to later chronic pancreatitis via necrosis-fibrosis
Labs for acute pancreatitis
increased serum amylase and lipase: normal doesnt exclude diagonosis
increased total bilirubin (direct) and alkaline phosphatase (if pancreas is compressing the bile duct): normal does not exclude diagnosis
vitamin deficiencies but uncomplicated (too fast)
glycosuria
autoimmune condition pancreatitis: IgG4/ANC/Ab-carbonic anhydrase II and lactoferrin/
Shows lymphoplasmacytic inflammatory infiltrate with characteristic IgG4 immunostaining
Autoimmune pancreatitis
Elevated IgG4
Elevated ANA
Ab to lactoferrin and carbonic anhydrase II
Pancreatic biopsy
Panceatic function tests
- Trypsinogen
- level is low in insufficiency (<20 ng/ml) causes steatorrhea
- Fecal elastase
- low in insufficiency (<100 mcg/gram stool)
- Pancreatic malabsorption
- when enzyme secretion is <5-10% takes >5 years
- Stimulation tests
- Cholecystokinin/secretin
Imaging in Pancreatitis
X-ray: calcifications
CT: more detailed calcifications, plus ductal dilations, atrophy or heterogeneity of the gland. “tumfactive chronic pancreatitis”- concern for pancreatic cancer
ERCP: most detailed for calcifications, ductal dilations, stones, strictures, pseudocyst. Rarely used alone for diagnosis. Results may be normal with minimal change chronic pancreatitis.
MRCP:
Can enhance imaging with secretin
- diffuse enlargement of the pancreas, a peripheral rim of hypoattenuation, and irregular narrowing of the main PD (autoimmune)
- Lobularity with honey-combing of pancreatic parenchyma
- Hyperechoic foci with shadowing indicative of calculi in main pancreatic duct (PD)
the three components of the “Rosemont criteria” observed with EUS
complications of acute pancreatitis
- Opioid addiction
- Brittle diabetes mellitus
- Pancreatic pseudocyst or abscess
- Cholestatic liver enzymes +/- jaundice Bile duct stricture
- Pancreatic insufficiency
- Steatorrhea
- Malnutrition Osteoporosis
- Peptic ulcer
- Pancreatic CA
- 4% after 20 years
- ↑ to 19% by age 70
Pancreatic insufficiency
- Exocrine
- Confirmed by response to therapy with pancreatic enzyme supplements
- Secretin stimulation test
- Detection of decreased fecal chymotrypsin
- Decreased Pancreatic fecal elastase (<100mcg/gram)
-
40% have B12 malabsorption detected through labs
- Don’t see it as clinical deficiency though
- Don’t see clinical deficiency of fat soluble vitamins either
- Endocrine
- 80% develop DM after 25 years of chronic pancreatitis
complications of pancreatic insufficiency
- Low fat diet
- Alcohol is forbidden
- Precipitates attacks Avoid opioids if possible
- Use acetaminophen, NSAIDs, tramadol, + tricyclic antidepressants, SSRIs, gabapentin or pregabalin
- Steatorrhea
- Pancreatic supplements with high lipase activity
- Use H2 blocker, PPI, or sodium bicarb
- Patient’s with CF Chronic Pancreatitis
- High dose pancreatic enzyme therapy has been associated with strictures of the ascending colon
- Treat associated diabetes mellitus
- Autoimmune Chronic Pancreatitis
- Corticosteroids, taper after a few months
- Rituximab or azathioprine if having no response or relapse with corticosteroids
- Endoscopic or surgical therapy (stent, dilation, lithotripsy, surgical drainage or resection)
- if biliary tract disease ensure free flow of bile, drain pseudocysts, treat other complications, eliminate obstruction of PD, relieve pain, exclude pancreatic CA
cystif fibrosis and pancreatitis
pancreatic insufficiency is the most common effect of CF on children.
newborns with CFTR mutation often suffer meconium ileus
pancreatic insufficiency: complications and mortality issues
- Chronic pain
- Often leads to disability and reduced life expectancy
- Pancreatic CA is main cause of death
- Better in patients with etiology from a remediable condition or autoimmune hepatitis.
MEN Type 1
- Two or more of the following:
- Parathyroid
- Hypercalcemia, ↑intact PTH
- Pancreas
- Gastrinoma aka Zollinger Ellison
- MC in duodenum, then pancreas
- Insulinoma- hypoglycemia
- Gastrinoma aka Zollinger Ellison
- Pituitary
- (possible, acromegaly, Cushing)
- Thyroid (less often)
- Adrenal (less often)
- Carcinoid (Rare)
- Parathyroid
MEN Type 2A
- Two or Three of the following:
- Thyroid (Medullary Thyroid CA)
- Elevated calcitonin ( low calcium)
- Adrenal (Pheochromocytoma)
- Elevated catecholamines
- Parathyroid
- Hypercalcemia, ↑intact PTH
- These patient’s may have normal Ca due to thyroid and parathyroid canceling each other out.
- Thyroid (Medullary Thyroid CA)
- Two to five percent will develop Hirschsprung disease
MEN Type 2B
- MEN Type 2B
- Marfanoid body habitus Medullary thyroid cancer
- Elevated calcitonin Pheochromocytomas
- Elevated catecholamines Neuromas
- Occur on lips, tongue, mouth, eyelids, etx. Frequently a new gene mutation
- No family history
