Pancreatitis

Question 1

elevated lipase with abdominal fullness after resolved attack of acute pancreatitis

Answer 1

pancreatic pseudocyst

Question 2

Pancreatic pseudocysts happen when

Answer 2

4-6 wks post acute pancreatitis

seen more in alcoholic than non alcoholic pancreatitis

Question 3

Symptoms of pancreatic pseudocyst

Answer 3

asymptomatic or abdominal pain and fullness

Question 4

Complications of pancreatic pseudocyst

Answer 4

infected pseudocyst (see fever)
pseudocyst can swell and result in gastric outlet or biliary obstruction, vascular occlusion)
can have fistula formation to adjacent viscera

Question 5

Lipase level trend in pancreatitis

Answer 5

increases 4-8 hrs after pancreatitis
peaks at 24 hrs
returns to normal in 8-14 days

Question 6

Follow lipase levels??

Answer 6

no not in acute pancreatitis. Persistent levels can show pancreatic duct blockage or pseudocyst in sympotmatic patients

Question 7

Diagnosis of pancreatic pseudocyst

Answer 7

CT scan - thick walled, rounded fluid filled mass adjacent to pancreas

Question 8

Treatment of pancreatic pseudocyst

Answer 8

resolve spontaneously and asymptomatic cysts do not need intervention

regardless of size.

Only treat if they are causing significant symptoms

Question 9

When to treat pancreatic pseudocyst

Answer 9

When complicated with infection, or if causing duodenal or biliary obstruction (drain percutaneously, surgically, or endoscopically)

Question 10

chronic pancreatitis symptoms

Answer 10

abdominal pain or pancreatic insufficiency (steatorrhea, malabsorption, diabetes

Question 11

is lipase elevated in chronic pancreatitis

Answer 11

no. it’s fibrosed or only mildy elevated.

Question 12

acute pancreatitis presentation

Answer 12

abdominal pain radiation through back, nasuea, vomiting, unexplained hypotension

Question 13

First line therapy to treat chronic pancreatitis?

Answer 13

stop ETOH and smoking, increase fluid intake, eat small meals with low fat intake.

Need pancreatic enzyme replacement with exocrine insufficiency and helps with pain even if there’s no exocrine insufficiency (fat soluble vitamin deficiency or steatorrhea.)

Question 14

what are you supplementing in chronic pancreatitis?

Answer 14

pancreatic enzyme replacement - by supplying it as a supplement, you suppression of cholecystokinin CCK release by pancreas so it’s not as streased out.

Question 15

How do you treat abdominal pain in patients with chronic pancreatitis

Answer 15

non opioid pain medication as a rule but sometimes will need intermittent opioid medications. but need to rule out pseudocyst formation or PUD prior to starting opiate therapy

TCA can help with pain and are preferred over long term opioids

Question 16

If long term opioids are needed to treat pain related to chronic pancreatitis, which ones are preferred?

Answer 16

MS contin or morphine sulfate or fentanyl due to long duration of action. Only 30% patients responded to placebo in one study so there’s often comorbid psychiatric illness

Question 17

management of triglyceride induced pancreatitis

Answer 17

IVF and pain control
glucose>500 consider insulin infusion
glucose<500 or severe pancreatitis (lactic acidosis and hypocalcemia) consider aphresis (therapeutic plasma exchange)

Question 18

At what range can TG cause pancreatitis?

Answer 18

<500 TG minimal risk
500-999 mild risk
1000-1999 moderate risk
>2000 high risk

other risk factors include pregnancy, ETOH, obesity and uncontrolled DM2

Question 19

management of mild gallstone pancreatitis

Answer 19

supportive care (analgesics, IVF’s)

Question 20

management of moderate gallstone pancreatitis (no common bile duct obstruction)

Answer 20

supportive care

consider endoscopic ultrasound/ MRCP/ERCP if no improvement in 72 hrs

Question 21

management of severe gallstone pancreatitis (with common bile duct obstruction or cholangitis)

Answer 21

ERCP within 24 hrs of admission

Question 22

severe gallstone pancreatitis symptoms

Answer 22

see obstruction, dilated CBD, signs of acute cholangitis

• need urgent (<24hrs) ERCP with sphincterotomy to decrease severity

Question 23

acute cholangitis with gallstone pancreatitis management

Answer 23

analgesics for pancreatitis, IVFs and broad spectrum abx

needs ERCP with schinterotomy (in 24 hrs) to remove obstructed stone

Question 24

pts who have gallstone pancreatitis should eventually have:

Answer 24

cholecystectomy to reduce risk of recurrence

during same hospitalization.

Question 25

if you suspect infected necrotizing pancreatitis what do you do?

Answer 25

Either give empiric antibiotics (carbapenem or floroquinolone + metronidazole)

or get CT guided FNA and if sterile necrosis give supportive care and if infective necrosis give tailored antibiotics

ultimately if doesn’t improve, needs surgical debridement. (called necrosectomy)

Question 26

how often does infected necrosis of pancreas occur in necrotizing pancreatitis?

Answer 26

in 1/3 of pts who have severe necrotizing pancreatitis.

They do not improve or deteriorate clinically after a week of hospitalization for pancreatitis

Question 27

how to treat infected necrotizing pancreatitis

Answer 27

tx with abx
carbapenem or floroquinolone + metronidazole

or get CT guided aspiration with Gram stain and culture

Question 28

non pancreatic causes of elevated lipase:

Answer 28

of non pancreatic elevations for lipase are renal insufficiency, DKA, and SBO or ileus.

can be mildly elevated.

Question 29

chronic pancreatitis complication

Answer 29

can have splenic vein thrombosis from chronic pancreatic inflammation

Question 30

when to get ERCP for suspected gallstone pancreatitis

Answer 30

only do ERCP if there’s

• choledolithiasis on imaging studies
• persistently elevated liver chemistries

Question 31

four types of pancreatic fluid collections related to acute pancreatitis

Answer 31

1. acute peri-pancreatic fluid collections - seen within first 4 weeks and no signs of necrosis. result from rupture of main or side branch ducts as a result of inflammation. these resolve spontaneously.
2. pancreatic pseudocysts- acute peri-pancreatic fluid collections that persist >4 weeks and develop into well defined walls and contain no solid debris (necrosis)
3. acute necrotic collections - areas of necrosis in the pancreatic parenchyma and or peripancreatic tissues in the first 4 weeks of acute pancreatitis
4. walled off necrosis - occurs after 4 weeks, when body liquifies the necrosis contains it within a well defined wall.

Question 32

initial management of acute pancreatitis

Answer 32

IVF resuscitation with LR (decrease risk for SIRS) at 250-500 ml/hr and most beneficial in 12-24 hrs

Question 33

treatment of walled off necrosis from pancreatitis

Answer 33

can’t be amenable to percutaneous or endoscopic drainage due to solid necortic debris within cavity and may ned endoscopic, radiological or sugrical debridement.

Question 34

mild pancreatitis is defined as

Answer 34

no organ failure or local systemic complications

Question 35

moderate pancreatitis

Answer 35

local or systemic complications such as necrosis or transient organ failure (<48 hrs)

Question 36

severe acute pancreatitis is

Answer 36

SIRS, persistent organ failure (kidney or respiratory) >48 hrs and one or more local complications

mortality rate is as high as 50%

most often it’s respiratory failure and cardiac collapse in <48 hrs.