Pancreatitis: Acute and Chronic Flashcards
AP is _____
inflammation of the pancrea
the leading cause of ER visits and hospitalizations for GI diseases in the US
pancreatitis
3 strategies to increase positive outcomes for AP patients
diagnose rapidly, fluid initiate within 12 hours and nutrition within 24 hours, follow up
__% of AP cases are severe
20
most common cause of pancreatitis
gallstones
second most leading cause of AP
alcohol consumption
third most leading cause of AP
hypertriglyceridemia
pathogenesis of AP
obstruction of common duct, ampulla of vater–> bile refluxed back into pancreas and damages acini. pancreatic secretions accumulate in the pancreas, proteolytic enzymes are activated= initiate AP.
what indicates that gallstones/sludge were the cause of AP
cholecystetomy or removal of gallbadder with subsequent recovery
how high are triglycerides to cause AP
> 1000 mg/dL
what are some more rare causes of AP
ERCP, some drugs
classification: mild AP
inflammation, edema of pancreas. peripancreatic fluid collections, pancreatic fluid collections. no organ failure, no systemic complications. recover in 3-7 days
classification: moderately severe AP
necrosis, inflammation, edema, fluid collections, transient organ failure <48 hours
classification: severe AP
necrosis, persistent organ failure, 20% mortality
_____ increases the severity of AP
infection of the pancreas and peripancreatic collections (fluid and necrotic tissue)
______ is death of cells & tissues associated with moderate and severe AP
necrosis
what 2 things contribute to organ failure with AP?
the pancreatic enzymes are activated in the pancreas and damage the surrounding tissue, they can leak into the circulation and damage other organs thus leading to organ failure. also: the immune response, systemic inflammatory response syndrome (SIRS)
diagnostic marker for severe AP
C reactive protein, CRP > 150 at 48 hours: indicates systemic disease.
symptoms of AP
severe pain, acute onset, epigastric, may radiate to the back. nausea, vomiting, fever
AP physical exam indications
abdominal distention
history to gather for AP
past hx of AP (pt and fam), identify possible cause, gallstone disease, alcohol use, medications, etc
if the fluid collection is still there at 4 weeks it is called
pseudocyst
when the fluid collections include necrotic tissue at 4 weeks they are called
walled off necrosis
if the necrotic collection becomes infected, they are called
infected walled off necrosis
there is an increase in mortality associated with infected necrotic collections and ____ are necessary
antibiotics (fluoroquinolones)
systemic complications of AP
organ failure (transient or persistent), cardiovascular: hypovolemia, hypotension from fluid loss
most important laboratory tests for AP
elevation of serum amylase and lipase 3x ULN or greater
longer half life: amylase or lipase?
lipase: so it remains elevated for a longer time 8-14 days. whereas amylase has shorter half life and returns to normal in 3-5 days
what findings are suggestive of gallstone disease
liver tests, direct bilirubin, and alkaline phosphatase
why is fluid loss such an important problem
it means a loss of blood volume, leads to hypoperfusion or organs–> damages them.
symptoms of fluid loss
decreased BP, increased HR, decreased urine output, increased hematocrit and BUN
imaging for diagnosis
ultrasound if suspecting gallstones. CT and MRI to detect necrosis after 3 days if patient does not improve/gets worse.
2/3 things for diagnosis of AP
characteristic pain, elevated amylase/lipase 3x ULN, positive imagine results
3 treatment goals for AP
early fluid resuscitation, early initiation of nutrition (lowers mortality, prevents progression), relieve pain
guidelines for fluid resuscitation
initiate within 12 hrs: lactated ringers or normal saline. monitor vitals, BUN elevated at 24 hours is a sign of increased mortality
how does early nutrition help
counteracts the catabolic state, prevents damage to organs such as mucosal lining of intestines, reduces morbidity and mortality
nutrition for mild AP
low fat soft/solid oral diet as early as 12h after diagnosis if it does not exacerbate pain.
removal of the gallbladder is carried out as early as _____ if this is the cause
24-48h after diagnosis (before they leave the hospital)
nutrition for moderately severe or severe AP
initiated about 24h after diagnosis and admission. oral if tolerated, enteral thru nasogastric or nasojejunal if not.
what if there are contraindications for enteral feeding
parenteral can be initiated
drugs for pain
opioids: IV LD, continuous IV, PCA. fentanyl is more potent and given in mcg (others are mg)
why is meperidine not first line
because possible accumulation of its metabolite normeperidine has CNS effects/seizures
prophylactic antibiotics?
not usually. can be initiated if infection is suspected. if infection is not confirmed then drug would be discontinued.
what is chronic pancreatitis
progressive inflammation with structural and functional loss (permanent) of both endocrine and exocrine functions
major cause of chronic pancreatitis
alcohol abuse
other factors that increase the risk of CP
cigarette smoking, hereditary, obstruction of pancreatic ducts, previous AP episodes
pathogenesis of chronic pancreatitis
chronic inflammation and damage to acinar cells, islets, duct cells–> permanent structural/functional losses. lost cells replaced by fibrous material. calcified pancreatic proteins block or damage ducts, inflammation, activation of enzymes
CP increases the risk of _____
pancreatic cancer
diagnosis of CP: pain?
usually not as severe as AP. in epigastric area, can be intermittent or chronic episodic flare-ups. can radiate to the back. nausea and vomiting common
diagnosis of CP: malnutrition?
loss of exocrine function= malabsorption of nutrients leading to malnutrition and weight loss (because loss of enzymes for digestion of the 3 major foods, digestion must occur before absorption of nutrients). loss of lipase: malabsorption of fats, fat soluble vitamins
diagnosis of CP: endocrine function?
loss of endocrine function results in insulin-dependent diabetes mellitus
diagnosis of CP: steatorrhea?
lack of lipase: dietary fat eliminated in the feces= steatorrhea
how can you determine steatorrhea
evaluate 72 hour collection for fecal fat or measure elastase in feces (elastase not degraded in intestines)
diagnosis of CP: serum amylase and lipase?
usually normal or below normal: loss of gland tissue is gradual, acinar cells no longer synthesizing and releasing the enzymes
diagnosis of CP?
test of choice is MRCP. may be useful for observing calcified protein deposits that block pancreatic ducts and alcoholic CP
guidelines for selection of a pancreatic enzyme supplement
administered to correct malabsorption (because of insufficient digestion). dosing/choice: focus on achieving nutritional goals.
administration of the enzymes depends on
amount of food, rate of consumption. entire dose may be taken with first bite, or half at the beginning and other half in the middle of the meal
the number associated with the name of the pancreatic enzyme preparation is the amount of _____ units in the preparation
lipase
how to take pancreatic enzyme capsules
can be swallowed whole or opened/sprinkle contents on acidic food such as applesauce. follow consumption with a beverage. do not chew or crush capsules or their contents.
