Pancreatitis & Celiac Disease

Question 1

What are the 2 key concepts in acute pancreatitis tx?

Answer 1

requires early and aggressive intravenous fluid resuscitation

Managed similarly to pts with sepsis

Question 2

What sx are present in an inflammatory episode of acute pancreatitis?

Answer 2

intrapancreatic enzyme activation with pain

nausea and vomiting

intestinal ileus

Question 3

What are the 5 causes of Acute Pancreatitis?

Answer 3

Alcohol

Gallstones (including microlithiasis)

Trauma/surgery

Acute discontinuation of medications for diabetes or hyperlipidemia

Following endoscopic retrograde cholangiopancreatography (ERCP)

Question 4

What meds can cause acute pancreatitis?

Answer 4

ACE, ARBS; thiazide diuretics, furosemide

Antimetabolites (mercaptopurine and azathioprine)

Corticosteroids; glyburide; exenatide (Byetta)

Mesalamine; pentamidine

Sulfamethoxazole/trimethoprim

Valproic acid

HMG-CoA reductase inhibitors, especially simvastatin

Question 5

What are 4 possible mechanisms of drug-induced acute pancreatitis?

Answer 5

direct toxic effects of the drug or its metabolites

hypersensitivity

drug-induced hypertriglyceridemia

alterations of cellular function in the pancreas and pancreatic duct

Question 6

What is the 1st line tx for acute pancreatitis?

Answer 6

Fluid resuscitation: isotonic crystalloid solution— NS or LR

Question 7

Why is fluid resuscitation given in acute pancreatitis?

Answer 7

to reduce the risks of SIRS and organ failure

Question 8

What should you do if vomiting persists past fluid resuscitation in acute pancreatitis?

Answer 8

NPO or NG tube

Question 9

Fluid resuscitation can be ____________ or _________.

Answer 9

Fluid resuscitation can be e__nteral or parenteral.

Question 10

Begin oral alimentation after pain, tenderness, and ileus have resolved: small amounts of high-carbohydrate, low-fat, and low-protein foods; advance as tolerated

What type of pancreatitis is this tx used for?

Answer 10

Acute Pancreatitis

Question 11

What should you advise pts with acute pancreatitis during discharge?

Answer 11

dietary modification to reduce dietary fats, alcohol, and added sugars

Question 12

Long-standing and progressive destruction of pancreatic tissue due to persistent inflammation

Results in exocrine and/or endocrine insufficiency

Which type of pancreatitis?

Answer 12

Chronic Pancreatitis

Question 13

What are the hallmark complications of Chronic Pancreatitis?

Answer 13

chronic pain

malabsorption with resultant steatorrhea

diabetes mellitus

risk of pancreatic cancer

Question 14

What are the primary treatments for malabsorption due to chronic pancreatitis?

Answer 14

pancreatic enzyme supplementation

reduction in dietary fat intake

Question 15

Which drug can cause an increase in sphincter of Oddi pressure?

Answer 15

Morphine

Question 16

Why should you avoid Demerol in tx of acute pancreatitis?

Answer 16

porential of accumulation of a toxic metabolite normeperidine

Question 17

What tx is no longer recommended for acute pancreatitis?

Answer 17

prophylactic abx

Question 18

How do you tx pts with ascending cholangitis or necrotizing pancreatitis?

Answer 18

B-lactam/B-lactamase inhibitor: piperacillin/tazobactam can be considered for initial treatment before cultures (especially of aspirated collections) if a strong suspicion of active infection.

Question 19

What do you tx acute pancreatitis with if pt has cholangitis and pt is allergic to penicillin?

Answer 19

Levofloxacin

Question 20

What should you be vigilant for when giving prophylactic abx in acute pancreatitis?

Answer 20

fungal superinfections

Question 21

What are the tx options for chronic pancreatitis?

Answer 21

enteric-coated pancreatic enzyme supplements

antisecretory agent + pancreatic enzyme supplementation

Question 22

What can you add to enteric-coated pancreatic enzyme supplements to increase the effectiveness of enzyme therapy for malabsorption and steatorrhea found in chronic pancreatitis?

Answer 22

Histamine2-receptor antagonist or proton-pump inhibitor

Question 23

What would adding an antisecretory agent to pancreatic enzyme supplementation help achieve?

Answer 23

may increase the effectiveness of enzyme therapy for malabsorption and steatorrhea

Question 24

What are possible chronic pancreatitis txs?

Answer 24

Analgesics: tramadol, chronic opioid, gabapentin, pregabalin, SNRIs or TCAs, traditional pancreatic enzyme supplements

Uncoated enzymes (Viokase)

Octreotide

Question 25

Uncoated enzymes (Viokase) may be more efficacious for what sx when given with what other medication?

Answer 25

Uncoated enzymes (Viokase) may be more efficacious for pain control (when given with proton pump inhibitors [PPIs] to protect their integrity) compared with coated enzymes, but this strategy is controversial.

Question 26

**T/F:** There is a theoretical benefit to using PPIs, even with coated enzymes, in patients with vitamin deficiency to allow faster release of enzymes into the proximal duodenum where fat-soluble vitamin absorption occurs

Answer 26

True

Question 27

When would you treat pts with corticosteroids?

Answer 27

autoimmune pancreatitis

Question 28

When should you administer pancreatic enzymes?

Answer 28

during or just after meals

Question 29

**T/F:** Products containing enteric-coated microspheres or minimicrospheres may be **less** effective than other dose forms

Answer 29

False; Products containing enteric-coated microspheres or minimicrospheres may be **more** effective than other dose forms

Question 30

Primarily used to treat **malabsorption** associated with **chronic pancreatitis** also used to **treat pain from the disease** **Which drug?**

Answer 30

Pancreatic Enzymes

Question 31

Relief of pain is thought to be due to their **ability to break down CCK** Which drug?

Answer 31

Pancreatic Enzymes

Question 32

**T/F:** the release of CCK, which causes an increase in pancreatic secretion, is **not** inhibited by trypsin

Answer 32

False; the release of CCK, which causes an increase in pancreatic secretion, is inhibited by trypsin

Question 33

Which drugs cause a decrease in the production of trypsin in patients with chronic pancreatitis?

Answer 33

Pancreatic Enzymes

Question 34

Proteases in pancreatic enzymes supplements act as what?

Answer 34

substitutes for endogenous trypsin, leading to a decrease in CCK release

Question 35

Autoimmune condition: Immune-mediated reaction to dietary gluten: found in wheat, barley, rye Affects small intestine Genetically predisposed individuals--Homogenicity for **HLA-DQ2/DQ8** **Which disease is this?**

Answer 35

Celiac Disease

Question 36

Individuals with this disease have a **sensitivity to gliadin fraction in glutens** Which disease?

Answer 36

Celiac Disease

Question 37

What is the pathology of Celiac Disease?

Answer 37

Immunologic **cross-reactivity**, inflammation, and **tissue damage (villous atrophy)** with subsequent malabsorption

Question 38

What does the mnemonic for Celiac Disease stand for?

Answer 38

**C:** Consultation with a skilled dietician **E:** Education about the diease **L:** lifelong adherence to a gluten-free diet **I:** identifying and treating nutritional deficiencies **A:** Access to an advocacy group **C:** Continuous long-term follow-up bu a multidisciplinary team

Question 39

Which 4 things are overlooked as sources of gluten?

Answer 39

1. oral prescription drugs 2. nonprescription drugs 3. vitamin and mineral supplements 4. health and beauty aids and cosmetics

Question 40

What is the main tx for Celiac Disease?

Answer 40

remove gluten from the diet

Question 41

What are safe and palatable substitutes for gluten?

Answer 41

Rice, corn, soybean flour Grains: uncontaminated oats, rice, corn, tapioca, quinoa, amaranth, sorghum

Question 42

What should the oat limit be if you have Celiac disease?

Answer 42

50-60g a day

Question 43

Levels of _________ normalize with gluten abstinence

Answer 43

IgA antigliadin

Question 44

What 5 medications would you use for refractory disease-case reports of Celiac disease?

Answer 44

Steroids Azathioprine Cyclosporine Tacrolimus Infliximab, alemtuzumab

Question 45

Nutritional deficiencies of what require supplementation?

Answer 45

vitamins (A, D, E, B12) calcium carotene copper zinc folic acid ferritin iron

Question 46

**T/F:** Pneumococcal vaccination: celiac disease is associated with hyposplenism

Answer 46

True