Pancreatitis (exam 3) Flashcards
in pancreatitis, there is a premature activation of _________________ within the pancreas leading to activation of other digestive enzymes and _________________ of the gland
trypsinogen to trypsin
autodigestion
systemic inflammatory syndrome
shock/organ failure
when there is a release of cytokines form T cells, there is an enhance in the inflammatory response, leading to
damage to tissue, edema/necrosis, hemorrhage, pseudocyst, and abscess
defining features of SIRS
temperature over 38.3C or under 36C
HR over 90 beats/min
RR over 20 breaths/min or PaCO2 under 32 mmHg
WBC count over 12,000 cells/mm3, under 4000 cells/mm3, or over 10% immature forms
two categories of acute pancreatitis
without recognizable tissue necrosis
necrosis
mild acute pancreatitis
no organ failure or local/systemic complications
moderately severe acute pancreatitis
transient organ failure and/or local/systemic complications without persistent organ failure
lasts under 48 hrs
severe acute pancreatitis
persistent organ failure that may involve one or more organs
acute pancreatitis etiology
gall stones
ethanol
trauma
steroid use
mumps, mycoplasma, coxsakiae, malignancy
autoimmune
scorpion bite
hypertriglyceridemia
ERCP
Drugs
signs and symptoms of acute pancreatitis
abdominal pain
N/V
low grade fever
abdominal distention
pain radiating to back
tachycardia/mild hypotension
mental aberrations
jaundice
what test is most sensitive for acute pancreatitis?
serum lipase
when the serum lipase value is _________________ times the normal range, they are considered positive for acute pancreatitis
3-10
contrast enhanced computed tomography
determines the severity of the inflammatory process
estimate of risk for systemic and local complications
magnetic resonance cholangiopancreatography
non invasive
delineating the bile and pancreatic ducts, gallbladder and liver better than CT
endoscopic retrograde cholangiopancreatography
more invasive
used for biliary tract and pancreatic diseases
tissue sampling suspicion of malignancy
diagnostic criteria for acute pancreatits
two out of three of the following:
upper abdominal pain
3x or more elevation of pancreatic values in the blood
inflammation of the gland on CT scan
Ranson’s criteria
used to determine severity
can predict mortality
supportive care for acute pancreatitis
fluid resuscitation with normal saline or lactated ringers
pain control
nutritional support
_____________ can be given for nausea in acute pancreatits
IV antiemetics (ondansetron, prochlorperazine, promethazine)
Nutritional support should begin when
it is anticipated that oral nutrition will be held for longer than 5 days
what is preferred as the method for giving nutrition in severe acute pancreatitis
enteral feeding via nasogastric or nasojejunal tube
what are given for pain control in acute pancreatitis?
opioids
________________ fell out of favor as the opioid of choice for pain control in acute pancreatitis because
mepiridine
neuromuscular side effects and seizures from accumulation of metabolite normeperidine
are prophylactic antibiotics recommended in patients with acute pancreatitis?
no
patients with known or suspected infected acute pancreatitis should receive
broad spectrum antibiotics
mild pancreatitis treatment
initiate oral food when pain is decreasing and lab values improve
moderate pancreatitis treatment
assess need for ICU admission
treat systemic complications
gradually advance oral diet
severe pancreatitis treatment
ICU admission required
treat systemic complications
enteral tube feeding
when there is no improvement in severe pancreatitis after treatment,
rule out infected pancreatic necrosis or an extra pancreatic infection
and treat with antibiotics if infected
when a patient comes in with acute pancreatitis, what should be done?
screen for SIRS
replace fluids and correct electrolytes
treat metabolic abnormalities
control pain
assess medication as potential factors
consider _____________ if cholangitis or biliary pancreatitis with common bile duct obstruction
MRCP or ERCP
drug induced pancreatitis is classified based on
the number of cases reported
time from initiation of drug to development of pancreatitis
reactions with rechallenge
chronic pancreatitis
irreversible structural and functional loss of pancreatic function
chronic pancreatitis is caused by
long standing inflammation and repeated injury
repeated injury results in loss of
both exocrine and endocrine function
signs and symptoms of chronic pancreatitis
chronic abdominal pain
steatorrhea
weight loss/cachexia
jaundice
hyperglycemia
complications from chronic pancreatitis
diabetes
pseudocysts
calcification
ascites
biliary stricture
laboratory diagnosis for chronic pancreatitis
serum amylase and lipase usually normal
hyperglycemia, low albumin, and hypocalcemia may be present
what may be elevated in ductal obstruction?
total bilirubin
alkaline phosphatase
hepatic transaminases
pancreatic function tests in chronic pancreatitis
low serum trypsinogen/trypsin (under 20 ng/ml)
low fecal elastase (under 200 mcg/g)
increased fecal fat estimation (over 7g/day)
secretin stimulation
what is essential for management of chronic pancreatitis?
abstinence from alcohol
pain management for chronic pancreatitis
combination of nonnarcotics first
ONLY narcotics if non fails
antiemetics for chronic pancreatitis
ondansetron, prochlorperazine, promethazine
the goal for nutrition is to
maximize caloric intake and weight gain and reduce steatorrhea
what pharmacological management can be done for chronic pancreatitis?
use of pancreatic enzyme replacement therapy
pancreatic enzyme replacements are
enteric coated microspheres/tablets that contain lipase, amylase and protease
immediate release non-EC formulation should always be administered with
an acid suppressor
how do microspheres work?
dissolve in a more basic pH of the duodenum
act locally to break down fats, starch, protein
starting adult doses for pancreatic enzyme replacements are generally
30,000 to 50,000 units per meal with one half dose for snacks
enzymes are given
before or during a meal
patient may need _________________ if maximal response of enzymes is not seen
to add a PPI or H2RA
dosing of enzymes is based on
lipase content (units) of the product
adverse effects of pancreatic enzyme replacement products
nausea/abdominal cramping
fibrosing colonopathy (abdominal vomiting and swelling)
hyperuricosuria
hyperuricemia
pancreatic enzyme replacement products are pregnancy category
C
there is a concern for what allergy when using pancreatic enzyme replacement products
pork allergy
patients with chronic pancreatitis may develop
type 2 diabetes mellitus
what is given if the patient with chronic pancreatitis develops T2DM
metformin
insulin
metformin lowers the risk of
secondary pancreatic carcinoma
when there is no improvement after beginning enzyme supplement, first
decrease dietary fat to 0.5g/kg/day
if decreasing dietary fat does not improve chronic pancreatitis then
increase enzyme dose (max 90,000 units/meal or 10,000 units/kg/day)
if there is no improvement after increasing enzyme dose then,
add PPI or H2RA
