Pancreatitis -Jenkins

Question 1

How do you differentiate between mild acute, moderately severe acute and severe acute pancreatitis?

Answer 1

Mild acute:
Absence of organ failure and local or systemic complications

Moderately Severe acute:
Transient organ failure that resolves within 48hr and/or local or systemic complications without persistent organ failure (>48hr)

Severe Acute:
Persistent organ failure that may involve one or multiple organs

Question 2

What are the 3 major causes of acute pancreatitis? What tests should be ordered if this is suspected?

Answer 2

• major (75%)=gallstones and alcoholism
• also hypertriglyceridemia (>1000) (only 1.3-3.8%)

ask if they drink and then do an US and get a lipid panel, and look at meds to find the cause of pancreatitis

Question 3

What is the most common cause of pediatric pancreatitis?

Answer 3

trauma

Question 4

What tests should be ordered in the ER for suspected pancreatitis? Which is more sensitive? Do these correlate with the severity/prognosis of the disease?

Answer 4

serum amylase (rises 6-12 after onset and can remain elevated for 6-12 days) and lipase* (lipase rises w/in 4-8 hours--> elevated for a week.) 
-because synthesis continues even with secretion blockage --> digestive enzymes out of acinar cells into blood 

Lipase is more sensitive compared to amylase

*do NOT correlate with the severity of the disease ==> good for diagnosis

Question 5

How does alcohol cause acute pancreatitis?

Answer 5

increases the production of pancreatic enzymes

Question 6

What types of medications can cause acute pancreatitis?

Answer 6

AIDS therapy
Antimicrobials
ACE Inhibitors
Diuretics
IBD medications
Immunosuppressive agents
Neuropsychiatric agents
Anti-inflammatory agents
Calcium
Estrogen
Tamoxifen

Question 7

What do you do for pancreatitis in a preggo?

Answer 7

order a lipid panel –> probably have abnormal lipid panel

Question 8

If a pt has hemorrhagic pancreatitis, what signs can you see?

Answer 8

Grey-Turner’s sign (ecchymotic discoloration of flanks), due to retroperitoneal bleeding in patients with pancreatic necrosis

Cullen’s sign – discoloration in periumbilical area

Question 9

What is the history helpful in determining in a case of acute pancreatitis?

Answer 9

if caused by alcoholism

-recurrent attacks suggest alcoholism but still do US to make sure not gallstones

Question 10

If someone has an elevated amylase/lipase, what should be done next?

Answer 10

US –> diffusely enlarged hypo-echoic pancreas

*if amylase/lipase were normal, do plain film for obstruction

Question 11

What is the most important test to diagnose and determine severity of acute pancreatitis?

Answer 11

CT

• enlargement of pancreas on contrast-enhanced CT==> acute pancreatitis
• unenhanced areas=necrosis

graded from normal –> bad (A–> E)

Question 12

What is the best test for gallstones? what about pancreatitis?

Answer 12

US =gallstones

pancreatitis=CT

Question 13

What advantage does an MRCP have over an MRI?

Answer 13

MRCP

• Better view of bile ducts and pancreatic ducts
• Detection of choledocholithiasis

MRI=better than CT at fluid collections (necrosis, abscess, hemorrhage, etc) and no contrast toxicity

Question 14

What is Ranson Criteria for? What is the best prognostic test?

Answer 14

prognosis of the pancreatitis (3+=severe course and inc mortality)

Serum Ca2+ is the best prognostic test for pancreatitis

Question 15

If AST> ALT, what is the likely cause of pancreatitis?

Answer 15

Alcoholic pancreatitis

Question 16

if ALT> AST, what is the likely cause of pancreatitis?

Answer 16

gallstone pancreatitis

Question 17

What pneumonic is used for treatment of acute pancreatitis?

Answer 17

PANCREAS
P=pain (morphine)
A=antibiotic if due to infectious causes
N=NPO
C=Calcium (if LOW, bad prognosis–> give calcium
R=Rest (bed)
E=electrolytes
A=antacids (increase pH in the stomach –> turn off secretin)
S=Suction –> NG tube

Question 18

What treatment for acute pancreatitis can also cause acute pancreatitis?

Answer 18

ERCP

Question 19

What is the pathogenesis of acute pancreatitis?

Answer 19

lysosomal enzymes activate trypsin –> released –> active trypsin, phospholipase, chymotrypsin and elastase –> auto digestion of the pancreas

• release of pancreatic enzymes damage the vascular endothelium, interstitial and acinar cells
• -> release neutrophils and macrophages and cytokines and ROS–> inc vascular permeability –> thrombosis and hemorrhage –> necrosis

Question 20

Why do we make a pancreatitis pt NPO?

Answer 20

pancreas secreted amylase and lipase in response to products of fat and protein in the duodenum stimulating CCK to stimulate the pancreas

bicarb released in response to low pH in duodenum

incretins (GLP-1) in response to carbs)

**no food–> no stimulus–> no pancreatic secretion

Question 21

What is the reason for giving a PPI to a pt with acute pancreatitis?

Answer 21

turn off secretin by increasing the pH in the stomach with PPI