Pancreatitis - Krugliak Flashcards
Criteria of acute pancreatitis
2/3 necessary for diagnosis:
- Epigastric pain
- Elevated serum amylase or lipase
- CT or MRI
Etiologies of acute pancreatitis
Biliary (40%), alchololic (more in chronic), idiopathic, other:
Autoimmune
Drug-induced (immunosuppressants, cholinergics)
Iatrogenic
IBD-related
Infectious
Inherited
Metabolic
Neoplastic
Structural
Toxic (environmental)
Traumatic
Vascular (HTN)
ERCP-Induced Pancreatitis
Risk factors, cause
Highest cause of iatrogenic pancreatitis
Acinarization during recanalization and increased pressure. Stenting reduces risk.
Risks:
Younger/female, normal ducts, Sphincter of Oddi dysfunction, Anicteric, Difficult cannulation, Pancreatic injections, Acinarization, shincterectomy
Autoimmune pancreatitis:
Properties, epidemiology and treatment
6-10% of pancreatitis
Subacute symptoms
Irregular, narrowed duct
Periductal lymphocytic-plasmacytic inflammation and fibrosis
IgG4 (diagnostic), IgE, autoimmune markers
Steroid responsive
Systemic Effects of Enzymes in Acute Pancreatitis
Clinical Features of Acute Pancreatitis
99% have pain (if not, die at home)
Lab tests are not specific
Check amylase and lipase
Lipase elevated slightly longer than amylase (a week vs 2-3 days), more specific
Red Flags of Acute Pancreatitis
Encephalopathy (stuperous)
Hypoxemia
Tachycardia >130 (hypovolemia)
Hypotension <90
Hematocrit >50 (hypovolemia), oliguria <50ml/h (due to loss of fluid and acute renal failure)
Azotemia
Major complications of Acute Pancreatitis
Local:
Fluid collections
Necrosis (10% mortality)
Infection (with necrosis: 30-50%)
Ascites
Erosion into adjacent structures
GI obstruction
Hemorrhage
Systemic:
Pulmonary (ARDS, noncardiac pulmonary edema)
Renal
CNS
Multiorgan failure
Metabolic:
Hypocalcemia (hypoparathyroidism, hypoalbuminuria)
Hyperglycemia (insulin 4x glucagon 10x)
Treatment of Acute Pancreatitis
Supportive care:
Aggressive fluid and electrolyte replacement
Monitoring: vital signs, urine output, O2 sat, pain
Analgesia, anti-emetics
Other treatment:
Acid suppression
Antibiotics
NG tube (severe cases only)
Nutritional support (better prognosis)
Urgent ERCP
Clinical features of Chronic Pancreatitis
Pain in vast majority (from inflammation and increased pressure in parenchyma and pancreatic duct)
Calcification (not all but diagnostic)
Steatorrhea (from lack of pancreatic lipase)
Diabetes after 10-15y
Diagnostic tests of Chronic Pancreatitis
Most sensitive: ERCP for structure and secretin for function (time consuming, intubate and xray, insert NG tube to evacuate gastric fluid, inject secretin and CCK, measure papillary secretions of enzymes/electrolytes, see decreased volume and bicarb excretion in pancreatitis).
Less sensitive: CT/Ultrasound/MRI for structure and PABA (excretion in urine after Bentiromide ingestion, low sensitivity, high specificity), serum trypsinogen and fecal chymotrypsin for function
Least sensitive: Abdominal Xray for structure and fecal fat in late cases, blood glucose in diabetes for function
In actuality: do US/CT then ERCP then secretin
Treatment of Chronic Pancreatitis
Give enzymes to split P protein: CCK-releasing peptide stimulates CCK release.
Improves maldigestion, decreases pressure and pain.
Endoscopic therapy by ERCP: stent improves pain in 50-75%. Sphincterectomy, protein plugs or stone removal, stricture dilation, cyst drainage
For stones: dissolution, stenting, lithotripsy (crush stone), laser, extraction. No proven efficacy for pain relief.
Lateral pancreaticojejunostomy
