S2 MTA - Pancreatitis Flashcards
Sudden inflammation and hemorrhaging due to its destruction by its own digestive enzymes “autodigestion”
Acute pancreatitis
Functional division of the pancreas
- Endocrine (10%) with alfa cells for glucagon and beta cells for insulin
- Exocrine (90%) with acing cells that secrete digestive enzymes to digest macromolecules
Normal physiology of the pancreatic exocrine system
- 1) duodenum releases enteropeptidase/ enterokinase
- 2) enteropeptidase activates trypsinogen to tripsin (and so on)
-3) activation of pancreatic zymogens
What happens to the zymogens in acute pancreatitis
Zymogens get activated early due to injury to acinar cells or impaired secretion of zymogens
Most common cause of acute pancreatitis
- Alcohol abuse
- Gallstones
How does alcohol contribute to acute pancreatitis
- 1) alcohol causes an increase in zymogen secretions
- 2) Decrease fluid and bicarbonate in ducts
- 3) THICK PANCREATIC JUICE
- a) blocks the ducts
- b) increase of pressure that distends ducts
- c) CHAOTIC MEMBRANE TRAFFIKING
- d) zymogen granules come into contact with lysosomes
- 4) activation of zymogens
How do gallstones contribute to acute pancreatitis
- 1) gallstones cause a blockage @ Oddi sphincter
- 2) blocks release of pancreatic juices
Other causes of acute pancreatitis
- Idiopathic
- Gallstones (40%)
- Ethanol abuse
- Trauma
- Steroids
- Mumps virus
- Autoimmune disease
- Scorpion stings
- Hypertriglyceridemia and hypercalcemia
- ERCP
- Drugs
What drugs can cause pancreatitis
- Steroids
- Protease inhibitors
- NRTIs
- Anticonnvulsants
- Metronidazole
- Diuretics
- Estrogen
- Sulfonamides
- Azathiprine
Characteristics of acute respiratory distress syndrome
- Massive inflammation
- Leaky vessels
- Difficulty breathing
Characteristics of acute pancreatitis
- Pancreatic tissue destruction (protease and inflammatory response)
- Blood vessels leak (rupture and swell)
- Lipases can destroy pancreatic fat (liquefy tissue)
- LIQUEFACTIVE HEMORRAGIC NECROSIS
Whats the diagnosis for acute pancreatitis
- Pain @ epigastric region that radiates to the back
- High amylase and lipase (mostly lipase)
- CT scan to show inflammation, necrosis and pseudocyst
Treatment for acute pancreatitis
- Pain management with opioids (meperidine 25 to 50 mg)
- Hydration
- Electrolytes
- Rest the bowels? if the patient can tolerate oral food GIVE IT TO THEM
- Oxygen and antibiotics (infection of gallbladder)
- Antiemetics
Complications of acute pancreatitis
- Pancreatic pseudocyst
- Infected pancreatic pseudocyst by E. coli
- Hemorrhage from damaged blood vessels
- Systemic activation of coagulation factors
- Blood clots
Whats a pancreatic pseudocyst and all of those things involved
- Fibrous tissue surrounding the LIQUEFACTIVE NECROTIC tissue; filled with pancreatic juice
- Abdominal pain, loss of appetite and palpable mass
- Labs: high ass amylase and lipase, also bilirubin
- Pseudocyst may rupture and release enzymes that leads to massive inflammation
Infected pancreatic pseudocyst signs and symptoms
Abscess + high fever and WBC
A hemorrhage from a damaged blood vessel can lead to
Hypovolemic shock
Persistent inflammation and repeated bouts of acute pancreatitis may lead to…
Chronic pancreatitis
What causes chronic pancreatitis
Changes to the structure: fibrosis, atrophy and calcification (IRREVERSIBLE DAMAGE)
The prolonged inflammation of the pancreas may lead to activation of
- Fibrogenic cytokines
- Transforming factor beta
- Platelet derived growth factor
- Myofibroblasts
- Collagen production
- Fibrosis
The constant tissue replacement in chronic pancreatitis leads to
- Misshaped ducts
- Fibrosis
- Calcium deposits (by alcohol)
- Acinar atrophy
Causes of chronic pancreatitis
- T: toxins, tumors and trauma
- I: idiopathic
- G: genetic (cystic fibrosis)
- A: autoimmune (IgG related)
- R: recurrent acute pancreatitis
- O: obstruction (gallstones or a pancreatic head tumor)
Common complications of chronic pancreatitis
- Pancreatic pseudocyst
- Ascitis
- Pancreatic insufficiency
- Diabetes mellitus due to damage of alfa and beta cells
- ADEK vitamin deficiency
- Pancreatic cancer
Treatment for chronic pancreatitis
- Medications: for pain management and pancreatic enzyme intake
- Diet modifications: alcohol cessation and a low fat diet
- Surgery: resectional/ drainage of the pseudocyst, fistula or ascites
The treatment for chronic pancreatitis is mainly…
Paleative care, low-key just managing the pain and keeping them confortable
A CT scan on a patient with chronic pancreatitis may show
- Dialation of the ducts
- Calcification
- Atrophy
- Pseudocyst
When doing and ultrasound on a patient with chronic pancreatitis you can only see the hyperechogenecity of the pancreas
False, you can also see: pseudocyst, pseudoaneurysms and ascites
Name of the pattern seen while doing an ERCP procedure on a patient with chronic pancreatitis
Chain of lakes pattern
Most common place for pancreatic tumors
The head of the pancreas
Biliary sludge is more common to cause acute pancreatitis
True
Levels of triglycerides that indicate an acute pancreatitis by hypertriglyceridemia
> 1000 mg/dL and > 2000 mg/dL increase the risk by 10 to 20%
Lab results in patient with acute pancreatitis
- ↑Hematocrit
- ↑WBC
- ↑BUN, creatinine and lactate
- ↑Blood glucose
- ↑CRP or prolactin
- ↑IL6
- ↑LDH
- ↑ALT/AST
- ↑Triglycerides
Clinical features in a patient with acute pancreatitis
- Constant epigastric pain that radiates to the back
- Nausea and vomiting
- Fever
- Retroperitoneal bleeding
What may cause the acute pancreatitis pain to WORSEN
- After meals
- Standing up
Retroperitoneal bleeding is common in acute pancreatitis, what are the visible signs of this?
- Cullen sign: periumbilical ecchymosis
- Grey-Turner sign: flank eccymosis
- Fox sign: inguinal ligament ecchymosis
Types of acute pancreatitis
- Necrotizing
- Interstitial
Complicated (20%) and blood supply interrupted, infected and walled-off (sterile)
Necrotizing acute pancreatitis
Infected necrotizing acute pancreatitis sings, labs and treatment
- ↑Leukocytes, bacteremia, and inflammation markers
- Gas within pancreas and fluid collection
- Empiric antibiotics
- Drainage if AB not working
WTF is a walled-off sterile cosa esa in acute pancreatitis
Encapsulated collection of sterile secreting material, usually occurs after 4 weeks; treated with drainage
Interstitial acute pancreatitis is mostly uncomplicated and its about 80% of the cases
Yuh
Findings in a patient with interstitial acute pancreatitis
- Pancreatic pseudocyst
- Acute pancreatic fluid collection
Severity scores used for acute pancreatitis
- Atlanta grade
- Ranson criteria
- APACHE II
- BISAP
- Marshall’s
Severity score that categorizes acute pancreatitis in mild, moderate and severe
Atlanta grade
Severity score that can be used after 48 hours
Ransons criteria
Severity score used in the ICU
APACHE II
Severity score used to predict in-hospital mortality
BISAP
Organ failure score
Marshall’s
Mutations that cause hereditary chronic pancreatitis
PRSS I or SPINK I mutation
Most common cause of pancreatitis in kids
Cystic fibrosis
Chronic pancreatitis causes pancreatic insufficiency, this results in?
- Exocrine: low-grade amylase, lipase and protease
- Weight loss and malnutrition
- Steatorrhea
- Osteoporosis or osteopenia
- Deficiency of ADEK and zinc
- Endocrine: loss of beta cells and insulin
Main characteristics of a pancreas facing chronic pancreatitis
- “Salt and pepper” at X ray
- Enlarged pancreatic duct
- “Skinny” pancreas
