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91 Cards in this Set

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INTRODUCTION
Acute pancreatitis is an acute inflammatory process of the pancreas.
It is usually associated with
severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes.
Most cases are associated with
alcoholism or gallstones
Acute pancreatitis can be suspected clinically, but requires
biochemical, radiologic, and sometimes histologic evidence to confirm the diagnosis.
Demographic features — The two most common causes of acute pancreatitis in adults are
gallstones and alcoholism.
Symptoms —
acute upper abdominal pain at the onset [2].
The pain is
steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side.
Biliary colic, which may herald or progress to acute pancreatitis, may occur
postprandially.
On the other hand, acute pancreatitis related to alcohol frequently occurs after a binge or cessation of drinking
one to three days
Unlike biliary colic, which may last for six to eight hours, the pain of pancreatitis can last for
days.
Its onset is rapid, but not as
abrupt as that with a perforated viscus, reaching maximum intensity in many cases within 10 to 20 minutes.
One characteristic of the pain that is present in about one-half of patients, and that suggests a pancreatic origin, is
band-like radiation to the back.
Painless disease is
uncommon (5 to 10 percent) and may be seen in the postoperative setting (especially renal transplantation), in patients receiving peritoneal dialysis, and those with Legionnaire's disease [3].
The abdominal pain is typically accompanied (in approximately 90 percent of patients) by
nausea and vomiting, which may persist for many hours.
Patients with fulminant attacks may present in
shock or coma.
Hemorrhagic complications are
rare.
Ecchymotic discoloration of the flanks
(Grey-Turner's sign) is due to retroperitoneal bleeding in patients with pancreatic necrosis.
Bleeding may also occur into
pseudocysts [4] or rarely bleeding into the pancreatic duct is visible on endoscopy as blood coming from the ampulla (hemosuccus pancreaticus).
Systemic features include
fever, tachycardia, and, in severe cases, shock and coma.
In mild disease, the epigastrium may be
minimally tender.
However, severe episodes are often associated with
abdominal distention, especially in the epigastrium, and tenderness and guarding
dyspnea may occur if there is
an associated pleural effusion.
Ecchymotic discoloration in the flank
(Grey-Turner's sign)
Ecchymotic discoloration in periumbilical region
(Cullen's sign)
These signs reflect intraabdominal hemorrhage and are associated with a
poor prognosis.
Obstruction of the common bile duct, due to choledocholithiasis or edema of the head of the pancreas, can lead to
jaundice.
Less common features include
subcutaneous nodular fat necrosis (panniculitis), thrombophlebitis in the legs, and polyarthritis .
Pancreatic enzymes —
synthesis continues while there is a blockade of secretion. As a result, digestive enzymes leak out of acinar cells through the basolateral membrane to the interstitial space and then the systemic circulation.
Serum amylase — It rises within
6 to 12 hours of onset,
Serum amylase is cleared
fairly rapidly from the blood (half-life approximately 10 hours).
In uncomplicated attacks, serum amylase is usually elevated for
three to five days.
An elevated serum amylase level is a nonspecific finding because it occurs in a number of conditions other than acute pancreatitis
The serum amylase concentration in acute pancreatitis is usually more than
three times the upper limit of normal
the serum amylase may be normal or minimally elevated
thrue
... percent of filtered amylase is excreted, increases to approximately ...percent
3-10
Serum lipase — Because lipase measurements have been .........., they have been less frequently ordered than serum amylase
difficult to perform and lacked precision
The sensitivity of serum lipase ranges from
85 to 100 percent
The level of pancreatic enzyme elevation correlate with severity of disease.
Falsh
Other pancreatic enzymes
phospholipase A, trypsin, carboxylester lipase, carboxypeptidase A, and co-lipase
Nonenzymatic pancreatic secretory products
Pancreatitis-associated protein (PAP) ,trypsinogen activation peptide (TAP),
Markers of immune activation/nonspecific markers
IL-6, IL-8, IL-10, TNF, PMN elastase, and C-reactive protein.
Levels of C-reactive protein above discriminates severe from mild disease
150 mg/dL at 48 hours
Abdominal plain film
exclude other causes of abdominal pain such as obstruction and bowel perforation.
The radiographic findings
range from unremarkable in mild disease to localized ileus of a segment of small intestine ("sentinel loop") or the "colon cutoff sign" in more severe disease.
.....of patients with acute pancreatitis have abnormalities on the chest roentgenogram
one-third
Abdominal ultrasound
A diffusely enlarged, hypoechoic pancreas ,gallstones in the gallbladder
CT scan
most important imaging test
The severity of acute pancreatitis has been classified into five grades based upon findings on unenhanced CT
Grade A — Normal pancreas consistent with mild pancreatitis ,
Grade B — Focal or diffuse enlargement of the gland, including contour irregularities and inhomogeneous attenuation but without peripancreatic inflammation
Grade C — Abnormalities seen in grade B plus peripancreatic inflammation ,
Grade D — Grade C plus associated single fluid collection ,
Grade E — Grade C plus two or more peripancreatic fluid collections or gas in the pancreas or retroperitoneum
The advantages of MRI over CT include:
lack of nephrotoxicity of gadolinium, ability of MRI to better categorize fluid collection as acute fluid collections, necrosis, abscess, hemorrhage, and pseudocyst [37], and the greater sensitivity of MRI to detect mild acute pancreatitis compared to CT.
MRI was reliable for staging the severity of AP, had prognostic value, and was associated with fewer contraindications compared to CT, and was able to
detect pancreatic duct disruptions
Gallstones and alcohol abuse account for
60 to 75 percent and should be diligently looked for in all patients presenting with acute pancreatitis.
patients with acute biliary pancreatitis discharged from the hospital without a cholecystectomy,
30 to 50 percent develop recurrence of pancreatitis ,occurring an average of 108 days after discharge
removing the gallbladder in biliary pancreatitis is
imperative.
conventional transabdominal ultrasonography should be performed in every patient with a first attack of acute pancreatitis to search for
gallstones in the gallbladder
gallbladder visualization may be inadequate due to excessive bowel gas in ___________ percent of patients. In such cases, a ..............should be performed after resolution of acute pancreatitis
25 to 35
repeat ultrasound
MRCP may be an alternative to detect
common duct stones in such patients.
A randomized trial showed that laparoscopic exploration of the common bile duct was as __________as postoperative ERCP in clearing the common duct of stones
safe and effective
An increase in serum alanine aminotransferase (ALT) is suggestive of
gallstone pancreatitis
value greater than 150 IU/L strongly suggests gallstone pancreatitis
lipase-to-amylase ratio greater than 2.0 was 91 percent sensitive and 76 percent specific for detecting
alcoholic pancreatitis
Idiopathic recurrent pancreatitis
no obvious etiology is identifiable in approximately
30 percent of patients
T/F extensive investigation for unusual causes of pancreatitis is required after the first episode of idiopathic pancreatitis
False
GENERAL PRINCIPLES OF THERAPY
correcting any underlying predisposing factors and at the pancreatic inflammation itself.
Mild pancreatitis is treated for several days with supportive care including
pain control
intravenous fluids
nothing by mouth.
Supportive treatment
monitoring of vital signs and urine output every few hours in the first 24 to 48 hours.
Fluid resuscitation
Oxygen
Prophylaxis against deep vein thrombosis
Inadequate hydration can lead to In addition,
hypotension and acute tubular necrosis.
fluid depletion damages pancreatic microcirculation and results in
pancreatic necrosis.
approximately _______cc of intravenous fluids per hour are typically required for ______ hours if the cardiac status permits
250 to 300
48
Pain management
Meperidine
Fentanyl
morphine caused an _______in sphincter of Oddi pressure
increase
Approximately _______of patients with pancreatic necrosis develop infected necrosis
one-third
The important organisms causing infection
Escherichia coli, Pseudomonas, Klebsiella, and Enterococcus spp.
Fungal infection and infection with gram-positive organisms are
uncommon
Three approaches have been taken to decrease bacterial infections in acute necrotizing pancreatitis
Enteral feeding to avoid central line related infections, maintain gut barrier integrity, and decrease bacterial translocations
Selective decontamination of the gut with nonabsorbable antibiotics
Prophylactic systemic antibiotics
Selective decontamination of the gut
combination of oral norfloxacin, colistin, and amphotericin
Systemic antibiotics
cefuroxime (1.5 g three times daily)
ceftazidime, amikacin, and metronidazole given intravenously for 10 days
imipenem
Cefuroxime is given until clinical recovery and normalization of the .
CRP level
contrast-enhanced CT scan is indicated only in patients who are
deteriorating or have severe pancreatitis determined clinically and by APACHE II score
T/F A CT scan is required on the first day
False
If there is necrotizing pancreatitis (involving more than approximately 30 percent of the pancreas), we initiate
antimicrobial therapy with imipenem/meropenem and continue it for at least one week.
If at any time the patient becomes unstable from pulmonary, cardiovascular, or renal complications, we perform a
minimally invasive necrosectomy, (endoscopic, or percutaneous radiologic) if possible
If there has been no improvement after one week of antibiotics, we perform a
percutaneous CT-guided aspiration
If there is bacterial infection, we consider performing a
necrosectomy
CT-guided percutaneous catheter drainage may also be an option before considering
surgical debridement
We suggest open surgical debridement for patients with infected necrosis (and rarely for sterile necrosis) who have
persistent pain and cannot tolerate oral intake if the minimally invasive methods fail to resolve the fluid collections
T/F nutritional support is required in patients with severe pancreatitis
True
A major potential benefit of enteral nutrition is its ability to maintain the
intestinal barrier
Enteral nutrition was associated with a
significantly lower incidence of infections (RR 0.45, 95% CI 0.26 to 0.78), reduced surgical interventions (RR 0.48, 95% CI 0.22 to 1.0), and a reduced length of hospital stay (mean reduction 2.9 days
Nasojejunal feeding with
high protein, low fat preparations such as Peptamen
Initiation of oral feedings
We begin oral feedings by giving 100 to 300 mL of clear liquids every four hours for the first 24 hours.
GALLSTONE PANCREATITIS
early endoscopic or surgical intervention to remove bile duct stones may lessen the severity of gallstone pancreatitis.
early endoscopic papillotomy is of proven benefit in humans with acute biliary pancreatitis
T/Fearly ERCP and papillotomy is beneficial in patients with acute biliary pancreatitis without obstructive jaundice or biliary sepsis
False