Pancreatitis

Front 1

endocrine/exocrine function of pancreas

Back 1

-Endocrine: produces hormones which regulate digestion (insulin, glucagon, somatostatin, pancreatic polypeptide). 20% of function.
-Exocrine: forms digestive juices rich in enzymes and bicarbonate. Amylase digests carbohydrate. Lipase digests fat. Trypsin digests protein. 80% of function.

Front 2

pancreatic enzymes

Back 2

-1 liter of pancreatic juice produced each day, released in a non active state
-trypsin converts proenzymes into active forms in duodenum

Front 3

acute pancreatitis

Back 3

-inflamm disease of the pancreas
-discrete episodes of abd pain and elevated serum amylase and lipase levels
-structure and function of pancreas goes back to nml
-etiology: ALCOHOL AND BILARLY TRACT DISEASE (gallstones)

Front 4

alcohol

Back 4

-usually the pancreas has prior damage from alcohol (5-10yrs of heavy drinking), can also happen from a binge
-alcohol results in spasm of sphincter of oddi, toxicity to tissue and increased secretion of enzymes. It also increases prot content of pancreatic juice forming prot plugs which block pancreatic outflow

Front 5

gallstones

Back 5

-Cholelithiasis and choledocholithiasis can result in stones lodging in the pancreatic duct or ampulla of vater leading to extravasation of enzymes into to the pancreatic parenchyma.
-obstruction may also be cased by sphincter dysfunction, abnormalities of pancreas and pancreatic ca

Front 6

acute pancreatitis- drugs and toxins

Back 6

-Drugs: immunosuppressants (azathioprine), valproic acid,DDI, TMP-SMX, diuretics (furosemide), estrogens, tetracycline, corticosteroids
-Toxins: insecticides, methanol, scorpion venom

Front 7

acute pancreatitis: metabolic

Back 7

-hypertriglyceridemia: occurs when triglyceride levels are >1000mg/U

Front 8

acute pancreatitis: other causes

Back 8

-genetic factors
-instrumentation (ERCP)
-autoimmune
-viruses (mumps, EBV, varicella)
-bacteria (mycoplasma, salmonella)
-abd trauma
causes: GET SMASHED

Front 9

pathophys acute pancreatitis

Back 9

-activation of diegestive enzymes results in autodigestion of pancreatic tissue
-digestive enzyme release is stimulated by: toxic metabolites of alcohol, drugs, toxins, infectious agents
-inflamm mediators are released and stick to vessel walls causing injury

Front 10

acute pancreatitis-SSX

Back 10

-dull, boring, abd pain which is sudden in onset and intensifies and becomes a constant ache
-pain in epigastric region with radiation to back
-not relieved by vomiting
-N/V, anorexia
-pts lie in fetal position or bend forward
-fever, tachycardia
-dec bowel sounds, local tenderness, generalized rebound, guarding, distension
-jaundice

Front 11

acute pancreatitis-severe attacks

Back 11

- hypotension, tachypnea, tachycardia, dyspnea, hemodynamic instability, may occur
-tissue can become necrotic

Front 12

Greys Turners sign

Back 12

-in necrotizing pancreatitis
-ecchymosis of flanks from retroperitoneal blood dissecting along tissue planes

Front 13

Cullen sign

Back 13

-ecchymosis of periumbilical area

Front 14

Dx of acute pancreatitis

Back 14

-H & P: alcohol, meds, trauma, stones
-Serum amylase: rises fast during 1st 2-12 hrs and return to nml over 3-5 days (not specific)
-Serum lipase: increases parallel to amylase; levels remain elevated longer, TEST OF CHOICE
-amylase and lipase levels do not correlate w/severity of disease!
-Labs: WBC, inc Hct, mild hyperglycemia, hypocalcemia, CRP >6 mg/dL
-Abd xrays: dilated loop of small bowel, overlying pancreases (sentinel loop) or dilation of transverse colon with abrupt cut off of gas column at splenic flexure

Front 15

If CBD obstructed see...

Back 15

-elevated bilirubin, alkaline phosphatase and aminotransferase levels
-hypoalbuminemia
-serum triglyceride levels >1000mg?dL

Front 16

U/S, CXR, CT,MRI, MRCP in acute pancreatitis

Back 16

U/S:
-inflammed pancrease may apear hypoechoic due to edema
-uneven outline of gland
CXR: pleural effusion and bibasilar atelectasis
CT: w/IV contrast shows poor perfusion of pancrease suggesting necrosis
MRI: equal to CT
MRCP: shows dilated pancreatic ducts, stones

Front 17

Endocsopic Ultrasonography

Back 17

-Endoscopic procedure in which high frequency ultrasound transducer is inserted into GI tract to visualize pancreas and biliary tract.
-Can be used to guide needle aspiration

Front 18

Endoscopic Retrograde Cholangiopancreatography- ERCP

Back 18

-take tube stick it into mouth through duodenum and finds the point of the blockage
-not helpful in Dx of pancreatitis Detects bile duct stones. Pancreatitis may occur after ERCP

Front 19

Ranson's Criteria on admission

Back 19

-evaluates inflamm repsonse and complications
-Age > 55yrs
-AST >250 U/L
-WBC >16,000
-LDH > 350
-glucose >200
-3 + on admission predicts severe course and pancreatic necrosis

Front 20

Ransons criteria 48 hrs after admission

Back 20

Hct drop of > 10%
Arterial PO2 of < 60 mm Hg
Serum Ca < 8 mg/dL
BUN increase of > 5 mg/dL
Base deficit of > 4 meq/L
Fluid sequestration of > 6 L
-Development of above in 48 hours indicates worsening prognosis.
-7-8 = 100% mortality rate

Front 21

Tx of acute pancreatitis

Back 21

-no therapy directly affects inflamm
-fluid resuscitation, maintaining fluid balance, monitor of complications
-may require ICU
-if abd pain and dec BS, no food or fluid PO
-NG suction is vomiting and ileus present (replace fluids)
-total parenteral nutrition (TPN) needed to maintain caloric needs
-gallstones --> surgically correction during mild episode, with severe --> ERCP, spinchterotomy, stone extraction

Front 22

Pain control

Back 22

-acetaminophen for mild pain
-Tranadol (Ultram): centrally acting analgesic for moderately severe pain
-Meperidine (Demerol)
-Hydromophone (Dilaudid) IV

Front 23

Pancreatic necrosis

Back 23

-in infected pancreatic necrosis see worsening of sx, fever, leukocytosis
-may require emergency CT, aspiration of fluid for Gm stain and Cx
-surgery
-abx: imipenem/cilastin or fluoroquinolones or metronidazole

Front 24

Pancreatic pseudocyst

Back 24

-complication from AP
-leakage of pancreatic juices from ducts
-Dx w/Us or CT

Front 25

Pancreatic ascites

Back 25

-complication from AP
-results when pancreatic fluids drain into peritoneal cavity

Front 26

complications of AP

Back 26

-Renal and respiratory failure
-Renal failure form hypovolemia and decreased perfusion, Tx by fluid correction
-resp failure may progress to ARDS (occurs when enzymes are absorbed into circulation injuring epithelium of pulmonary capillaries.)

Front 27

Chronic pancreatitis

Back 27

-inflamm disease of the pancreas characterized by changes in structure and function of pancreas which persist after correction of precipitating cause
-highest in alcoholics
-calcifying chronic pancreatitis with fibrosis
-obstructive chronic pancreatitis: dilation fo ductal system, atrphy of parenchyma, and fibrosis

Front 28

Etiology of chronic pancreatitis

Back 28

-ALCOHOL!
-malnutrition, injury, diet
-cystic fibrosis resulting in plugging of ducts
-Tropical pancreatitis” from casava in diet or malnutrition

Front 29

clinical manifestations of chronic pancreatitis: ssx

Back 29

-abd pain, epigastric, dull, constant
-pain attacks can last for several days with pain free intervals or constant. Aggravated by eating
-may improve as pancreatitis worsens
-causes: inflammation, increased intrapancreatic pressure, stenosis of CBD
-N/V, anorexia, wt. loss

Front 30

clinical manifestations of chronic pancreatitis

Back 30

-malabsorption from pancreatic insufficiency: when pancreatic lipase is reduced, diarrhea and steatorrhea occur. Amylase deficiency results in decreased carbohydrate digestion resulting in osmotic diarrhea. Maldigestion of fat soluble vitamins: A,D,E,K.
-DM: occurs late in disease

Front 31

Dx of chronic pancreatitis

Back 31

-H&P, imaging, labs
-Pancreatic exocrine function eval with 72hr fecal fat. If >7g/d exocrinse secretion dec by >90%
-amylase/lipase may be eleva, nml or low
-Structural studies ie; calcifications on plain film diagnostic of chronic pancreatitis

Front 32

U/S, CT, in chronic pancreatitis

Back 32

US: see irregular contour of gland, dec echogenicity, dilation of duct, calcification and dilation of main pancreatic duct
CT: shows ductal dilation, calcifications, cystic lesions

Front 33

ERCP MRCP and in chronic pancreatitis

Back 33

-ERCP: most sensitive and specific. Ducts become more stenotic, tortuous and dilated as disease increases in severity.
-MRCP: shows pancreatic parenchyma and ductal system

Front 34

Tx of chronic pancreatitis

Back 34

-pain control: stop alcohol, analgesics, dec triglycerides, D/C drugs
-acetaminophen or NSAIDS, opiates
-oral pancreatic enzymes may reduce pain by inhibiting their secretion (25,000-30,000 units of lipase per meal)
-surgery last resort

Front 35

complications of chronic pancreatitis

Back 35

1. Pancreatic cancer
2. Portal HTN/gastric varices from obstructed splenic vein
3. Pseudocysts (may rupture or become infected)
4. Pancreatic ascites (from duct leakage or pseudocyst rupture)