Acute and chronic pancreatitis – Flashcards

acute inflammatory process of the pancreas - may also involve peripancreatic tissues and remote organs (kidney, bowel, liver) -severity is based on the prescence of abscence of necrosis

BAD SHIT b- bilary- gall stones blockage A- alcolhol d- divisum (malformation/malunion) opening of the major and minor ducts are reversed, drugs(HIV meds, diuretics, ABX s- surgery h- hypertriglycreidemia, hypercalcemia, herditary i- infection, iatrogenic(ERCP)m idiopathic, ischemic t- tumor, trauma (MVA seatbelt), TRinidad scorpion B& A account for about 90% of all acute pancreatitis

Not really understood -Impairement of pancratic microcirculation -deveopment of pancreatic necrosis - development of pancreatic infection -development of systemic compications **not all patients will progress to most severe

Abdominal pain in epigastic area with radiation to the back, N/V, fever EXAM- abdominal distension, tendernes,, gaurding, hypoactive bowel sounds Labs- Pancreatic enzymes elevated amylase and Lipase 3x normal (lipase is more specific to pancreas) Imaging- not too helpful except for US with biliary cause, CT only for refractory patients not acute

Done at admission and then again at 48 hours at admission - >55 yr old -WBC >16.000 -LDH >350 -Glucose >200 -AST >250 During inital 48 hours - HCT decrease >10 - BUN increase of >5 -CA <8 -PaO2 4 - Fluid sequestration >6 All of these are worth a point and the more points the more aggressive the treatment and high mortality *increasei n BUN/CREAT shows lean toward renal failure and fluid sequestration, watch I/O carefully

Fluid replacement- RINGER's lactate is the best nothing by mouth treat pain with analgesia Almost always resolves in a matter of days

ERCP with sphicnterotomy and stone removal if evidence of cholangitis/bilary obstruction or patient not improving - this may need to be urgent if a large blockage

ICU!!!!- aggressive supportive care and extensive monitoring for local or systemic complications (possible respiratory compromise) - if necorsis or fluid sequestration (need to aspiriate) give Imipenem- for sure if culture is positive but can even give for prophylaxis- done case by case Nutritional support- espeically if it is greater than 4 hours - enteral is better but if patient cannot parenteral *** these patients can get sick very fast

Local- necrosis, peri-pancreatic fluid collections and pseudocysts (false walled cyst will happen over time) Systemic- WORRY!!! Secondary to the inflammatory cascade - GI bleed, shock, coagulopathy, respiratory failure, renal failure, hyperglycemia, hypocalcemia, - very worried about organ failure

High mortality rate - suspect if no clinical improvement and/or fever after 5-7 days - diagnosed by CT - use Imipenem for fevers - Pecutaneous aspiration or necrosis infected- surgical debridement sterile- usually conservative management Much higher chance of infection once the pancreas become necrotic also much higher mortality

Chronic inflammatory condition of the pancreas characterized by FIBROSIS, destruction of exocrine tissues and endocrine tissues can result from multiple acute attacks These patient can have trouble with diabetes (think of a patient will controlled and then glucose out of control)

TOXIN!!!= ETOH a direct pancreatic toxin- lead to pancreatic juice rich in high viscous protein- due to direct damage to pancreas cells - so precipitation of the protein "plugs" in the small ductules that get blocked and damage the larger ducts Decreased production of Lithistatin- leads to increase of plug and stone formation

Episodes of recurrent pancreatitis/insults to the pancreas and the pancreatic ductal system leads to fibrosis/necrosis, further ductal changes, strictures, and damage- this means they are at increased risk for pancreatic cancer

Pain!!!- mid-epigastric with radiation to the back, worsens with food, chronic and steady malabsorption- loss of exocrine pancreas - 80 % of gland destroyed, weight loss, MILD STEATORRHEA with foul smell, vitamin deficiencies Diabetes- due to loss of endocrine function <10 % of normal function

Abdominal x-ray- 30-40% calcifications US-70% sensitive- dilation of ducts, calcifications, change id pancreatic parenchyma CT- sensitivity of 75-90% ****ERCP- 95% sensitive - abnormal main and side branches, stricture, dilation, stones- common to see recurrent cases

Not very helpful Amylase and lipase can be normal or minimally elevated Stool for fat, fecal chymotrypsin- both insenstive and time consuming for patient and lab staff

Pain- analgesia (narcotics), pancreatic enzymes - inhibit CCK feeback loop on pancreatic stimulation celiac plexus block Malabsorption -pancreatic enzyme replacement - varying amounts of lipase, amylase, and protease Surgery- due to blockage - dilated main pancreatic duct -disease in head of pancreas -total or near total pancreatectomy Make sure they stop drinking harder to treat

Pseudocyst Common bile duct obstruction Pancreatic fistula/leak Duodenal obstruction Splenic vein thrombosis Pancreatic Cancer- low risk but still need to worry about it

high mortality- not commonly found until very last Pain is epigastric with radiation to the back- constant Jaundice Weight loss worsening symptoms of diabetes if already diagnosed with diabetes acute pancreatitis- not common

Age, male, african american population, Diabetes (think of it when you see a controlled diabetic suddenly out of control), chronic pancreatitis esp. with a longer duration, tobacco (increases risk 2x normal), high fat diet

LABs- CEA adn CA 199, mild amylase & lipase, elevated bilirubin and ALP Imaging studies- THIS IS THE MAIN WAY TO FIND IT -CT scan >80% sensitive -ERCP- 90% sensitive & specificity Endoscopic ultrasould >90% sensitivity- only really good for tumors <2 cm Uses TNM criteria for staging

85 % of patient are unresectable common - pancreatic head surgery- pancreaticduodenectomy (whipple) Cancer of body and tail- distal pancreatectomy surgical resection still has a vrey bad prognosis only used for patients with no lymph node involement or metastatses (otherwise surgery for pallative care only)

Pain relief- narcotics, celiac ganglion block Biliary obstruction- surgical bypass or endoscopic/percuatneous stenting Dupdenal obstruction- surgical bypass or endoscopic stent Chemotherpy/radiation