Morning Report

March 25, 2011

Pancreatitis Causes

Adult Gallstones Alcohol

Children Blunt trauma Idiopathic (25%) Drug-related Infections

Mumps, Enterovirus, EBV, HepA, Coxsackievirus B

Gallstones less common Still look for them

Pancreatitis Drug-related

Idiosyncratic Direct toxic effect Timing

Depends on drug Few weeks to many months Not very straightforward

Drugs Valproic Acid Azathioprine Corticosteroids Sulfasalazine Cimetidine Estrogens Thiazides Of note

6MP and pentamidine have also been known to cause pancreatitis

Pancreatitis Other causes

Hypercalcemia Hyperlipidemia Vasculitic diseases

SLE, HSP and Kawasaki Sepsis Shock Multiorgan failure CF

Pancreatitis Pathogenesis

Activation of enzymes Autodigestion Tissue Injury

Proinflammatory and cytokine responses ARDS, DIC, multiorgan failure

Because there is no capsule, the inflammation can spread easily to other structures

Pancreatitis Presentation

Abdominal pain Location

Mid-epigastric R or LUQ

Quality Constant Boring

Radiation to back Also flank, chest or lower abdomen

Aggravators Lying supine

N/V +/- Jaundice

Pancreatitis FH

If present look for hereditary systemic or metabolic disorders Ask about

Diarrhea, vasculitis, joint pain, rashes and pulmonary diseases

PE Vary depending on severity Mild fever Tachycardia 30-40% hypotension Abdominal tenderness with absence of peritoneal

irritation

Pancreatitis Late Signs

Grey Turner sign Large ecchymoses in

flanks

Cullen sign Ecchymoses in umbilical

area

Represent blood dissecting from the pancreas along fascial planes

Pancreatitis Amylase

Specificity 70% Rises within 6-24 hours Peaks at 48h Normalizes 5-7d Sensitivity decreases after

24-48h Lipase

Rises within 4-8h Peaks at 24h Normalizes 8-14d Lipase also exists in other

tissues The degree of elevation is

not a marker of severity

Pancreatitis Other labs

CBC Chemistry LFTs Coags

Systemic-wide effects

Pancreatitis Imaging

US Gallstones Dilation of the biliary tree Confirm diagnosis of pancreatititis

Enlarged edematous pancreas Rule out obstructive anomalies

CT Complicated cases

Hemorrhage, pseudocyst, abscess or vascular abnormalities Considering surgery Deteriorating course

Pancreatitis Mimickers

Bowel perforation Ischemic bowel Ruptured ectopic pregnancy

All may mimic pancreatitis and cause an elevation in amylase

Pancreatitis Treatment

Admission Unpredictable course Possible complications

Supportive Fluids

Follow UOP Pain medication

Meperidine Less likely to cause spasm of the sphincter of Oddi

Nutrition GI

Consult if gallstones Surgery

If focal findings are present on US or worsening condition

Pancreatitis Treatment

Nutrition Oral feeding

Time course depends Mild cases

Early feeding and advancement is encouraged Pain improvement and decreased narcotic requirement 24-48h

NJ Elemental or semi-elemental

Increased protein and decreased fat Preferred to TPN if tolerated

Intestinal barrier Eliminates complications of parenteral therapy

TPN If nutritional goals not met in 2 days

Pancreatitis Complications

Shock Hyperglycemia

Decreased insulin and increased glucagon Hypocalcemia

Sequestration into necrotic areas Hypoalbuminemia Hypomagnesemia Hyperglucagaonemia Inactivation of PTH

Pancreatitis Complications

Pseudocysts 2-3 weeks after acute episode

Long-term Chronic pancreatitis Recurrent pancreatitis DM Digestive disorders Malabsorptive disorders

Pancreatitis Complications

Predictibility of complex course Elevations of

Glucose LDH BUN

Decreases of Hct Ca Alb Partial pressure of Oxygen

Ranson’s criteria Other criteria exist as well

Pancreatitis Prognosis

Most patients Mild, self-limited

15-20% Severe and complicated Mortality rate

5% if mild initial presentation Very high if hemorrhagic or multisystem