Pancreatitis chap. 87 tintinalli

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Pancreatitischap. 87tintinallis emergency
medicine

• Robert Moosally, DO

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acute pancreatitis

• Most common causes
• Alcohol
• Biliary dz
• Drugs
• Infection
• Inflammation
• Trauma
• Metabolic disorders
• make up most of the cases

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pathophysiology

• Activation of digestive zymogens in pancreatic
  acinar cells gt autodigestion of pancreas
• Edema
• Interstitial hemorrhage
• Vascular damage
• Coagulation
• Cellular necrosis

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clinical features

• Midepigastric pain or LUQ pain
• Constant, boring pain that radiates to the back,
  flanks, chest, or lower abdomen
• Pain can be exacerbated by supine position
  relieved by sitting with trunk knees flexed
• Nausea/vomiting
• Abdominal bloating (gut hypomobility) dec. BS
• Low grade fevers
• Tachycardia
• Hypotension (from 3rd spacing shock MODS)
• Pleural effusion (left sided) rarely ARDS
• Cullen sign bluish discoloration around
  umbilicus
• Grey Turner sign bluish discoloration of the
  flanks

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diagnosis

• Labs
• Amylase pancreas/salivary glands low levels
  found in fallopian tubes, ovaries, testes,
  adipose tissue, small bowel, lung, thyroid,
  skeletal muscle certain neoplasms some
  excreted by kidneys so will also see elevations
  in renal failure most sensitive at 36 hrs
• Lipase pancreas also found in gastric and
  intestinal mucosa liver heparin administration
  can cause a release of lipase into the serum
  also cleared by the kidneys so will be elevated
  in renal failure longer half-life so will be
  elevated even when amylase at baseline
• absolute levels do NOT correlate w/ severity of
  dz

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imaging

• CXR
• Used to r/o other causes if you see
  calcifications of pancreas then indicates more
  chronic dz
• May see sentinel loop indicating regional ileus
• May see left sided pleural or pericardial
  effusions
• US
• Used to see dilatation of biliary tree or
  gallstones
• Pancreatic edema or pseudocysts
• CT
• Better to visualize severity of dz and other
  anatomy

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prognostic markers

• Usually pancreatitis is a self-limiting dz
• 5-10 of cases suffer significant
  morbidity/mortality
• Ranson criteria
• Age gt 55
• BS gt 200 mg/dL
• WBC ct gt 16,000/L
• SGOT gt 250 units/L
• LDH gt 700 IU/L

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treatment

• rest the pancreas
• NPO (no evidence to support the NGT, other than
  to remind the pt that they are NPO!)
• FLUID RESUSCITATION!!
• Parenteral narcotics
• Antiemetics
• If biliary pancreatitis, then requires emergent
  decompression
• Antibiotics only in severe dz
• Peritoneal lavage/laparotomy (ascites or hemor.)

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disposition

• Mild dz that can be managed with outpt therapy
  can go home pts tolerating PO and pain
  controlled
• All others.admit
• Pancreatic abscesses need a surgeon

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chronic pancreatitis

• Chronic inflammation of pancreas that causes
  irreversible damage to its structure and function
• Most cases are alcohol related second is
  idiopathic
• Pathophysiology
• Interstitial inflammation w/ duct obstruction
  dilatation leading to parenchymal loss fibrosis
• Eventual impairment of both exocrine and
  endocrine pancreatic functions the latter coming
  later in dz
• Significant malabsorption syndrome does not occur
  until gt 90 of glandular function is lost

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clinical features

• Abdominal pain (midepigastric radiating to back)
• Nausea/vomiting
• Pain worse after alcohol or fatty meals
• Pts will look chronically ill
• Cachectic
• Steatorrhea
• Clubbing
• Polyuria
• Stigmata of liver dz (if alcoholic pancreatitis)

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diagnosis

• Amylase/lipase may be normal
• Glucose tolerance impaired (elev. fasting BS)
• Elevated bilirubin alk phos
• CXR will see calcifications in pancreas
• CT or US will show complications of chronic
  pancreatitis (pseudocysts or abscesses)

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treatment

• IV narcotics
• Antiemetics
• Correct fluid and electrolyte abnormalities
• Relief of mechanical obstruction or complications
• Correction of malabsorption
• Alteration of dz course
• 5 year mortality rate of chronic alcoholic
  pancreatitis in pts who continue to drink alcohol
  is 50

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disposition

• Most chronic pancreatitis pts can go home after
  any complications have been ruled out/addressed
• Secure follow-up
• Admit if pt has intractable pain