Pancreas

Introduction

• Acute onset of pancreatic and peripancreatic inflammation
• Rate is rising (10-45 cases / 100,000), 5% mortality rate.
• Classification:

  • Severity	Criteria
    Mild Pancreatitis	- 80% of cases
    Severe Pancreatitis	Organ failure     - hypoxemia     - hypotension     - renal failure OR Complications:    - Pancreatic Necrosis    - Fluid collections

• Premature activation of intracellular pancreatic trypsinogen to trypsin conversion (activation).
  • Triggers inflammatory cascade, causing capillary leak --> Can cause SIRS

Causes

• Causes of Pancreatitis

  G - Gall Stones (45%) (MOST COMMON)    - Microlithiasis E - Ethanol (35%)  (MOST COMMON) T - Tumors (choledochocele) S - Steroids M - Mumps A - Autoimmune (Polyarteritis Nodosa, SLE)    - (Other infections: viral [CMV, MUMPS], parasitic [toxoplasma, Ascaris lumbricoides]) S - Scorpion bite H - Hypertriglyceridemia (TG > 11.3) Hypercalcemia E - ERCP (post-ERCP), Emboli, Ischemia D - Drugs SAND Mnemonic S - Simvastatin A - Azathioprine, 6-MP N - NSAIDS D - Diuretics (Furosemide, thiazides) Mesalamine, asparaginase, didanosine   Others: - Pancreas divisum (two congenital pancreatic ducts) - Genetic, Ischemia

• Pancreatic Enzymes
  • Lipase, Amylase, Trypsin, Chemotrypsin
• Symptoms:
  • Pain: epigastric, noncolicky, constant, can radiate to back.
  • NV, fever, Jaundice (compression of bile duct)
  • Cullen's Sign
  • Grey-Turner's Sign
  • Tetany (transient hypocalcemia)
  • Hypovolemic shock, ARDS, Coma
  • Hypocalcemia - Ca precipitated as soap in the abdomen (unclear)
• Prognosis
  • Ranson's Criteria on Admission
    • Age > 55yo
    • WBC > 16,000/uL
    • Blood glucose > 11 mmol/L
    • Serum LDH > 350 IU/L
    • Serum AST > 250 IU/L
  • Ranson's Criteria after 48hrs of admission
    • Fall in hematocrit by >10%
    • Fluid sequestration of > 6L
    • Hypocalcemia (Serum Ca < 2.0 mmol/L)
    • Hypoxemia (Po2 < 60 mmHg)
    • Increase in BUN to > 1.98 mmol/L after IV rehydration
    • Base deficit > 4 mmol/L
  • Score:
    • 0 - 2: 2% mortality
    • 3 - 4: 15% mortality
    • 5 - 6: 40% mortality
    • 7 - 8: 100% mortality

Causes

Treatment

1. IV HYDRATION -> Aggressive!!!
   • High risk of necrotizing pancreatitis (contrast CT often demonstrates inflammation and hypoperfusion).
   • Monitor hypovolemia signs (tachycardia, hypotension, dry MM, hematocrit).
   • Rehydration helps prevent organ failure.
2. Notes On Other Therapies
   1. Antibiotics? --> NOT INDICATED in acute pancreatitis, even if necrosis is present.  In the past used carbapenems.
      • Studies show no benefit of prophylactic abx in severe necrotic pancreatitis.  (abx raise risk of abdominal fungal infections)
      • If significant pancreatic necrosis --> can consider percutaneous fine-needle aspiration (culture + Gram stain).
      • Treat only if culture-proven infected necrosis of the pancreas.
   2. ERCP ?
      • ->  Can worsen pancreatitis.  Only indicated if gallstone pancreatitis and worsening liver chemistry + instability (or if concerning for ascending cholangitis).
   3. NG suction? --> NOT INDICATED
      • Early feeding decreases hospital stay, mortality.  No need to NG suction.
   4. Probiotics contraindicated: increases mortality.
   5. Surgery:
      • If necrotic, high mortality.
      • However have to repeat OR many times, keep taking out necrotic tissue.
      • Investigated various drains.

         

Reference

• Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101(10):2379-2400. PMID: 17032204