Pancreas

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    MKSAP 16

    Acute Pancreatitis

    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

    Insulinoma

    • Presenting with neuroglycopenic symptoms and recurrent hypoglycemic episodes.
    • First test: 8h fasting glucose (will be low!), and can directly measure insulin (will be inappropriately high)
    • Imaging:
      • Start with CT (r/o large tumors and metastasis)
      • if CT negative, (can miss small <2cm lesions) do endoscopic ultrasound (90% detection).