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

        (Most Cases)

        Acute pancreatitis that does not meet

        "severe" criteria".

        Severe Pancreatitis

        - 20% of acute pancreatitis

        - up to 20% mortality

        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

    • 80% of all acute pancreatitis are from Gall Stones or EtOH
    • 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 > 5.6) Hypercalcemia

      E - ERCP (post-ERCP), Emboli, Ischemia

      D - Drugs

      • SAND Mnemonic
      • S - Simvastatin
      • A - Azathioprine, 6-MP
      • N - NSAIDS?
      • D - Diuretics (Furosemide, hydrochlorthiazide)
      • Mesalamine, asparaginase, didanosine

       

      Others:

      - Pancreas divisum (two congenital pancreatic ducts)

      - Genetic, Ischemia

    Symptoms

    • Sudden onset pain in epigastric region with radiation to the back.
      • (more comfortable seated position than supine).
    • Nausea, vomiting, fever.
    • Pleural Effusions --> dyspnea. (from capillary leak).

     

    Diagnostic Criteria

    • Diagnostic Criteria for Acute Pancreatitis

      Need at least two of:

          1.  Typical clinical symptoms

          2.  Elevated serum amylase and/or lipase level> 3x ULN

          3.  Typical findings on cross-sectional imaging.


       
    • Lipase has a longer half-life, MUCH more specific.
    • Amylase is less specific (can see in salivary glands, fallopian tubes rises sooner.
      • Non-specific, also seen in:
        • Perforated peptic ulcer
        • Intestinal ischemia
        • Acute hepatitis or cholecystitis
        • Rupture ectopic pregnancy
        • Parotidis
        • CKD
      • Macroamylasemia
        • Bening condition - multimers of amylase that are poorly filtered (need to do SPEP to find out). 
      • Gullo Syndrome
        • Rare cause of benign amylase and sometimes even lipase elevations.
    • Contrast CT - only if clinical picture is not clear.
      • Pancreatic or peripancreatic edema (+inflammatory stranding), fluid collections
      • Pancreatic necrosis (but rare on initial imaging). 
      • Splenic vein thrombosis? 

     

    Prognosis

    • Ranson Criteria  (need parameters on admission + 48hrs later).
      • Problem: Complexity, and cannot make initial analysis.
    • Apache Score (MORE COMMON)
      • The Acute Physiology and Chronic Health Evaluation (APACHE) II
      • More accurate than Ranson, but cumbersome. (i.e. need ABG, etc...)
    • Hemoconcentration
      • Potential predictor of morbidity and mortality (marker of capillary leak).
      • **Elevated BUN (serum)** Most important, most reliable, can trend.
      • Elevated Creat
      • Elevated Hematocrit
    • Others:
      • Medical comorbidities
      • >75, 
      • BMI > 30

    Management

    • ADMIT ALL
      • ICU if hemodynamically unstable or breathing challenges
    • Require:
      • Narcotic analgesia
      • Bowel rest (NPO)
      • Aggressive early fluids (Pancreas can sequester a lot of fluid) --> decrease ECV --> AKI + other organs.
    • Other therapies:
      • NG Tube
        • Usually not needed, unless have ileus as a result from pancreatitis
      • ERCP:
        • ERCP: AVOID Except: in gall stones or worsening sympsoms + rising liver chemistry
          • Gall-stones as reason for pancreatitis and concominent ascending cholangitis
          • Concominant Ascending cholangitis (Fever, RUQ pain, Jaundice).
            • Consider if gall-stone pancreatitis, not improving, worsening liver chemistry  -->billiary tree obstructed.
      • Starting: Naso-Jejunal feeding
        • Criteria: Start as soon as feasible NJ feeding, especially if no signs of improvement in first 72-92hrs.
        • Avoid IV nutrition (high risk fungemia, bacteremia).
      • Cholecystectomy
        • If gall stone pancreatitis, perform cholecystectomy BEFORE discharge (previously done as O/P once "cool off".
      • Prophylactic Antibiotics
        • NO BENEFIT on mortality, but predisposis to intra-abdominal fungal infections
        • However, treat if documented source of infection.
        • If documented necrotizing pancreatitis and develop clinical instability (Fever, Hypotension)
          • Must sample pancreatic bed (endoscopically, percutaneously, or surgical).
          • Helps guide antimicrobial therapy.
          • May need drainage, if infected.

     

    Complications

    • Pseudocysts (Most Common)
      • Fluid collection without solid degree (no epithelial layer)  - Most common complication
        • Often walled off pancreatic necrosis
      • Pancreatic fluid collections due to destruction of main pancreatic duct or branches.
      • Often have continued abdominal pain, failure to thrive, hospitalization etc..
        • Can have mass effect on stomach
      • Pseudocysts typically resolve spontaneously, and do not need treatment.
      • If persist or have mass effect: surgical decompression, percutaneously, endoscopically.
    • Leaking Pancreatic Ducts (30%)
      • If untreated, can develop fistulas.
      • Treated with:
        • Endoscopic stenting.
        • Can use octreotide to decrease secretions. 
        • Pancreatic enzymes to replace what is lost.
        • Bowel rest.
    • Splenic Vein Thrombosis
      • Anticoagulation not recommended.
      • Secondary to inflammation around that vein in pancreas.
      • Can cause gastric varices.
    • Diabetes
      • If lost a lot of pancreas.

     

     

    • 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).