Etiology & Risk Factors
What are the 2 most common causes of acute pancreatitis
Gallstones (choledocholithiasis 40% of cases)
Chronic alcohol use or abuse (35% of cases)
yellow polkadots
Sudden onset of abdominal pain in the left upper quadrant, periumbilical region and/or epigastrium radiates throughout abdomen and into chest or mid-back
Initially pain worsens after eating or drinking especially fatty foods and becomes constant over time
In some cases pancreatitis may be painless
List the diagnostic criteria for diagnosing acute pancreatitis
2 of 3 findings
Abdominal pain suggestive of pancreatitis
Serum amylase and/ or lipase levels at least 3 times the normal level
Characteristics finding on imaging
Does the degree of elevation of the serum amylase or lipase predict the severity of acute pancreatitis?
No – degree of elevation of the serum amylase or lipase level has no prognostic value
Lists the mainstays of treatment of acute pancreatitis
Pain control
Hydration
Bowel rest
True or false Type 2 diabetes increases the risk of acute pancreatitis
True or false Obesity is a risk factor for chronic pancreatitis and pancreatic cancer.
True- Type 2 diabetes increases the risk of acute pancreatitis by a factor of 2 or 3.
Diabetes is also a risk factor for chronic pancreatitis and pancreatic cancer
True- Obesity is a risk factor for chronic pancreatitis and pancreatic cancer.
List at least 3 associated symptoms with acute pancreatitis
Nausea/vomiting
Indigestion
Abdominal fullness, bloating or distension
Clay-colored stools
Decreased urine output
Frequent hiccups
Syncope
Fever
What is the diagnostic standard for radiologic evaluation of acute pancreatitis
Contrast-enhance abdominal CT
What are potential complications of fluid resuscitation to monitor for?
Volume overload, increased risk for abdominal compartment syndrome, respiratory distress/intubation/death
Fluid therapy needs to be tailored to the degree of intravascular volume depletion and the cardiopulmonary reserve that is available to handle the fluid
What treatment in the first 24 hours reduces morbidity and mortality?
Aggressive fluid administration
Vigorous fluid therapy is most important during the first 12 to 24 hours after the onset of symptoms and is of little valve after 24 hours
List at least 3 less common causes/risk factors for acute pancreatitis
Endoscopic retrograde cholangiopancreatography (4% of cases)
Medications (2% of cases)
Abdominal trauma (1.5% of cases)
Abnormalities of the pancreas (annular pancreas, pancreas divisum, sphincter of Oddi dysfunction)-debatable and research has not supported this
Autoimmune disorders
Hereditary factors
Hypercalcemia (excessive vitamin D therapy, hyperparathyroidism, total parenteral nutrition)
Hypertriglyceridemia
Infections (viral, bacterial, fungal, and parasitic)
Surgical procedures
Toxins (scorpion or snake bites)
Tumors
Vascular abnormalities (ischemia, vasculitis)
Differential Diagnosis: List at least 5 diagnosis that might have a similar presentation as acute pancreatitis
Acute myocardial infarction
Cholangitis
Cholecystitis
Diabetic ketoacidosis
Gastric outlet obstruction
Gastric volvulus
Hepatitis
Intestinal infarction
Pancreatic cancer
Perforated peptic ulcer
Tubo-ovarian abscess
List what bloodwork/imaging should be ordered at presentation of acute pancreatitis and why
CBC (infection)
CMP (assess hepatic function and renal function (complication and prognosis), alkaline phosphatase level and bilirubin can help determine is etiology is due to gallstones)
Lipid panel or triglyceride level (etiology of hypertriglyceridemia)
Contrast abdominal CT or U/S (to assess for gallstones)
What are the most useful predictors of severe acute pancreatitis?
Elevated blood, urea, nitrogen (BUN)
Elevated creatinine levels
Elevated hematocrit
Particularly if they do not return to the normal range with fluid resuscitation
For a patient with mild acute pancreatitis would you wait until they have complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started?
No
In patients with mild acute pancreatitis who do not have organ failure or necrosis there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started
A low fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods.
1) How much alcohol or for what period of time patient does a patient need to abuse alcohol in order to attribute his/her acute pancreatitis to alcohol use
and
2) Does occasional binge drinking alcohol trigger acute pancreatitis?
1) 4-5 drinks daily over a period of more than 5 years
2) No; Binge drinking in the absence of long-term, heavy alcohol use does not appear to precipitate acute pancreatitis
List 2 physical signs associated with acute pancreatitis
Cullen sign (ecchymosis and edema in the subcutaneous tissue around the umbilicus
Grey Turner sign (ecchymosis of the flank)
What imaging modality can you us to assess acute pancreatitis in a patient with AKI or allergy to contrast
MRI
79% sensitivity and 92% specificity for identification of severe pancreatitis
What does a rising hematocrit or blood urea nitrogen or creatinine level, persistent SIRS after adequate fluid resuscitation during the first 48-72 hours indicate?
During the first 48-72 hours a rising hematocrit or blood urea nitrogen or creatinine level, persistent SIRS after adequate fluid resuscitation or the presence of pancreatic or peripancreatic necrosis on cross-sectional imaging constitutes evidence of evolving severe pancreatitis
What type of fluid is recommended?
What is the recommended rate of fluid resuscitation?
NS or LR
1 trial suggested superiority of LR compared to NS in reducing inflammatory markers
Rate of 200-500 ml per hour or 5 to 10ml per kilogram of body weight per hour within the first 24 hours
List 2 medications that can potential cause acute pancreatitis
Azathiprine (Imurna)
Didanosine (Videx)
Estrogens
Furosemide (Lasix)
Pentamindine (Pentam 300)
Sulfonamides
Tetracycline
Valproic acid
6-mercaptourine
Didanosine
ACEi
Mesalamine
What lipase-to-amylase ratio strongly supports an alcoholic cause of pancreatitis
Lipase-to-amylase ratio of greater than 4 or 6 strongly supports an alcoholic cause of pancreatitis
Aside from helping with diagnosis what additional information does abdominal CT provide
Helps predicts disease severity and prognosis
List at least 5 potential complications of acute pancreatitis
Abdominal compartment syndrome
Acidosis
Acute renal failure
Acute respiratory distress syndrome
Ascites
Bowel infarction
Development of chronic pancreatitis
Disseminated intravascular coagulation
Gastric varices
Ileus
Mesenteric venous thrombosis
Pancreatic abscess
Pancreatic arterial pseudoaneurysms
Pancreatic necrosis
Pseudocyst formation
Splenic venous thrombosis
In gallstone associated acute pancreatitis which 2 treatment plans decrease the length of hospital stay and complication rates
Early cholecystectomy
Endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP)