Etiology/Classification
What are the two most common causes of acute pancreatitis in the US?
Gallstones (40%)
Alcohol use (30%)
Also:
Ampullary tumors, HPLD, hypercalcemia, medication side effects, hereditary pancreatitis, autoimmune pancreatitis, trauma including post-instrumentation (ERCP) issues, and anatomic obstruction from congenital malformations (choledochal cysts)
What is the diagnostic criteria for acute pancreatitis?
At least 2 of these 3:
-Elevated lipase >3x upper limit of normal
-Acute-onset mid-epigastric pain/vomiting
-Imaging findings consistent (acute interstitial pancreatitis, necrosis)
What is the cornerstone of treatment for acute pancreatitis?
FLUID RESUSCITATION
and supportive care
What is the surgical management of gallstone pancreatitis?
What is the risk if this is not done?
Cholecystectomy same admission (after clinically resolved and ?lab values normalized?)
25% recurrent rate of AP in 3 mo
What medication can help prevent post-ERCP pancreatitis?
Indomethacin (100mg suppository)
Describe the severity classifications for acute pancreatitis
Mild: no end organ failure OR local/systemic complications
Moderate: Transient organ failure that resolves in <48hr, may have local/systemic complications
Severe: Persistent organ failure >48hr affecting one or more organ systems
*Ranson score >3*
What are the types of fluid collections associated with pancreatitis based on timing:
Acute (<4 weeks)
Chronic (>4 weeks)
Acute:
-Acute (Peri-)pancreatic fluid collection
-Acute necrotic collection
Chronic:
-Pseudocyst
-Walled off necrosis
Role of antibiotics for AP?
Diet recommendations?
ONLY for highly suspected infection
Early nutrition better if tolerated, enteral preferred but ileus/GI symptoms may preclude this
What is the first step in treatment of a pancreatico-pleural fistula with a large/symptomatic pleural effusion?
Chest tube placement!
Also: parenteral nutritional support, and administration of octreotide
If ongoing drainage then ERCP with sphincterotomy
How do you manage a pancreatic pseudocyst?
IF symptomatic - cystgastrostomy (endoscopic or open) OR ERCP with sphincterotomy
IF asymptomatic - leave it alone
List at least 2 risk factors for chronic pancreatitis
Excessive alcohol use (MC)
Smoking
Cassava ingestion (India?)
Genetic mutation (PRSS1 MC in hereditary pancreatitis)
Hx of autoimmune conditions
How is chronic pancreatitis diagnosed?
Objective tests for pancreatic function:
Exocrine - fecal elastase (<200)
Endocrine - measure BS & A1c
Two modifiable risk factors for chronic pancreatitis?
Alcohol use
Tobacco use
Counsel on cessation of both
nicotine with alcohol use makes pancreatitis more likely and more likely to have gland dysfunction
Generally describe the following surgical procedures for chronic pancreatitis:
Puestow procedure
Frey procedure
Beger procedure
Longitudinal pancreaticojejunostomy - filet open duct and sew to bowel, no intervention on head
Frey - resection of head entirely and longitudinal pancreaticojejunostomy
Beger- head resection and loop of bowel brought up for PJ/HJ connections
Puestow
What are the common cell types of the following and what do they secrete respectively:
Exocrine
Endocrine
Exocrine: acinar cells secrete digestive enzymes (proteinases like trypsin, lipase)
Endocrine:
Alpha - Glucagon
Beta - Insulin
Delta - Somatostatin
What are the imaging findings expected for chronic pancreatitis?
Duct dilation, calcifications, and atrophy of the pancreas
How to treat chronic exocrine dysfunction of pancreas?
Creon (pancreatic enzyme replacement)
Improves absorption of fat-soluble vitamins
Continue for at least 1mo to see effect
What is the surgical treatment for pancreatic divisum?
Minor papilla sphincterotomy/sphincteroplasty (can be done endoscopically or surgically)
What procedure for chronic pancreatitis with calcifications in head of pancreas with dilated CBD but body/PD spared?
Beger (duodenal sparing head resection)
What is the cause of the most common congenital pancreatic anomaly?
Pancreatic divisum:
Failure of the ventral and dorsal bud to fuse
Secretin-enhanced MRI demonstrating failure of ventral/dorsal duct fusion
How should pancreatic divisum be treated in the following scenarios:
Asymptomatic
Mild/infrequent symptoms
Acute pancreatitis
No treatment
low-fat diet, analgesia, and rarely pancreatic enzyme supplementation
Managed medically similar to any episode of AP
1. Supportive Care, IV abx if infected
2. Endoscopic vs percutaneous drainage
3. Upsize Drain
4. VARD/surgical debridement
If develop abdominal compartment syndrome, viscus perforation, ongoing sepsis then OR earlier
What procedure to treat chronic pancreatitis with calcifications in the head and body, and CBD and PD dilations?
Frey Procedure - treats both head and body disease