History
Pain caused by pancreatitis is typically relieved by this maneuver...
sitting up or leaning forward
SIRS stands for
Some patients with severe pancreatic damage develop systemic complications including fever, acute respiratory distress syndrome (ARDS), pleural effusions, kidney failure, shock, and myocardial depression due to SIRS.
results from Activated pancreatic enzymes (phospholipase, elastase, trypsin, etc) and cytokines (tumor necrosis factor, platelet activating factor) released into the circulation from the inflamed pancreas
Monitoring this serum biomarker over the first 24 hours is useful when assessing for adequate fluid resuscitation
BUN. if it does not improve, consider increasing fluids. both the BUN at the time of admission and the change in BUN during the first 24 hours of hospitalization predict mortality
OTHERS: improvement in vital signs (goal heart rate <120 beats/minute, mean arterial pressure between 65 to 85 mmHg), urine output (>0.5 to 1 cc/kg/hour) and reduction in hematocrit (goal 35 to 44 percent).
This older scoring criteria assesses patients at 0 hours and at 48 hours with acute pancreatitis and attempts to predict mortality
Ranson's Criteria (slide)
- Disadvantages: Many scoring systems (eg, Ranson, Glasgow) take 48 hours to complete, can be used only once, and do not have a high degree of sensitivity and specificity. truly not the best test but it is still widely used.
- severity prediction tools using artificial intelligence and machine learning are currently being investigated
This doctor has swum in Lake Superior in December!
Dr. Boudreau
The superficial swelling and bruising of tissue around the umbilicus associated with pancreatitis is called...
Cullen's sign
bruising in the flanks is called grey turner's sign
Describe the pathogenesis of gallstone pancreatitis
reflux of bile into the pancreatic duct due to transient obstruction of the ampulla during passage of gallstones, or obstruction at the ampulla secondary to stone(s) or edema resulting from the passage of a stone
Fluid resuscitation with this type of fluid can reduce the risk of SIRS
Lactate ringers. compared to normal saline.
This common cause of pancreatitis has been most associated with poor outcomes
Alcoholic pancreatitis
- increased risk of pancreatic necrosis and the need for intubation in some reports
Dr. Pere went to medical school in this Irish town
Limerick
Acute severe pancreatitis can present without pain in what percentage of patients?
- 5 to 10 percent and they can have unexplained hypotension (eg, postoperative and critically ill patients, patients on dialysis, organophosphate poisoning, and Legionnaire's disease)
trypsin --> autodigests pancreatitis.
What is the rate of moderate fluid resuscitation in acute pancreatitis?
1.5 mL/kg/hour. this rate has shown to be adequate for most patients with acute pancreatitis based on WATERFALL trial. if evidence of volume overload, should give bolus (10-20mg/kg) first before fluid infusion
Name one of two acute local complications that can result from acute pancreatitis (bonus if both)
acute peripancreatic fluid collection, or acute necrotic collection
Dr. Hirte's ride or die football team
This person "discovered" Pancreatitis
Reginald Fitz
- the first case was described in 1652 but our understanding did not come until Fitz in late 19th centure
A patient gets pancreatitis after a trip to the desert, what question do you ask about the cause?
Any scorpion bites?
- Shout out to Dr. Owens, class of 2023, who always asked about any pet scorpions or exposoure to scorpions
When should you start antibiotics?
When an extrapancreatic infection (eg, bloodstream infections, pneumonia, and urinary tract infections) is suspected. this can occur in Up to 20 percent of patients with acute pancreatitis.
- Also in suspected infected pancreatic necrosis.
This can develop as a complication of necrotizing acute pancreatitis in approx 50% of patients
Portosplenomesenteric venous thrombosis (PSMVT)--it is rare in the absence of necrosis
Dr. Miller's favorite book genre
classical literature
This type of pancreatitis causes rapid onset (within 10-20min), well-localized pain
- gallstone pancreatitis, the pain is well localized and the onset of pain is rapid, reaching maximum intensity in 10 to 20 minutes.
- patients with pancreatitis due to hereditary or metabolic causes or alcohol, the onset of pain may be less abrupt and the pain may be poorly localized.
Name a gene associated with pancreatitis
PRSS1, CFTR, SPINK1
Gain-of-function mutations in the PRSS1 gene, which encodes cationic trypsinogen, result in an autosomal dominantly inherited form of hereditary pancreatitis. Mutations in the CFTR gene have been associated with an autosomal recessively inherited pancreatitis. Pancreatitis has also been associated with low penetrance mutations in the SPINK1, which may act as a disease modifier and lower the threshold for developing pancreatitis from other genetic or environmental factors.
The majority of "idiopathic" cases appear to have genetic risk, especially in younger patients (age <35 years)
Patients with genetic risk for pancreatitis may present as recurrent acute pancreatitis, or childhood pancreatitis without a known cause and eventually progress to chronic pancreatitis.
1. Plasmapheresis
2. Insulin (plasmapheresis is unavailable or cannot be tolerated)
- Worrisome features:
Hypocalcemia
●Lactic acidosis
●Signs of worsening systemic inflammation (two or more):
•Temperature >38.5°C or <35.0°C
•Heart rate of >90 beats/min
•Respiratory rate of >20 breaths/min or partial pressure of carbon dioxide (PaCO2) of <32 mmHg
•White blood cell (WBC) count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) forms
●Signs of worsening organ dysfunction or multi-organ failure as defined by Modified Marshall scoring system for organ dysfunction
This imaging-based scoring system is used to classify severity of pancreatitis based on CT findings
the Balthazar score (also called CT severity index)
- based on the degree of necrosis, inflammation, and the presence of fluid collections
This doctor played hockey
Dr. Spurlock