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Morning Report

Morning Report. March 25, 2011. Pancreatitis. Causes Adult Gallstones Alcohol Children Blunt trauma Idiopathic (25%) Drug-related Infections Mumps, E nterovirus , EBV, HepA , Coxsackievirus B Gallstones less common Still look for them. Pancreatitis. Drug-related Idiosyncratic

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Morning Report

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  1. Morning Report March 25, 2011

  2. Pancreatitis • Causes • Adult • Gallstones • Alcohol • Children • Blunt trauma • Idiopathic (25%) • Drug-related • Infections • Mumps, Enterovirus, EBV, HepA, Coxsackievirus B • Gallstones less common • Still look for them

  3. Pancreatitis • Drug-related • Idiosyncratic • Direct toxic effect • Timing • Depends on drug • Few weeks to many months • Not very straightforward • Drugs • Valproic Acid • Azathioprine • Corticosteroids • Sulfasalazine • Cimetidine • Estrogens • Thiazides • Of note • 6MP and pentamidine have also been known to cause pancreatitis

  4. Pancreatitis • Other causes • Hypercalcemia • Hyperlipidemia • Vasculitic diseases • SLE, HSP and Kawasaki • Sepsis • Shock • Multiorgan failure • CF

  5. Pancreatitis • Pathogenesis • Activation of enzymes • Autodigestion • Tissue Injury • Proinflammatory and cytokine responses • ARDS, DIC, multiorgan failure • Because there is no capsule, the inflammation can spread easily to other structures

  6. Pancreatitis • Presentation • Abdominal pain • Location • Mid-epigastric • R or LUQ • Quality • Constant • Boring • Radiation to back • Also flank, chest or lower abdomen • Aggravators • Lying supine • N/V • +/- Jaundice

  7. Pancreatitis • FH • If present look for hereditary systemic or metabolic disorders • Ask about • Diarrhea, vasculitis, joint pain, rashes and pulmonary diseases • PE • Vary depending on severity • Mild fever • Tachycardia • 30-40% hypotension • Abdominal tenderness with absence of peritoneal irritation

  8. Pancreatitis • Late Signs • Grey Turner sign • Large ecchymoses in flanks • Cullen sign • Ecchymoses in umbilical area • Represent blood dissecting from the pancreas along fascial planes

  9. Pancreatitis • Amylase • Specificity 70% • Rises within 6-24 hours • Peaks at 48h • Normalizes 5-7d • Sensitivity decreases after 24-48h • Lipase • Rises within 4-8h • Peaks at 24h • Normalizes 8-14d • Lipase also exists in other tissues • The degree of elevation is not a marker of severity

  10. Pancreatitis • Other labs • CBC • Chemistry • LFTs • Coags • Systemic-wide effects

  11. Pancreatitis • Imaging • US • Gallstones • Dilation of the biliary tree • Confirm diagnosis of pancreatititis • Enlarged edematous pancreas • Rule out obstructive anomalies • CT • Complicated cases • Hemorrhage, pseudocyst, abscess or vascular abnormalities • Considering surgery • Deteriorating course

  12. Pancreatitis • Mimickers • Bowel perforation • Ischemic bowel • Ruptured ectopic pregnancy • All may mimic pancreatitis and cause an elevation in amylase

  13. Pancreatitis • Treatment • Admission • Unpredictable course • Possible complications • Supportive • Fluids • Follow UOP • Pain medication • Meperidine • Less likely to cause spasm of the sphincter of Oddi • Nutrition • GI • Consult if gallstones • Surgery • If focal findings are present on US or worsening condition

  14. Pancreatitis • Treatment • Nutrition • Oral feeding • Time course depends • Mild cases • Early feeding and advancement is encouraged • Pain improvement and decreased narcotic requirement • 24-48h • NJ • Elemental or semi-elemental • Increased protein and decreased fat • Preferred to TPN if tolerated • Intestinal barrier • Eliminates complications of parenteral therapy • TPN • If nutritional goals not met in 2 days

  15. Pancreatitis • Complications • Shock • Hyperglycemia • Decreased insulin and increased glucagon • Hypocalcemia • Sequestration into necrotic areas • Hypoalbuminemia • Hypomagnesemia • Hyperglucagaonemia • Inactivation of PTH

  16. Pancreatitis • Complications • Pseudocysts • 2-3 weeks after acute episode • Long-term • Chronic pancreatitis • Recurrent pancreatitis • DM • Digestive disorders • Malabsorptive disorders

  17. Pancreatitis • Complications • Predictibilityof complex course • Elevations of • Glucose • LDH • BUN • Decreases of • Hct • Ca • Alb • Partial pressure of Oxygen • Ranson’s criteria • Other criteria exist as well

  18. Pancreatitis • Prognosis • Most patients • Mild, self-limited • 15-20% Severe and complicated • Mortality rate • 5% if mild initial presentation • Very high if hemorrhagic or multisystem

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