Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury

1. Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury Sankar R. Chirumamilla M.D. PGY II Physical Medicine & Rehabilitation An Equal Opportunity University

2. Anatomy An Equal Opportunity University

3. Pancreatic Secretions Neurohumoral regulation Secretin & Cholecystokinin Parasympathetic predominant via vagus nerve Sympathetic – α receptors in pancreas and α1 in sphincter of oddi An Equal Opportunity University

4. Acute Pancreatitis “acute inflammation and destructive auto digestion of pancreas and peripancreatic tissue” (5). Most common cause in United States (70% to 80%) – Alcohol and gall stones Other – hypertriglyceridemia, drugs, iatrogenic, hereditary, and idiopathic An Equal Opportunity University

5. Abdominal pain, nausea, vomiting Serum amylase and lipase 3 times the upper normal limit Radiographic evidence of enlargement and edema of pancreas An Equal Opportunity University

6. Case 18 y/o female, restrained driver, involved in MVC. No h/o LOC, chemically paralyzed, intubated at scene. Initial GCS was 7. Trauma W/U R depressed temporal fracture ICH, IVH, SAH, No midline shift Multiple facial fractures T3 burst fracture with 8 mm retropulsion Mediastinal hematoma An Equal Opportunity University

7. Acute Care Right TP craniectomy Tracheostomy PEG TLSO brace for T3 burst fracture Antibiotics for Serratia pneumonia An Equal Opportunity University

8. Case cont. PMH & PSH: None Home medications: None Allergies: NKDA FH: HTN in mother SH: single, senior in high school, no H/O tobacco or alcohol or illegal drug use. An Equal Opportunity University

9. Case cont. Admitted to Disorders of Consciousness program on day 14 Rancho Los Amigos Level III First episode of dysautonomia on day 20 An Equal Opportunity University

10. Case cont. Hospital course/complications Pneumonia Paroxysmal Sympathetic Hyperactivity Otitis externa Vomiting / elevated amylase & lipase (day 66) Electrolyte abnormalities An Equal Opportunity University

11. Case cont. Elevated serum amylase & lipase Amylase – 231 Lipase – 161 US abdomen – negative CT Head - negative Bowel rest , IVF, changing TF to Vivonex Amylase – 57 Lipase – 42 An Equal Opportunity University

12. Pancreatitis in TBI Bouwman et al. in 1983 studied 27 patients for elevated serum amylase (1) zero our of 7 with maxillofacial trauma One out of 10 with head trauma but without ICH (10%) Six out of 10 with head trauma but with ICH (60%) None with clinical pancreatitis An Equal Opportunity University

13. Justice et al. studied 38 patients with intracranial bleeding for elevated amylase and lipase (2) 17 (44.7%) with elevated amylase & lipase 25 (65.7%) with elevated lipase None with clinical pancreatitis An Equal Opportunity University

14. Liu et al. retrospectively studied 75 patients (3) 11 (15%) patients had elevated amylase and lipase No clinical or radiographic evidence of pancreatitis Pancreatitis in high level spinal cord injury (4) An Equal Opportunity University

15. Proposed Theories Vagal stimulation (2) Change in central control (2) Cholecystokinin release from brain (2) Sphincter of oddi dysfunction (6) Autonomic failure (6) An Equal Opportunity University

16. Hypothesis Paroxysmal sympathetic hyperactivity or dysautonomia Sympathetic and parasympathetic mismatch Hypermetabolic state An Equal Opportunity University

17. Discussion PSH before onset clinical symptoms Serological confirmation Response to conventional treatment Normalization of serum amylase & lipase An Equal Opportunity University

18. Discussion cont. Serum amylase & lipase testing Not indicated if there is no clinical evidence May be indicated if there is clinical evidence Radiographic confirmation An Equal Opportunity University

19. Conclusion Adequate management of PSH Consider pancreatitis Pancreatitis workup It’s more than just pancreatitis An Equal Opportunity University

20. Questions ? An Equal Opportunity University

21. Thank You Dr . Silke Bernert M.D. Dr. Lumi Sawaki M.D. Dr. Sara Salles M.D. An Equal Opportunity University

22. References Bouwman D, Altshuler J, Weaver D. Hyperamylasemia: A result of intracranial bleeding. Surgery 1983;94:318- 323. Justice A, Dibenedetto R, Stanford E. Significance of elevated pancreatic enzymes in intracranial bleeding. South Med J 1994;87:889- 893. Liu K, Atten M, Lichtor T, Cho M, et al. serum amylase and lipase elevation is associated with intracranial events. Am Surg2001;67:215-220. Nobel D, Baumberger M, Eser P,et al. Nontraumatic pancreatitis in spinal cord injury. Spine 2002;27:E228-E232. An Equal Opportunity University

23. References cont. Sonnenday CJ, Simeone DM, McPhee SJ. Chapter 15. Disorders of the Exocrine Pancreas. In: McPhee SJ, Hammer GD, eds. Pathophysiology of Disease. 6th ed. New York: McGraw-Hill; 2010. http://www.accessmedicine.com/content.aspx?aID=5370194. Accessed May 16, 2012. Thor PJ, Goschinski I, Kolasinska-Kloch W, Madroszkiewicz D, Madroszkiewicz E, Furgala A. Gastric myoelectric activity in patients with closed head brain injury. Medical Science Monitor 2003;9:932-935. An Equal Opportunity University