Morning Report March 25, 2011

Pancreatitis Causes Adult Children Gallstones Alcohol Blunt trauma Idiopathic (25%) Drug-related Infections Mumps, Enterovirus, EBV, HepA, Coxsackievirus B Gallstones less common Still look for them Pancreas is fixed and retroperitoneal – mild trauma may transmit injury Gallstones – overweight teens Also look for alcohol abuse in adolescents

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

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

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

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

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

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

Pancreatitis Amylase Lipase 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 3 times the upper limit of normal

Pancreatitis Other labs CBC Chemistry LFTs Coags Systemic-wide effects

Pancreatitis Imaging US CT 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

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

Pancreatitis Treatment Admission Supportive 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 Follow the UOP for patients with pancreatitis because they are likely to third space

Pancreatitis Treatment Nutrition Oral feeding NJ TPN 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

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

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

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

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