1. Morning Report
March 25, 2011

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. Pancreatitis Amylase Lipase
Specificity 70%
Rises within 6-24 hours
Peaks at 48h
Normalizes 5-7d
Sensitivity decreases after h
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

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

15. 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

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

17. 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

18. 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

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

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

21. 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

22. 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