1. Mark Lybik, MD Northside Gastroenterology Sept. 14, 2013

2.  Acute Pancreatitis is responsible for over 280,000 admissions to hospitals  In 2010 the average length of stay was 5 days  At a cost of 2.9 billion dollars

3.  We do not have a number of admissions for chronic pancreatitis  The incidence is 3 to 10/ 100,000  This is new case per year  In Indianapolis that would be 30 to 100

4.  Why is this important?  Because it is hard to take care of patients with acute and chronic pancreatitis

5.  How do we diagnosis pancreatitis ?

7.  For the diagnosis of Acute Pancreatitis ◦ Upper Abdominal Pain ◦ Elevated amylase or lipase > 3 times the normal ◦ CT scan findings  Need at least 2 of these

8.  Who is at risk for development of pancreatitis?  Anyone is …. Children… Teens … adults and the elderly  There are also racial differences ◦ The African American population has a 2 -3 higher risk of pancreatitis ◦ Increase incidence in the pediatric population

9.  When does the treatment start?  Once the diagnosis is made, so normally that is in the ER  And this is an important point and one of the pitfalls that is seen …. Under treatment

10.  Important factors to look at  The HCT if it is > 44 patients are at higher risk of severe pancreatitis  Crt  Obesity has a 3 fold increase in severe pancreatitis ◦ Gallstone and nongallstone ◦ This is related to proinflammatory effects of unsaturated fatty acid generated by lipolysis, this is related to the volume of visceral adipose tissue

14.  These markers suggest that patients are dehydrated  And the guidelines suggest aggressive volume resuscitation  Remember that under resuscitation leads to a poor out come

16.  Patients need 20 ml/kg in the ER as a bolus  Then 3 ml/kg per hour with reassessment every 6 hours for fluid over load

17.  Average length of stay 3 to 5 days  If longer ◦ Nutritional support is a big concern ◦ Using a nasal jejunal tube is better then TPN

18.  Fever may develop; what to do? ◦ Antibiotic ? ◦ Fever develops because it is an inflammatory condition and not an infection ◦ No antibiotic are needed

19.  When do you need an ERCP? ◦ Typically when patients have gallstone and it appears they have cholangitis

22.  Chronic pancreatitis ◦ Consider as a SYNDROME ◦ Consist of PAIN, AND LOSS OF ENDOCRINE AND EXOCRINE FUNCTION

24.  Breakdown ◦ Early phase …. Mainly consist of PAIN ◦ Mistaken for acute pancreatitis ◦ Biggest point : clear cut evidence of chronic pancreatitis may not be here

25.  Pain is a big issue  It can take years 5 to 10 to develop changes

26.  Biggest risk : ◦ Smoking and alcohol ◦ Alcohol is a big problem but it is NOT the cause in most people ◦ > 5 drinks a day or ◦ Smoking, it has been known since 1982 that smoking was a risk factor for chronic pancreatitis ◦ And the amount of alcohol drank also noted to increase the amount one smokes ◦ Smoking gives one a 25% risk of chronic pancreatitis

27.  What is biggest problem with Chronic pancreatitis? ◦ PAIN ◦ PAIN develops much sooner then changes on ct or ultrasound or EUS ◦ Leads to a low quality of life; high disability ; and greater use of the health care system

29.  Where does the pain come from? ◦ In the 1990’s it was thought this was from obstruction of duct ◦ And relieving the obstruction should relieve the pain

31.  The changing thinking now is Pain is from the neurons  Increase in size and are surrounded by inflammatory infiltrates  And some enzymes and food stimulate the pain  Once the pathway is sensitized this goes to the spinal cord

33.  Once the nerve is sensitized it now can produce hyperalgesia  So pain is a wiring problem  And less of a plumbing problem

35.  Treatment ◦ Opiods … ◦ Pregabalin 300 mg bid has promise ◦ Antioxidents… 2 studies plus and minus ◦ EUS is safe but on limited effectiveness ◦ ERCP but pain may not resolve even if they have strictures or dilated duct or stone

36.  Acute pancreatitis : Needs better mgmt in the first 24 hours  Chronic Pancreatitis : Pain is the biggest problem and think now of wiring and not so much plumbing