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Pancreatitis chap. 87 tintinalli’s emergency medicine

Pancreatitis chap. 87 tintinalli’s emergency medicine. Robert Moosally, DO. acute pancreatitis. Most common causes: Alcohol* Biliary dz* Drugs* Infection Inflammation Trauma Metabolic disorders *make up most of the cases. pathophysiology.

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Pancreatitis chap. 87 tintinalli’s emergency medicine

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  1. Pancreatitischap. 87tintinalli’s emergency medicine Robert Moosally, DO

  2. acute pancreatitis • Most common causes: • Alcohol* • Biliary dz* • Drugs* • Infection • Inflammation • Trauma • Metabolic disorders *make up most of the cases

  3. pathophysiology • Activation of digestive zymogens in pancreatic acinar cells => autodigestion of pancreas • Edema • Interstitial hemorrhage • Vascular damage • Coagulation • Cellular necrosis

  4. clinical features • Midepigastric pain or LUQ pain • Constant, boring pain that radiates to the back, flanks, chest, or lower abdomen • Pain can be exacerbated by supine position; relieved by sitting with trunk & knees flexed • Nausea/vomiting • Abdominal bloating (gut hypomobility); dec. BS • Low grade fevers • Tachycardia • Hypotension (from 3rd spacing; shock; MODS) • Pleural effusion (left sided); rarely ARDS • Cullen sign – bluish discoloration around umbilicus • Grey Turner sign – bluish discoloration of the flanks

  5. diagnosis • Labs • Amylase – pancreas/salivary glands; low levels found in fallopian tubes, ovaries, testes, adipose tissue, small bowel, lung, thyroid, skeletal muscle & certain neoplasms; some excreted by kidneys so will also see elevations in renal failure; most sensitive at 36 hrs • Lipase – pancreas; also found in gastric and intestinal mucosa; liver; heparin administration can cause a release of lipase into the serum; also cleared by the kidneys so will be elevated in renal failure; longer half-life so will be elevated even when amylase at baseline **absolute levels do NOT correlate w/ severity of dz

  6. imaging • CXR • Used to r/o other causes; if you see calcifications of pancreas then indicates more chronic dz • May see sentinel loop indicating regional ileus • May see left sided pleural or pericardial effusions • US • Used to see dilatation of biliary tree or gallstones • Pancreatic edema or pseudocysts • CT • Better to visualize severity of dz and other anatomy

  7. prognostic markers • Usually pancreatitis is a self-limiting dz • 5-10% of cases suffer significant morbidity/mortality • Ranson criteria: • Age > 55 • BS > 200 mg/dL • WBC ct > 16,000/L • SGOT > 250 units/L • LDH > 700 IU/L

  8. treatment • “rest the pancreas” • NPO (no evidence to support the NGT, other than to remind the pt that they are NPO!) • FLUID RESUSCITATION!! • Parenteral narcotics • Antiemetics • If biliary pancreatitis, then requires emergent decompression • Antibiotics only in severe dz • Peritoneal lavage/laparotomy (ascites or hemor.)

  9. disposition • Mild dz that can be managed with outpt therapy can go home; pts tolerating PO and pain controlled • All others…….admit • Pancreatic abscesses need a surgeon

  10. chronic pancreatitis • Chronic inflammation of pancreas that causes irreversible damage to its structure and function • Most cases are alcohol related; second is idiopathic • Pathophysiology • Interstitial inflammation w/ duct obstruction & dilatation leading to parenchymal loss & fibrosis • Eventual impairment of both exocrine and endocrine pancreatic functions; the latter coming later in dz • Significant malabsorption syndrome does not occur until > 90% of glandular function is lost

  11. clinical features • Abdominal pain (midepigastric radiating to back) • Nausea/vomiting • Pain worse after alcohol or fatty meals • Pts will look chronically ill • Cachectic • Steatorrhea • Clubbing • Polyuria • Stigmata of liver dz (if alcoholic pancreatitis)

  12. diagnosis • Amylase/lipase may be normal • Glucose tolerance impaired (elev. fasting BS) • Elevated bilirubin & alk phos • CXR – will see calcifications in pancreas • CT or US will show complications of chronic pancreatitis (pseudocysts or abscesses)

  13. treatment • IV narcotics • Antiemetics • Correct fluid and electrolyte abnormalities • Relief of mechanical obstruction or complications • Correction of malabsorption • Alteration of dz course • 5 year mortality rate of chronic alcoholic pancreatitis in pts who continue to drink alcohol is 50%

  14. disposition • Most chronic pancreatitis pts can go home after any complications have been ruled out/addressed • Secure follow-up • Admit if pt has intractable pain

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