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Changing ideas about pancreatitis

Changing ideas about pancreatitis . Mark Lybik , MD Northside Gastroenterology Sept. 14, 2013. Pancreatitis. 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 . Pancreatitis .

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Changing ideas about pancreatitis

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  1. Changing ideas about pancreatitis Mark Lybik, MD Northside Gastroenterology Sept. 14, 2013

  2. Pancreatitis • 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. Pancreatitis • 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. Pancreatitis • Why is this important? • Because it is hard to take care of patients with acute and chronic pancreatitis

  5. Pancreatitis • How do we diagnosis pancreatitis ?

  6. Pancreatitis • 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

  7. Pancreatitis • 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

  8. Pancreatitis • 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

  9. Pancreatitis • 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

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

  11. Pancreatitis • 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

  12. Pancreatitis • 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

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

  14. Pancreatitis • When do you need an ERCP? • Typically when patients have gallstone and it appears they have cholangitis

  15. Pancreatitis • Chronic pancreatitis • Consider as a SYNDROME • Consist of PAIN, AND LOSS OF ENDOCRINE AND EXOCRINE FUNCTION

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

  17. Pancreatitis • Pain is a big issue • It can take years 5 to 10 to develop changes

  18. Pancreatitis • 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

  19. Pancreatitis • 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

  20. Pancreatitis • 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

  21. Pancreatitis • 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

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

  23. Pancreatitis • 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

  24. Pancreatitis • 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

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