Changing ideas about pancreatitis

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 ?

7. 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

8. Pancreatitis • Who is at risk for development of pancreatitis? • Anyone is …. Children… Teens … adults and the elderly

9. 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

10. 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

14. 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

16. 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

17. 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

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

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

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

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

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

26. Pancreatitis • Biggest risk : • Smoking and alcohol • Alcohol is a big problem but it is NOT the cause in most people • > 5 drinks a day and smoking

27. 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

28. 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

30. Pancreatititis • 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

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

34. Pancreatitis • Treatment • Opiods … • Pregabalin300 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

35. 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