Indeed...
Today we discussed an approach to pancreatitis. A few points:
Acute = no pre-existing pancreatic pathology; usually resolves without permanent damage.
Chronic = pre-existing fibrosis/scarring/calcification. EtOH-induced is often acute on chronic.
Pancreatitis is essentially autodigestion, release of zymogens, and in severe cases, a retroperitoneal chemical burn injury.
Etiologies:
-EtOH
-Gallstone
-Drugs (commonly reported include some HIV medications, HRT, azathioprine, tetracycline, 5'ASA, sulfasalazine)
-Metabolic- hypertriglyceridemia, hypercalcemia
-Iatrogenic (esp. post-ERCP)
-Autoimmune
-Others- anatomic (pancreas divisum), scorpion bites (everyone's favourite), cystic fibrosis, infection
Symptoms: Epigastric abdo pain, better leaning forward (Ingelfinger's sign for medical jeopardy fans), radiating to back, N+V
Things to look for on exam:
Vitals: Tachypnea, tachycardia, fever
-jaundice
-abdominal distension, absent bowel sounds (ileus)
-cullen/grey turner signs
-dull lung bases from pleural effusion
-abdominal tenderness.
Lab: Lipase/amylase (NB- macroamylasemia, salivary gland pathology, and tubo-ovarian pathology give high amylase but normal lipase). Lipase and amylase support the dx, not make it. The levels fall off in days.
Imaging:
Acute = no pre-existing pancreatic pathology; usually resolves without permanent damage.
Chronic = pre-existing fibrosis/scarring/calcification. EtOH-induced is often acute on chronic.
Pancreatitis is essentially autodigestion, release of zymogens, and in severe cases, a retroperitoneal chemical burn injury.
Etiologies:
-EtOH
-Gallstone
-Drugs (commonly reported include some HIV medications, HRT, azathioprine, tetracycline, 5'ASA, sulfasalazine)
-Metabolic- hypertriglyceridemia, hypercalcemia
-Iatrogenic (esp. post-ERCP)
-Autoimmune
-Others- anatomic (pancreas divisum), scorpion bites (everyone's favourite), cystic fibrosis, infection
Symptoms: Epigastric abdo pain, better leaning forward (Ingelfinger's sign for medical jeopardy fans), radiating to back, N+V
Things to look for on exam:
Vitals: Tachypnea, tachycardia, fever
-jaundice
-abdominal distension, absent bowel sounds (ileus)
-cullen/grey turner signs
-dull lung bases from pleural effusion
-abdominal tenderness.
Lab: Lipase/amylase (NB- macroamylasemia, salivary gland pathology, and tubo-ovarian pathology give high amylase but normal lipase). Lipase and amylase support the dx, not make it. The levels fall off in days.
Imaging:
AXR: may show colon-cutoff sign or ileus
CT may show pseudocyst or necrosis in addition to stranding, inflammation
Prognostic factors: Development of organ failure, SIRS (look for ARF-most common, ARDS), necrosis, abscess, pseudocyst. Others: Ranson criteria, APACHE score, etc.
Therapy:
Prognostic factors: Development of organ failure, SIRS (look for ARF-most common, ARDS), necrosis, abscess, pseudocyst. Others: Ranson criteria, APACHE score, etc.
Therapy:
Largely supportive; monitor closely for complications.
Principles of managment:
1) Fluid resuscitate aggressively as needed
2) Watch respiratory status, and intervene if necessary (ABG's, etc)
3) Watch for other organ involvement (AKI, DIC, etc)
4) Nutrition: Do not rest the pancreas; start enteral nutrition (increased metabolic requirements, decreased bacterial translocation) - evidence for early PO feeding.
5) Pain managment
6) Antibiotics- very controversial; only convincing evidence is in pancreatitis with necrosis (there are scoring systems based on CT), in which case meropenem has proven benefit. In some cases, a fine needle aspirate of a collection is done to determine whether infected and only treated if positive.
7) If gallstone-related, ERCP and cholecystectomy (during current admission if mild or delayed if severe) reduces recurrence risk from 25% to 8%.
If severe deterioration, consider surgery for debridement, but this is high-risk.
Links:
1) Fluid resuscitate aggressively as needed
2) Watch respiratory status, and intervene if necessary (ABG's, etc)
3) Watch for other organ involvement (AKI, DIC, etc)
4) Nutrition: Do not rest the pancreas; start enteral nutrition (increased metabolic requirements, decreased bacterial translocation) - evidence for early PO feeding.
5) Pain managment
6) Antibiotics- very controversial; only convincing evidence is in pancreatitis with necrosis (there are scoring systems based on CT), in which case meropenem has proven benefit. In some cases, a fine needle aspirate of a collection is done to determine whether infected and only treated if positive.
7) If gallstone-related, ERCP and cholecystectomy (during current admission if mild or delayed if severe) reduces recurrence risk from 25% to 8%.
If severe deterioration, consider surgery for debridement, but this is high-risk.
Links:
Click here for an interesting paper highlighting common problems and pitfalls in pancreatitis management
Click here for a Cochrane review of antibiotics in pancreatitis
Click here for a trial comparing symtom-drive vs. standing benzos for alcohol withdrawal
Very well written and informative article, thank you :-)
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ReplyDeleteTook Onglyza off and on for a year. I have an enlarged adrenal gland. Still I await the outcome of that CT, but I know that much. Will find out more.
I had the CT because of chronic pancreatic pain that started out as "attacks" from a couple of times a month to finally after 3 months of use without interruption, "attacks" 2-3 times a week. My PA put Onglyza on my allergies list.
In the meantime, I lost almost 50 lbs in 5 months due to illness. Loss of appetite, pancreatic pain, chronic diarrhea, then eventually, inability to move my bowels. Severe back pain from the pancreas, and severe chest pain sent me to the ER where I was worked up for cardiac pain. I was cardiac cleared, but told my amylase was very low.
Still seeking a diagnosis, but I lay the blame squarely on Onglyza. I'd had pancreatic issues in the past, and argued with the PA that prescribed it, she was calling me non-compliant, and I feared repercussion from my insurance company.
I even took an article about the dangers of Onglyza, particularly in patients with a history, and she made me feel foolish.
I wish I had listened to my instincts, I fear not only damage to my pancreas that is irreversible, but also severe damage to my left kidney, though I have bilateral kidney pain.
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