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
