GI: Acute Pancreatitis

When is ERCP indicated in acute pancreatitis?

- ERCP for gallstone pancreatitis if signs of cholangitis to relieve obstruction by stone. To be done by experienced endoscopist due to risk of worsening pancreatitis

What is macroamylasemia?

-Macroamylasemia : condition in which macromolecules of amylase exist bound to immunoglobulins or polysaccharides -Urine amylase:creatinine is nearly 0 in macroamylassemia and increased in pancreatitis

how long does it take for a pancreatic abscess to occur?

10-15 days after presentation of acute pancreatitis

What are the requirements for diagnosis of pancreatitis?

2/3: 1. Characteristic Abd Pain 2. + CT findings 3. Lipase > 3x ULN

Describe amylase levels in pancreatitis

> 3x ULN Level does NOT equal severity

Describe acute peripancreatic fluid collection and necrosis that can result from pancreatitis

Acute Peripancreatic Fluid Collection- acute fluid collection NOT encapsulated by a fibrous wall - doesn't take very long to form Necrosis or Walled off Necrosis- lack of blood supply & setup for abscess which increases mortality

What are the serological markers for pancreatitis? what is the most specific marker for acute pancreatitis? ************

Amylase: elevated in pancreatitis Lipase: most specific for pancreatitis macroamylasemia: get a urine amylase:creatinine

What is a sausage-shaped pancreas indicative of?

Autoimmune pancreatitis elevated IgG4 level

Answer the following

B Pseudocyst takes 4-6 weeks to form, phlegmon terminology no longer used, Duct disruption typically with trauma

What are the danger signals of acute pancreatitis?

Basis for SIRS criteria encephalopathy hypoxemia tachycardia >130 hypotension Hct oligouria

What is Grey Turner's sign?

Blue discoloration on the flanks. A sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum seen in acute pancreatitis

What type of imaging is used to analyze pancreatitis?

CT scan w/ IV contrast!! IV contrast lets you tell the difference between viable and necrosis

Describe pseudocysts as a sequelae of pancreatitis how long does it take to form?

Cystic, fluid-filled structure inside or extending outside of pancreas which matures (often communicates with pancreatic duct), rarely gets infected. Encapsulated by wall of granulation tissue. Takes 4-6 weeks after acute episode to form: have to have history of pancreatitis people might think that they have a hernia

Answer the following

D

Be familiar with different pancreas etiologies on ERCP

ERCP can cause acute pancreatitis moderate: note how it's dilated at the top because there's backup severe: massively dilated with big stones. rare normal: note it crosses the vertebral column (differentiate from common bile duct which does not pass the midline)

What are factors that prevent pancreatitis in normal individuals?

Enzymes in packages Trypsin inhibitor in each vacuole pro-enzyme form of enzymes pH and Calcium trypsin inhibitors in blood stream (a-1-anti-trypsin)

What are signs/symptoms of acute pancreatitis?

Epigastric pain: sharp pain that may go towards the back Eating can worsen the pain causing anorexia: can also lead to dehydration N/V pain may improve leaning forward SIRS response for shocky patients

What are the treatments for acute pancreatitis?

FLUID!!!! NPO: to quiet acinar cell (nothing by mouth) No ABX!! unless there is walled off necrosis or abscess Analgesia: note narcotics may worsen ileus O2 PRN Amylase/lipase monitoring not necessary!

What are the main causes of acute pancreatitis? *******************

Gallstone pancreatitis and alcohol use are the main two causes gallstone obstruction of common bile duct idiopathic: mostly secondary to microlithiasis but not super sure

What are the local effects of enzymes in acute pancreatitis?

Inflammation Third space losses Fat necrosis Pancreatic and peripancreatic necrosis inflammation starts to go back and wrap around the spine

What is acute pancreatitis?

acute inflammation/necrosis of pancreas, possibly spreading outside of pancreas to surrounding tissue

What are the only pancreatic enzymes without a pro-enzyme form?

amylase and lipase *

Be familiar with the following fluid collections in acute pancreatitis

black = air

What are possible complications of ERCP?

bleeding, infection, perforation pancreatitis 2-5% if you cannulate the pancreatic duct instead of the bile Rectal indometacin as NSAID to decrease inflammation and risk of pancreatitis

Be familiar with time course of lipase and amylase

can have normal amylase but lipase is still elevated just because lipase has a higher half life

Describe the cascade of pancreatitis - what is activating trypsinogen?

cathepsin B activate trysinogen to trypsin -activates other pro-enzymes -enzymes affect other targets

What genes are associated with hereditary pancretitis?

cationic trypsinogen gene mutations (PRSS1) most common also [SPINK1 mutations; CFTR (cystic fibrosis) mutations

Be familar with Ranson's criteria of severity

checks severity of acute pancreatitis at admission and then 48 hours after probs not on test increased ranson = increased mortality

What is chronic pancreatitis?

chronic lymphocytic inflammation on a background of fibrosis resulting in pancreatic insufficiency of both exocrine and endocrine function can lead to pancreatic atrophy

Describe relationship of pancreatic duct to vertebral column

duct should cross the vertebral column, if not can indicate displacement in trauma can tell it's damaged because the contrast is just being shot into the abdomen

What is Cullen's sign?

ecchymosis at the umbilicus due to retroperitoneal bleed occurs in pancreatitis too

What is shown in the following?

fat necrosis from calcification in acute pancreatitis

What is shown in the following?

grey-turner signs: bruising of the flank

What may cause false elevations of lipase?

heparin can falsely elevate

Be familiar with other causes of acute pancreatitis

hypertriglyceridemia > 1000 hypercalcemia: PTH, etc pancreatic divisum: 2 ducts don't come together during development infections trauma scorpion bites hereditary: cationic trypsinogen gene mutation and CFTR mutation tumors ERCP induced! autoimmune pancreatitis

How is mortality related to ranson's criteria?

increased ranson=increased mortality 6+ is usually necrotizing

What is shown in the following?

interstitial pancreatitis

What are the 2 types of acute pancreatitis? - interstitial vs. necrotizing which is more common?

interstitial: milder, no acinar cell death necrotizing: severe, most mortality

Label signs, lab tests, and differential diagnoses of acute pancreatitis

labs: amylase and lipase, BUN for management Fever and tachycardia more with SIRS criteria

What is the treatment for pseudocyst?

leave alone if asymptomatic can do needle aspiration (use ultrasound as guide), catheter drainage (infection), and surgical removal (no)

What are possible complications of severe pancreatitis?

left pleural effusion severe pain, obstruction, dissection, bleeding, infection, leakage (ascites, left side pleural effusions), rupture

Describe the levels of lipase, ALT, CRP, and BUN in pancreatitis

levels can stay up for awhile, don't need to keep them in the hospital for weeks ALT: >3 ULN (gallstone pancreatitis) CRP: >150 (severe acute pancreatitis) BUN: >20 (intravascular depletion and may be best lab to follow -- best prognostic factor. good for checking for dehydration)

What is pancreas divisum and what are the associated ducts?

minor duct *may be more susceptible to pancreatitis

What is shown in the following?

necrotizing pancreatitis

Does elevated amylase always mean pancreatitis? lipase?

no! Realize that not every elevation of amylase is pancreatitis lipase is mostly pancreatic related but can be other things (don't need to memorize chart)

Describe ARDS (adult respiratory distress syndrome) associated with acute pancreatitis associated with what condition? diagnosis? irreversible or reversible?

occurs in severe pancreatitis delayed onset associated w/ hyperlipidemia diagnosis: hypoxemia, normal wedge pressure possibly reversible

What is shown?

pancreatic divisum

What starts the cascade towards pancreatitis?

premature activation of trypsinogen

What is shown in the following?

pseudocyst obstruction: if asymptomatic leave alone

What is a colon cut off sign?

signs of pancreatitis, can cause colon damage sentinel loop

What is the use of a double pigtail stent?

stent from cyst to stomach which is used to drain the cyst

What is the use of MRCP in acute pancreatitis?

will give image of bile duct and pancreatic duct without radiation and risk of worsening pancreatitis. Can rule out pancreas divisum, tumor, stone, stricture, etc. lower risk than ERCP, can use this first to determine if ERCP is necessary much better than ERCP