Pancreatitis March 25th

Pancreatitis - we use the 2/3 critieria. Typically symptoms, constant abdo pain radiating to the back, lipase 3 x normal limit and imaging of the pancreas to show inflammation. If we have typical symptoms with an elevated lipase, we may not need a CT of the pancreas (refer to Balthazar classification).

Like most internal medicine things we go through are causes such as infections, malignancies, genetic, autoimmune, etc.

1. drugs - azathioprine, steroids, valproic acid, thiazide
2. infections (though low yield but associated with viruses like mumps)
3. etoh
4. gallstones
5. familial
6. trauma
7. Sphinctor of oddi dysfunction

Most commonly - alcohol and gallstones. Everyone needs an abod ultrasound to rule out gallstones, hwoever, ALT 3 x normal limit has a positive predictive value of 95% so woudl consider US right away if they were jaundice, feverish with RUQ pain to suggest ascending cholangitis from a blocked stone which would give them a ticket for ERCP to get that stone out!

Remember - patients deemed "idiopathic" most often have biliary sludge or microlithiasis, this can be found by ERCP. Potentially an MRCP or endoscopic ultrasound can be used to look for tumors/cancer in individuals with B symptoms or elderly.

We have multiple scoring systems to predict mortality, choose one!

BISAP, APACHE 2, and the classic Ransons.

Bisap is quite easy, but it does incorporate you knowing SIRS criteria (needed 2/4).

Complications range from acute to chronic.

Acute
I mentioned ARDS in class, they also get atelectasis, and pleural effusions. As they secrete enzymes from the pancreas when it is inflamed, one theory for atelectasis is the release of phospholipase A2 which breaks down phospholipids, which make up a large portion of surfactant! NO surfactant? airways have trouble staying open!

The pleural effusion is usually left sided and is because a pancreatic-pleural fistula can form. If patients are febrile 48 hours after, consider abscess, CT and general surgery consult or IR to drain it.

Chronic
Splenic vein thrombosis is possible because this vein sits behind the pancreas, making it vulnerable. We are careful to anticoagulate these clots because of concerns of hemorrhage in an inflamed pancreas. Pseodocysts are the feared complication patients get AFTER their pancreatitis has resolved, with increasing abod pain, these are generally drained when not resolving after 6 weeks (classically) or >6 cm. They can be drained by GI or IR, often going through the stomach! Pancreatic insufficiency can result in diabetes, as well us vitamin deficiencies ADEK, we treat this with pancreatic enzymes. They can have chronic abdo pain, fat in stools (grey stools) and calcifcation seen on abdo xray.

So how do we treat pancreatitis? Often a conservative approach, manage pain with opioids, NG tube for an ileus, and we NOW know feeding earlier is better. Studies comparing NG vs NJ having shown vast differences, but ideally and NJ tube for someone who has pain or does not want to eat at 48-72 hrs is ideal because we would be bypassing the pancreas. We know feeding patients enterally compared to TPN has mortality benefit, this thought of providing GUT nutrition.

Finally, there are other causes of elevated lipase - DKA often it can elevated (mechanism not completely clear), perforated peptic ulcer, ischemic gut, HIV, renal failure. Need to look for classic symptoms!