Acute Pancreatitis

hello on today's episode of intern crash course I'm discussing acute pancreatitis I'll start with its ideologies in the United States roughly half of cases are caused by gall stones however given how common gall stones are in the general population just finding stones in the gallbladder is not enough to definitively diagnose them as the etiology about one-quarter of cases are due to alcohol of the remaining quarter a significant number are idiopathic and the remaining cases include ERCP hypertriglyceridemia hypercalcemia pancreatic cancer particularly in those patients over the age of 50 hereditary predispositions to pancreatitis particularly in those under the age of 35 and very rarely medications acute pancreatitis is rarely a diagnostic mystery patients present with the acute onset of constant epigastric pain with a minority reporting the most severe pain being in the right or left upper quadrants about how the patients report the pain radiates to their back most have nausea and vomiting that's the presentation in most people the concurrent presence of dis mia which is rare at the time of presentation suggests the development of pleural effusions they RDS or abdominal compartment syndrome on exam almost all patients have epigastric tenderness a minority will also have abdominal distension secondary to an ileus and/or the development of ascites peri umbilical and flank ecchymosis are rare and suggest retroperitoneal hemorrhage secondary to pancreatic necrosis moving on to tests lipase elevation is nearly universal and is both more sensitive and more specific than amylase so much so that in my opinion you should not even bother ordering amylase to make this diagnosis having said that the degree of lipase elevation does not predict severity of disease like bass reduction does not track well with clinical improvement and trending cereal lipase levels is probably not helpful other common lab abnormalities seen include leukocytosis an elevated hematocrit from hemo concentration hypocalcemia which can mask the rare patient who develops pancreatitis due to hypercalcemia elevated urea or B un and either hyper or hypoglycemia if imaging is necessary abdominal CT is usually preferred though MRI and ultrasound are occasionally used for example in cases of kidney injury or pregnancy overall pancreatitis can be diagnosed when two of the following three things are present a consistent clinical history a lipase above three times the upper limit of normal and consistent imaging findings once the diagnosis of acute pancreatitis has been established there are four additional components to the patient's evaluation and treatment classify the severity initiate acute treatment assess for complications and assess for the underlying etiology the most common way to classify pancreatitis is the revised Atlanta classification system this first categorizes cases into either interstitial indominus acute pancreatitis or necrotizing pancreatitis depending on the pancreas is radiographic appearance then the severity of each is graded mild if there is no organ failure and no complications including no peri pancreatic fluid collections moderate if there is organ dysfunction lasting less than 48 hours and or there are complications without prolonged organ failure and severe if there is organ failure lasting longer than 48 hours there are several scoring systems used for prognostication in pancreatitis such as ransoms criteria but all have significant limitations for example patients generally look pretty similar at the time of initial presentation and it can take a few days before they start to differentiate out into those who will recover and go home quickly and those who will develop multi organ failure and stay in the ICU for weeks there are three major components to the acute treatment of pancreatitis the trickiest of which is fluid management almost all patients present with hypovolemia due to a combination of poor oral intake vomiting and third spacing meaning fluid leaking into places shouldn't be such as the development of ascites in the peritoneal space and the development of edema and fluid collections in the peri pancreatic and retroperitoneal tissues in the absence of a dramatic sodium derangement fluid resuscitation should be done with isotonic crystalloid lactated ringers is probably slightly better than normal saline except possibly in those patients who are hypercalcemia since there is a small amount of calcium in LR the general approach to fluid management is similar to patients with sepsis however anecdotally that is in my experience under resuscitation in pancreatitis is a more common mistake than over resuscitation beyond fluids another important component of acute treatment is pain control IV opiates that is morphine fentanyl and hydromorphone are necessary for most patients now because a quarter of patients with pancreatitis have problems with alcohol there is frequently some resistance to providing opiates to those in that category however also consider that pancreatitis is usually a very painful condition most patients need IV opiates only for a few days we are not committing them to an outpatient prescription the third component of treatments is nutritional support it's debated as to whether patients should be routinely made and P or presentation the competing considerations are that oral intake of food can stimulate pancreatic secretions that could worsen inflammation versus the fact that the GI mucosa requires nutrition to maintain its integrity and that there is a theoretical that is unproven increased risk of infection in patients who are without all nutrition for a prolonged period of time regardless of where one falls in that particular debates in most patients a limited low-fat solid diet can be initiated within 48 hours if pain and signs of inflammation are improving patients do not need to be fully pain free in order to eat however in patients with severe disease or persistent pain that is preventing them from eating a feeding tube should be considered a nasal jejunal tube is probably better than a bedside nasal gastric tube TPN on the other hand carries a lot of risk and should be avoided if at all possible when it comes with the complications of pancreatitis flu collections are the most common and the most complex to deal with there are four basic types of collections depending on whether they are are or are not associated with pancreatic necrosis and whether they do or do not have a well-defined wall which typically takes around four weeks to develop about 80% of collections are not associated with necrosis before they have a well-defined wall they're referred to as acute peri pancreatic fluid collections and after they have a wall they become pancreatic pseudocyst s' in the 20% of collections that are associated with necrosis they're initially referred to as an acute necrotic collection and later become walled off necrosis any of these collections may be sterile or infected though infections are more likely in necrotic collections about one third of patients when the closest will develop infection which typically comes two to four weeks after illness onset although these collections can look scary radiographically there is poor correlation between extent of necrosis or size of collection and the risk of infection here's an example of an acute necrotic collection on it and abdominal CT to orient you here is the liver here are the kidneys and this black stuff here is just normal air inside the lumen of the GI tract and this grayish Hayes is edema and poorly demarcated fluid in the region where the pancreas is supposed to be after about four weeks this patient went on to develop walled-off necrosis now there is a thin but well-defined walls surrounding the fluid there still appears to be some solid necrotic elements inside so how do we treat these there are two basic questions related to treatment does the patient need antibiotics and do we need to drain and or debride the collection and/or necrosis starting with antibiotics these are indicated if there is evidence the fluid is infected this evidence can include a positive culture if the fluid is aspirated which is not routinely done due to the risk of introducing infection if the space is actually startled gas within the collection seen on imaging or clinical deterioration after a period of stability if antibiotics are started common empiric options include a carbapenem or the combination of cefepime and metronidazole but consider your hospital's local resistance patterns with drainage and debridement this is generally only indicated if there is suspected infection or if the patient has moderate to severe symptoms such as intractable pain or problems from the collection compressing local structures or if the fluid is rapidly enlarging in size with the expectation that it will begin to cause problems soon one option for intervention is percutaneous drainage performed by ir at academic centers this has been partially replaced by endoscopic drainage plus or minus endoscopic debridement however this requires significant local expertise and of course there is surgical debridement with what is referred to as a nekross ectomy that's always an option the one whose frequency has been declining due to higher rates of mortality and complications compared to the less invasive approaches as a very general rule delayed debridement is preferable over early debridement as the procedure will be technically easier and allow better salvage of viable pancreatic tissue but it depends on the patient's clinical stability likewise a minimally invasive approach is preferable over an open procedure if possible however no single approach is best for all patients a significant number of cases of walled-off necrosis will resolve on their own without any invasive procedure at all so a conservative approach may be reasonable for some patients if there is uncertainty regarding the appropriate course of action consulting the relevant sub specialist early or referring the patient to a tertiary care center is never the wrong thing to do there are a few other notable complications of acute pancreatitis abdominal compartment syndrome occurs when edema ascites and bowel distension from an ileus collectively becomes severe enough that the in high intra-abdominal pressure starts to cause organ dysfunction mechanisms of dysfunction can include poor renal perfusion due to compression of the renal veins and elevation of the diaphragm leading to a number of pulmonary complications particularly in mechanically ventilated patients there is no one specific threshold of intra-abdominal pressure at which this starts to happen though most patients will have developed it once the pressure is above 25 millimeters of mercury intra-abdominal pressure can be measured via an intra bladder pressure transducer or by using a Foley catheter vented to the outside air as a manometer another complication is hemorrhage which can occur within the GI tract the peritoneal cavity the retroperitoneal space within the aforementioned fluid collections or within the pancreatic parenchyma itself the hemorrhage usually results from enzymatic degradation of local vessels in the peri pancreatic tissues splanchnic million thrombosis can involve the splenic vein hepatic vein or the superior mesenteric vein it can be detected incidentally on imaging but can also lead to small bowel ischemia acute hepatic dysfunction and GI bleeding secondary to varices depending on the specific location of the thrombus there is currently no consensus on the use of anticoagulation for these patients a decision for which is complicated by the aforementioned risk of hemorrhage pancreatic duct disruption secondary to pancreatic necrosis can worsen the extent of necrosis and lead to leakage of pancreatic fluid directly into the peritoneal cavity it usually requires stenting via ERCP or surgery and acute respiratory distress syndrome can be seen as a manifestation of systemic inflammation in the most severe cases it usually requires intubation and mechanical ventilation when it comes to determining the etiology of the pancreatitis critical elements of the history include a history of symptoms of gallstone disease and the patient's alcohol usage other questions to ask about are things like a history of weight loss in the weeks and months preceding the acute illness which could suggest an underlying malignancy medication history though for the vast majority of patients with pancreatitis who are also on a medication that's associated with pancreatitis the presence of both is a coincidence and not cause and effect and a family history of pancreatitis that could suggest a rare hereditary cause lab tests that all patients should get include liver function tests looking primarily for evidence of biliary disease triglycerides calcium and if normal it should be repeated in several weeks because patients with hypercalcemia induced pancreatitis can have a transiently normal calcium level at the time they present to the hospital and if relatively young or if there is a family history of pancreatitis consider genetic testing if it's available finally if the etiology remains uncertain consider an MRCP and/or endoscopic ultrasound in several months particularly if the patient's age is over 50 as pancreatic malignancies can be obscured by inflammation on imaging taken at initial presentation some final considerations patients with gallstone pancreatitis should have a cholecystectomy if there is no pancreatic necrosis it's preferable to do it during the same admission because the short-term recurrence rate is relatively high if there is pancreatic necrosis one should wait several months all patients should receive inpatient alcohol treatment counseling prior to discharge and finally if there is one single take-home message from this video it is to never underestimate the potential of a patient with acute pancreatitis to decompensate quickly they can go from being a clinically stable floor patient who looks ready for discharge to septic shock and multi organ failure in a matter of hours so it be generous with early resuscitation frequently reassess and if you are thinking about consulting of sub specialists you should probably go ahead and do so [Music] you

Channel: Strong Medicine

Views: 72,391

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Id: RvYS2RFz4LU

Length: 15min 51sec (951 seconds)

Published: Sun Jun 28 2020