Pancreatitis

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Quick Reference

Acute Pancreatitis - The Operative Review Of Surgery

Acute

Etiology:

• Gallstones (~40-60%).(30243452)
• Alcoholism (~30%).
• Hypertriglyceridemia (~10%).
• Hypercalcemia.
• Medications include:(29736167)
  • Antibiotics: tetracyclines, sulfonamides, pentamidine, HIV medications, isoniazid, metronidazole.
  • Immunosuppressives: azathioprine, sulfasalazine, mesalamine, 6-mercaptopurine.
  • Cardiac: amiodarone, losartan, furosemide, pravastatin, simvastatin.
  • Valproic acid.
  • All-trans-retionic acid (ATRA).
  • Glucagon-like peptide-1 agonist therapy for diabetes.
• Posterior penetrating ulcer.
• Trauma.
• Iatrogenic:
  • ERCP (4%)
  • Endoscopic ultrasound (EUS) with fine needle aspiration.
  • Surgery (including aortic surgery or CABG).
  • Radiation therapy,
• Pancreatic malignancy:
  • Intraductal papillary mucinous neoplasms (IPMNs).
  • Adenocarcinoma.
• Cystic fibrosis
• Autoimmune
  • IgG4 deposit disease

Clinical Features:

• Abdominal pain consistent with acute pancreatitis
• Persistent, severe, radiates into the back, worse when lying flat

Physical Exam Findings:

• Pain:
  • Typically in epigastric area or left upper-quadrant, may radiate to the back, may be relieved by sitting.
  • Epigastric tenderness on exam is usually present.
• Persistent nausea/vomiting.
• Hemorrhagic pancreatitis may cause Cullen Sign and Grey Turner Signs - this suggests a high disease severity.

Diagnosis:
2 of 3-

• Lipase 3x ULN
• Imaging
• Symptomology

Electrolytes and Friends:

• Calcium: Rarely, hypercalcemia is a rare cause of pancreatitis. More commonly, pancreatitis may cause hypocalcemia (which can occasionally be symptomatic).
• Triglyceride level: >1,000 mg/dL (>11.2 mM) suggests hypertriglyceridemic pancreatitis.
• Liver function tests: Significantly elevated bilirubin and alkaline phosphatase suggest obstruction, raising a possible concern of simultaneous ascending cholangitis.
  Imaging:
• RUQ US
• CT if required

Management:

• Pancreatoseptic Equivalence

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Chronic

Irreversible process resulting from chronic inflammation resulting in fibrosis and progressive destruction of both exocrine and endocrine function of pancreas

Etiology:
TIGAR-O classification
• Toxic-metabolic 60%
• Idiopathic 25%
• Genetic
• Autoimmune
• Recurrent or severe acute pancreatitis
• Obstructive

Clinical Features:

• Abdominal Pain
• Nausea and emesis
• Exocrine dysfunction (Steatorrhea)
• Endocrine dysfunction (i.e. Diabetes)
• Weight loss
• Fatigue
• Anorexia

Diagnosis:

Lipase generally lower than acute, Not useful in the diagnosis of chronic pancreatitis. Once exocrine/endocrine insufficiency sets in may not elevate.

• CT imaging

  • Calcifications
  • Dilated pancreatic duct
  • Pseudocyst
  • Gland atrophy

• ERCP/MRCP

  • Ductal dilation with stricturing
  • Blunting of side branches
  • Pancreatolithiasis