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Welcome. Today we will discuss disorders of the pancreas.
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So, we'll begin right away with a case.
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A 38-year-old man is evaluated in the ED for acute epigastric pain.
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The pain began four hours ago, radiates to the back
and is associated with nausea and bilious vomiting.
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He has no medical conditions. He drinks six beers a day.
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Vitals are notable for a heart rate of 110 and a respiratory rate of 25.
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He has epigastric tenderness without guarding or rebound.
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Bowel sounds are hypoactive. No jaundice is noted.
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His lab studies reveal a white cell count of 18,000 and a serum lipase of 1600.
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Abdominal ultrasound shows a normal gallbladder without biliary dilatation.
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What are the best initial steps in management?
So let's look at some key items in this case.
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He has acute abdominal pain radiating to the back.
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And he's a patient with known alcohol use disorder.
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In addition, his vitals are notable for tachycardia and tachypnea.
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And he has leukocytosis indicating SIRS or systemic inflammatory response syndrome.
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His labs otherwise are notable for an elevated serum lipase.
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And he has a normal gallbladder on his ultrasound.
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So, before we talk about management, let's talk about acute pancreatitis.
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How does acute pancreatitis occur?
So, the pathogenesis of pancreatitis begins with an obstruction of the pancreatic duct
or some trigger for pancreatic inflammation.
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Blockage of the pancreatic duct to then leads to premature activation of the pancreatic enzymes
that are normally secreted to help with digestion.
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When these enzymes are secreted and they have nowhere to go,
they then begin to auto digests the pancreas and create a lot of local inflammation.
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This then can contribute to capillary leak syndrome
and ultimately SIRS or systemic inflammatory response syndrome
which can appear as like sepsis.
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And in the worst-case scenario can develop multi-organ failure.
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There are many different causes of acute pancreatitis.
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One mnemonic that I find helpful
and that you will probably will encounter is the, IGETSMASHED mnemonic.
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This stands for idiopathic, gallstones, ethanol and trauma and all of the etiologies you see here.
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Note that about 80% of all cases are related to gallstones and ethanol.
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If you don't remember this mnemonic, note that there are many causes
that are listed here for your reference.
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I will point out that many medications can cause pancreatitis
some of which include hydrochlorothiazide, furosemide and azathioprine,
so all medications that can be used commonly.
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And infections can also cause pancreatitis
including mumps, Coxsackie virus and cytomegalovirus.
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So, the symptoms of acute pancreatitis usually include, severe upper abdominal pain
which often radiates to the back because of the anatomic location of the pancreas.
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Patients may present with fever and nausea and vomiting as well.
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The diagnosis is made based on having at least two of the three following clinical criteria.
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So, they must have an acute onset of upper abdominal pain.
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They may also have a serum amylase or lipase greater than three times the upper limit of normal.
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Or they may have characteristic findings of pancreatitis on imaging
which can be either a CT with contrast, an MRI or ultrasound.
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Here on the right, you can see an example of a CT of the abdomen showing acute pancreatitis.
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So you see an edematous or swollen pancreas with adjacent fat stranding around it.
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This is typical of acute pancreatitis on CT scan.
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As a quick high-value care aside, you should not check for both amylase and lipase
when you suspect acute pancreatitis.
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A serum lipase is enough to make the diagnosis
because it has better sensitivity and is elevated for longer than the amylase.
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So just remember when faced with acute pancreatitis, just test for lipase.
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So, now let's talk about the treatment and scoring severity of for acute pancreatitis.
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There are several severity scoring systems we can use to help us determine a patient's prognosis.
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They include the Apache II system and Ranson's criteria.
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I'm not gonna go into detail about what they include, but you can easily look them up.
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The management of acute pancreatitis depends mostly on aggressive IV fluid resuscitation.
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You should remember that pancreatitis because of all of the inflammation
occurring in the pancreatic tissues is similar to having a severe burn inside the body.
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So, with this, we should provide aggressive fluids.
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You also want to offer the patient to have a brief period of bowel rest.
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Keep in mind that once the patient feels a little bit better and their nausea, vomiting
and abdominal pain have improved, you can safely restart oral feeding.
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If they continue to feel terribly and they're not able to eat after 72 hours,
then evidence shows that starting enteral nutrition
by either a nasogastric tube or a nasojejunal tube can improve the patient's outcome.
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A third element of management is offering pain control as patients often have very severe pain.
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And lastly, you want to also give antiemetics to help them with their nausea.
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So, there are many complications that can occur from acute pancreatitis.
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The first one is just a peripancreatic fluid collection.
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This can happen early in the course of pancreatitis and usually resolved spontaneously.
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So no special management is needed.
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On the other hand, you may develop a pancreatic pseudocyst
which occurs usually about four weeks or more after the first episode of pancreatitis
and it is a persistent collection of fluid around the area.
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We usually manage this by just observing the pseudocyst
but if the patient becomes symptomatic or there is rapid enlargement of the pseudocyst,
you may drain the pseudocyst.
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The next complication is necrotizing pancreatitis.
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This is when there is such severe inflammation
that patients develop necrosis of the pancreas and any adjacent tissues.
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This makes them also at very high risk for developing an infection to the area.
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So, we manage them with providing broad-spectrum antibiotics if they deteriorate clinically.
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Because of all of the local inflammation,
patients may also present with splanchnic venous thrombosis.
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So you may have a clot form and any of the veins surrounding the pancreas
including the splenic vein, portal vein or the SMV.
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The management is purely by treating the underlying inflammation or pancreatitis.
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And lastly, one of the most dreaded complications
of acute pancreatitis is abdominal compartment syndrome.
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This is when the amount of inflammation within the abdomen has exceeded the pressure.
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So, an intra-abdominal pressure of greater than 20 mmHg along with organ failure.
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And we manage these patients with supportive care.
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In very severe cases, we may need to do surgical decompression
which involves opening the abdomen to allow relief of the high-pressure.
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So, we can now talk about all of these complications in terms of imaging.
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On imaging, you may see necrotizing pancreatitis
shown here with an area of walled off necrosis.
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The second thing you may see is a large collection of dark color fluid as shown here.
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This -- if you see this after about four weeks after the initial pancreatitis episode,
would be a pancreatic pseudocyst.
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Next, you may see a specific type of splenic vein thrombosis leading to infarct of the spleen.
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Here, you can see on the very innermost tip of the spleen a small area of darkening
which is the area that has been infarcted because of a thrombosis.
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And lastly, you may see evidence of ascites on imaging.
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So here on CT, the dark areas of fluid in the free abdomen or peritoneum represents ascites.
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So now let's return to our case.
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We had a 38-year-old man who has now acute abdominal pain radiating to the back.
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He has known alcohol use disorder.
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He has SIRS or the systemic inflammatory response syndrome
and an elevated serum lipase with a normal gallbladder on ultrasound.
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So, if we put this all together, we can suspect that he has acute pancreatitis
from his underlying alcohol use. He now has SIRS.
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And importantly, since his gallbladder looks normal on ultrasound without any gallstones,
we know that the alcohol was likely the trigger for his pancreatitis.
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So the best initial steps in management include giving aggressive IV fluids,
allowing for a brief period of bowel rest, so keeping patients NPO.
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Offering pain control and antiemetics.