Pancreatitis chap. 87 tintinalli

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Pancreatitis and Cholecystitis TINTINALLIS
CHAP. 82 (7e)
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acute pancreatitis

• Most common causes
• Alcohol
• Biliary dz
• Drugs
• Infection
• Inflammation
• Trauma
• Metabolic disorders
• make up most of the cases

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pathophysiology

• Activation of digestive zymogens in pancreatic
  acinar cells gt autodigestion of pancreas
• Edema
• Interstitial hemorrhage
• Vascular damage
• Coagulation
• Cellular necrosis

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clinical features

• Midepigastric pain or LUQ pain
• Constant, boring pain that radiates to the back,
  flanks, chest, or lower abdomen
• Pain can be exacerbated by supine position
  relieved by sitting with trunk knees flexed
• Nausea/vomiting
• Abdominal bloating (gut hypomobility) dec. BS
• Low grade fevers
• Tachycardia
• Hypotension (from 3rd spacing shock MODS)
• Pleural effusion (left sided) rarely ARDS

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Clinical features

• Cullen sign bluish discoloration around
  umbilicus
• Grey Turner sign bluish discoloration of the
  flanks

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diagnosis

• Labs
• Amylase pancreas/salivary glands. Most
  sensitive at 36 hrs
• Lipase pancreas also found in gastric and
  intestinal mucosa. Longer half-life so will be
  elevated even when amylase at baseline
• Preferred test
• Absolute levels do NOT correlate w/ severity of
  dz

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imaging

• Plain Films
• Used to r/o other causes
• May see sentinel loop indicating regional ileus
• May see left sided pleural or pericardial
  effusions
• US
• Used to see dilatation of biliary tree or
  gallstones
• Pancreatic edema or pseudocysts

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Imaging

• CT -Better to visualize severity of dz and other
  anatomy

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prognostic markers

• Usually pancreatitis is a self-limiting dz
• 5-10 of cases suffer significant
  morbidity/mortality
• Ranson criteria at presentation
• Age gt 55
• BGL gt 200 mg/dL
• WBC ct gt 16,000/L
• AST gt 250 units/L
• LDH gt 700 IU/L

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treatment

• rest the pancreas
• NPO
• FLUID RESUSCITATION!
• Maintain Urine OP of 0.5ml/kg
• Parenteral narcotics
• Antiemetics
• If biliary pancreatitis, then requires emergent
  decompression
• Abx If abscess. No evidence for
  prophylactic/mild cases

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disposition

• Mild dz that can be managed with outpt therapy
  can go home pts tolerating PO and pain
  controlled
• All others.admit
• Pancreatic abscesses need a surgeon

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chronic pancreatitis

• Chronic inflammation of pancreas that causes
  irreversible damage to its structure and function
• Most cases are alcohol related
• Pathophysiology
• Interstitial inflammation w/ duct obstruction
  dilatation leading to parenchymal loss fibrosis
• Eventual impairment of both exocrine and
  endocrine pancreatic functions
• Significant malabsorption syndrome does not occur
  until gt 90 of glandular function is lost

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clinical features

• Abdominal pain (midepigastric radiating to back)
• Nausea/vomiting
• Pain worse after alcohol or fatty meals
• Pts will look chronically ill
• Cachectic
• Steatorrhea
• Clubbing
• Polyuria
• Stigmata of liver dz

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diagnosis

• Amylase/lipase may be normal
• Glucose tolerance impaired (elev. fasting BS)
• Elevated bilirubin alk phos
• CXR will see calcifications in pancreas
• CT or US will show complications of chronic
  pancreatitis (pseudocysts or abscesses)

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treatment

• IV narcotics
• Antiemetics
• Correct fluid and electrolyte abnormalities
• Relief of mechanical obstruction or complications
• Correction of malabsorption
• Alteration of dz course
• 5 year mortality rate of chronic alcoholic
  pancreatitis in pts who continue to drink alcohol
  is 50

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disposition

• Most chronic pancreatitis pts can go home after
  any complications have been ruled out/addressed
• Secure follow-up
• Admit if pt has intractable pain

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Cholecystitis

• 4 major biliary tract emergencies
• Biliary colic (symptomatic cholelithiasis)
• Cholecystitis
• Gallstone pancreatitis
• Ascending cholangitis
• 4 Fs (the classical presenting pt)
• Female
• Forty
• Fat
• Flatulence

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pathophysiology

• Bile is made and secreted by hepatocytes stored
  in GB
• Wall of GB innervated
• with sympathetic
• parasympathetic
• nerves from celiac
• plexus

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pathophysiology

• Bile
• Water (80)
• Bile acids (10)
• Lecithin other phospholipids (4-5)
• Cholesterol (1)
• Conjugated bilirubin
• Electrolytes
• Mucous
• Various proteins
• Cholecystokinin (CCK) is stimulus for release of
  bile into small intestine

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types of gallstones

• Cholesterol (70)
• Radiolucent (calcium content lower here)
• Pigment (20)
• Black (pts w/ adv. liver dz hemolytic d/o)
• Brown (pts of Asian descent, bacterial/parasitic
  infection)
• Radiopaque (more calcium here)
• Mixed (10)

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Clinical features of acute cholecystitis

• Pain persisting gt 6 hours
• Nausea vomiting, anorexia
• Fever /- chills
• Hx of similar attacks/documented gallstones
• Pain becomes more localized to RUQ
• Murphys sign
• Signs of systemic toxicity, dehydration
• Localized peritoneal toxicity, distention
• Hypoactive bowel sounds

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specific presentations

• Kids infrequent. Gallstones may be idiopathic or
  due to hemolytic disorders, cystic fibrosis,
  obesity, ileal resection or long-term TPN
• Pregnancy increase of GB sludge/gallstones,
  predisposes cholelithiasis but rarely
  cholecystitis
• Elderly more likely to present with biliary
  sepsis/GB gangrene increased perioperative
  mortality (19)

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diagnosis

• High clinical suspicion
• US (modality of choice) CT not as sensitive
• Labs will most likely be normal
• CBC, CMP normal range
• Lipase to r/o pancreatitis
• Urine to r/o pyelo, uti, ectopic, kidney stones
• Plain films (esp. CXR to r/o pneumonia)
• EKG to r/o AMI ACS
• HIDA (sens. of 97 and spec. of 90)

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complications

• Mallory-Weiss tears
• Fluid electrolyte abnormalities
• Gallstone pancreatitis
• Ascending cholangitis (mortality can reach 100
  if no tx or improper tx)
• Cholecystitis leading to GB empyema
• Emphysematous (gangrenous) cholecystitis

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Treatment disposition

• If pt presents in shock, then IV fluids /-
  vasopressors, broad spectrum abx surgery to
  decompress biliary tree
• GB empyema develop gm neg. sepsis
• Broad spectrum axbx, fluids, stat surgery
• Gangrene of GB (segmental ischemia of GB wall)
  risk of perforation -gt surgery
• Emphysematous cholecystitis (gangrene of entire
  GB) pts are in septic shock

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Contrast CT scan showing emphysematous
cholecystitis with gallbladder wall disruption
(arrow), gas formation (arrowhead), and a biloma
Contrast CT scan showing gallstones (arrow) with
gallbladder rupture and fluid localized at the
gallbladder fossa (arrowhead)
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Abdominal radiograph of acalculous emphysematous
cholecystitis demonstrating curvilinear air
pattern conforming to the shape of the
gallbladder wall
CT images of emphysematous cholecystitis - same
patient
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Ultrasound findings of acalculous cholecystitis
include marked gallbladder wall thickening and
pericholecystic fluid.
Transverse ultrasound demonstrates marked
gallbladder wall thickening and pericholecystic
fluid collection in a patient with AIDS who was
managed conservatively