Pancreatitis

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Resident Version

Acute and Chronic Pancreatitis Module

Created by Dr. Teodora Konstantinova

Objectives:

1.  List two differences in the diagnosis of acute and chronic pancreatitis.

2.  Name 4 risk factors for developing pancreatitis

3.  List two differences between treatment approaches to acute and chronic pancreatitis

4.  Use Ranson criteria to predict severity of acute pancreatitis.

References:

1.  Whitcomb D. C., Acute pancreatitis, N Engl J Med 2006, 354:2142-2150

2.  Steinberg W, Tenner S, Medical Progress: Acute pancreatitis, NEnglJMed 1994, 330:1198-1210

3.  Michael L. Steer, MD, Irving Waxman, MD and Steve Freedman, MD,  Medical progress: Chronic Pancreatitis, N Engl J Med 1995, 332:1482-1490

4.  Ranson JH, Diagnostic Standards for Acute Pancreatitis World J Surg 1997, 21:136-42

CASE:

HPI: A 60 yo female presents to the ER with severe mid-epigastric pain with radiation to the back, nausea and vomiting that started after lunch the previous day.  Vomiting did not relieve the pain.  The patient also reports coughing with yellow sputum for about a day.  She doesn’t report fever, but states she has “chills” post emesis.  

PMH:

HTN, depression, GERD, and menopausal symptoms requiring hormone replacement therapy (HRT).  The patient also recently completed a course of nitrofurantoin for cystitis. 

PSH: cholecystectomy 6 months ago.

 

Social hx: Patient has no history of alcohol abuse. 

Medications:Lisinopril, Paxil, cimetidine, estrogen and completed course of nitrofurantoin 2 days ago.

Physical exam: VS: 100/60,  P- 110,  R-16,  T-37.0 C, P02 - 87 % on RA.

The exam is significant for left lower lung field rales and egophany.  The patient also had moderate mid-epigastric and RUQ tenderness without rebound or guarding. The rest of the exam is unremarkable.

Labs:

wbc: 16.5, H/H: 12/45

electrolytes are WNL

SGOT/SGPT: 500/400 U/l, alkaline phosphatase  400 U/l , total Bi 2.0 mg/dL

LDH:  860 IU per liter, serum lipase-5000, serum amylase- 2000, TG- 300

UA which is neg for LCE, nitrites, bacteria, WBCs or RBCs.

1.  At this point in your evaluation, what should you initially be concerned about? 

2. What could be the etiologies of this patient’s pancreatitis?

3.  What radiologic studies should you consider obtaining? 

4.  Are you able to calculate your patient’s Ranson’s score? 

Discussion Outline:

I. Differences between acute and chronic pancreatitis:

Acute and chronic pancreatitis are distinguished from each other on the basis of structural and functional criteria.

1.  Acute pancreatitis is an inflammatory condition of the pancreas. Acute disease is characterized by a normal pancreas that becomes inflamed prior to the attack and once the attack resolves the pancreas returns to normal.

2.  Chronic pancreatitis is a progressive disorder of the pancreas that causes destruction of the pancreas. It involves long-term inflammation and scarring of the pancreas that is irreversible.

II. Pathogenesis:

Acute pancreatitis:

1.  It relates to inappropriate activation of trypsinogen to trypsin (the key enzyme in the activation of pancreatic zymogens and a lack of prompt elimination of active trypsin inside the pancreas.

2.  Activation of digestive enzymes causes pancreatic injury and results in an inflammatory response that is out of proportion to the response of other organs to a similar insult.

3.  The acute inflammatory response itself causes substantial tissue damage and may progress beyond the pancreas to a systemic inflammatory response syndrome, multiorgan failure and death.

Chronic pancreatitis:

1.  The hypersecretion of protein from acinar cells in the absence of increased fluid or bicarbonate secretion from duct cells is characteristic of chronic pancreatitis.

2.  Plugs formed by the precipitation of protein within the interlobular and intralobular ducts are an early finding.

3.  The plugs contain multiple proteins (digestive enzymes, glycoproteins, and acidic mucopolysaccharides).

4.  The precipitation of calcium carbonate in the plugs results in the formation of intraductal stones (this is more common in patients with alcohol-induced or tropical pancreatitis).

5. Patients with idiopathic chronic pancreatitis frequently have an elevated pressure in the pancreatic duct.

III. Causes of pancreatitis:

1.  Gallstones (45 % of cases)

2.  Alcohol (35 % of cases)

3.  Drugs: Azathioprine, Mercaptopurine, Valproic acid, Estrogen, Tetracyclines, Metronidazole, Nitrofurantion, Pentamidine, Lasix, Sulfonamides, Methyldopa, Cimetidine, Ranitidine, Salicylates, Erythromycin                                               

4.  Metabolic abnormalities: Hypercalcemia, Hypertriglyceridemia

5.  Trauma: accidental or iatrogenic (ERCP, postoperative, endoscopic sphincterotomy)

6.   Infections:

Parasitic (ascariasis, clonorchiasis)

Viral (mumps, rubella, Hepatitis A, B, non-A, non-B, coxsackievirus B, Echo virus, adenovirus, varicella, Epstein-Barr virus, HIV virus)

Bacterial: (mycoplasma, Campylobacter jejuni, Mycobacterium tuberculosis, Legionella, Leptospirosis)

7. Miscellaneous causes: penetrating PUD, Crohn’s disease, Reye’s syndrome, cystic fibrosis)

8.  Idiopathic (10% of cases)

IV. Diagnosis

Diagnosis of acute pancreatitis:

1.  Characteristic abdominal pain (begins in the upper abdomen and spreads through the back)

2.  Nausea and vomiting (usually the vomiting doesn’t relief the pain)

3.  Elevated serum levels of pancreatic enzymes (amylase and lipase)

4.  Both enzymes remain elevated with ongoing pancreatic inflammation, with amylase level typically returning to normal shortly before lipase levels in the resolution phase.

5.  Imaging:

-  Ultrasound of the abdomen remains the most sensitive method of evaluating the biliary tract in acute pancreatitis. It has a sensitivity of 67% in the urgent diagnosis, and a specificity of 100%.

-  CT scan is the imaging method of choice in delineating the pancreas, as well as in determining the severity and complications.

-  ERCP plays a part in diagnosis in patients in whom no definite cause is found. Abnormalities revealed by this study include small pancreatic tumors, pancreatic ductal strictures, gallstones, pancreas divisum, sphincter of Oddi dysfunction.

Diagnosis of chronic pancreatitis:

1.  In developed countries, most patients with chronic pancreatitis have a history of prolonged and heavy alcohol use.  They typically have recurrent attacks of upper abdominal pain, which may radiate to the mid-back, nausea and vomiting.

2.  10-20 % of patients have “painless” pancreatitis.  They may present with DM, jaundice, malabsorption, steatorrhea with weight loss.

3.  Malabsorption resulting from exocrine insufficiency may cause fecal fat excretion to be elevated. Undigested fat is qualitatively detected by Sudan staining of feces.

4.  Routine blood studies (such as amylase, lipase) do not necessary show elevations.

5.  Plain film of the abdomen: The finding of pancreatic calcification is virtually diagnostic of chronic pancreatitis, but often this is not found.

6. There are several other tests: US, CT scan of the pancreas, ERCP, EUS, MRCP, MRI

7.  ERCP is the gold-standard imaging procedure for the diagnosis of chronic pancreatitis and planning treatment.

V. Treatment:

Acute pancreatitis:

1. Supportive therapy, vigorous IVF hydration, possible use of NG (especially with ileus and severe vomiting), correction of electrolytes.

2.  Immediate endoscopic removal of impacted stones in patients with severe disease appears to reduce mortality.

3.  Use of antibiotics: A potential role for prophylactic use of antibiotics in severe acute pancreatitis was initially given support by a randomized trial demonstrating that imipenem reduces infection complications.

Recent randomized trial failed to demonstrate differences in outcome among patients treated with Cipro and Flagyl, as compared with placebo, leading some experts to recommend against routine use of prophylactic antibiotics.

4.  Nutritional support: ensuring adequate nutrition is important in patients with severe or complicated pancreatitis.  Recent meta-analysis of 6 randomized trials involving a total of 263 patients demonstrated improved outcomes with enteral nutrition, including decreased rate of infections and surgical interventions, reduce length of hospital stay, reduced costs.

5.  Decision on the appropriateness of surgical management of sterile necrotic tissue should be made on a case-by-case basis, however, infected necrotic tissue and infected collections of fluid are best treated by surgical debridement.

Chronic pancreatitis:

1.  Pain:  abstinence from alcohol, administration of analgesic medications, and nerve blocks.  Exocrine insufficiency may lead to increased cholecystokinin-mediated stimulation of the pancreas.  This process theoretically could be interrupted by administration of digestive enzymes (trypsin, cholecystokinin receptor antagonists, or somatostatin).

2.  When the pain persists in spite of aggressive noninvasive therapy, patient should undergo ERCP to define the caliber and morphologic characteristic of the pancreatic ducts.

3.  Malabsorption:  when > 90 % of exocrine pancreatic function is lost, clinically overt malabsorption occurs. Treatment consists of low-fat diet. Medium chain triglycerides may be useful because their absorption depends on minimal amounts of pancreatic enzymes and does not require bile salts.

For persistent symptoms pancreatic-enzyme replacement should be given orally just before meals. Neutralization of gastric acid with orally administration bicarbonate, inhibition of acid secretion, or enteric coating of enzyme preparation may prevent degradation of these enzymes as they traverse the stomach.

4.  Pseudocysts: develop in 10 % of patients.  Most resolve spontaneously but hemorrhage into a pseudocyst, rupture or infection can occur.

Treatment is indicated for those who persist for 6 weeks or are either enlarging or cause symptoms. Treatment is resection, external or internal drainage.

5.  Pancreatic ascites or pleural fistulas. Diagnosis is made if paracentesis or thoracentesis yields fluid high in protein and amylase. Currently the treatment is surgery.

VI. Predicting severity of acute pancreatitis:

Many models exist although none are ideal and most of them take about 48 hrs to complete assessment. They also do not have high sensitivity or specificity, although relying on routine clinical assessment identifies only 30-40% of patient with severe acute pancreatitis.  These models are usually based on:

1. Presence or absence of organ failure, and local complications.

2. Systems that assess inflammation or organ failure (Ranson criteria)

3. Findings on imaging studies

Ranson criteria to predict severity of acute pancreatitis

At 0 Hours

Age > 55 yo                                                                       

Wbc> 16 k                                                                          

Glucose> 200 mg/dL                                                          

LDH> 350

SGOT (AST) > 250                                                    Mortality per positive criteria:

0-2 <5% mortality

3-4 20% mortality

At 48hours                                                                 5-6 40% mortality

Hct fall by > 10%                                                       7-8 100 % mortalit

BUN increase > 5 mg/dl despite fluids

Ca < 8 mg/dL

PO2 < 60 mm/Hg

Base deficit > 4mEq/L

Fluid sequestration > 6L

11 total criterias in Ranson scoring. The presence of 1 to 3 criteria represents mild pancreatitis; as the number of criteria increase, the severity of pancreatitis increase and so does the mortality associated with it.

Review Questions:

1.  A 27 yo patient is admitted with acute pancreatitis. Four days after admission patient develops high fever with worsening abdominal pain. The examination reveals a T of 102F and marked upper abdominal tenderness without rebound. A CT scan of the abdomen with contrast shows a solid mass and gram stain of the aspirate is positive for gram-negative organism.

Based upon the above information you will now recommend:

A)  IV broad spectrum antibiotics.

B)  IV antibiotics plus insert a CT –guided percutaneous drainage tube.

C)  IV antibiotics plus surgical debridement.

2..  A 60 yo man with known chronic pancreatitis caused by alcohol  reports  a 25 lbs weight loss in the past several months and frequent, greasy, and malodorous stools. A 72- hour fecal fat collection confirms steatorrhea. The patient no longer consumes alcohol and reports no abdominal pain.

Which of the following is the most appropriate first-line treatment for this patient?

A)   Administration of enteric-coated pancreatic enzyme replacement tablets with meals and snacks and concurrent use of a calcium containing antacids.

B)  Administration of non-enteric-coated pancreatic enzyme replacement tablets with meals and snacks with concurrent dosing with a histamine2 blockers.

C)  Endoscopic placement of a pancreatic dust stent.

D)  Institution of a low-fat diet (less than 20 g fat/day).

E)  Subcutaneous administration of octreotide daily.

Post Module Evaluation

Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111).

1) Topic of module:__________________________

2) On a scale of 1-5, how effective was this module for learning this topic? _________

(1= not effective at all, 5 = extremely effective)

3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4) Was the attending involved in the teaching of this module? Yes/no (please circle).

5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:

6) Please circle one: 

Attending        Resident (R2/R3)                    Intern               Medical student