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Acute Pancreatitis is responsible for over 280,000 admissions to hospitals
In 2010 the average length of stay was 5 days
At a cost of 2.9 billion dollars
Pancreatitis
We do not have a number of admissions for chronic pancreatitis
The incidence is 3 to 10/ 100,000 This is new case per year In Indianapolis that would be 30 to 100
Pancreatitis
Why is this important? Because it is hard to take care of patients
with acute and chronic pancreatitis
Pancreatitis
For the diagnosis of Acute Pancreatitis ◦ Upper Abdominal Pain ◦ Elevated amylase or lipase > 3 times the normal◦ CT scan findings
Need at least 2 of these
Pancreatitis
Who is at risk for development of pancreatitis?
Anyone is …. Children… Teens … adults and the elderly
Pancreatitis
When does the treatment start?
Once the diagnosis is made, so normally that is in the ER
And this is an important point and one of the pitfalls that is seen …. Under treatment
Pancreatitis
Important factors to look at The HCT if it is > 44 patients are at higher
risk of severe pancreatitis Crt Obesity has a 3 fold increase in severe
pancreatitis
Pancreatitis
J Martinez et al., Pancreas 1999; 19:15
Effect may be greatest with a high waist / hip fat ratio
Possible Mechanisms
Free fatty acids
Cytokines (TNFaIL-6)
Reduced diaphragmatic excursion
Body Mass Index (kg/m2)
%Patients
0
20
40
60
<25 25-29 >29
Severe Pancreatitis
Systemic complications
Obesity Worsens Prognosis
Autoimmune Pancreatitis
Obesity Worsens the Prognosis in Acute Pancreatitis
Hematocrit and Severity
Criteria Incidence of Necrosis
Admission hematocrit >44% 50%OR fails to fall over
first 24 hours
Neither present 4%
Acute Pancreatitis
Brown J, et al., Pancreas 2000; 20:367
Hematocrit and Severity of Acute Pancreatitis
MechanismsAcute Pancreatitis: Mechanisms
Insult
Zymogen activation Generation of
inflammatory mediators Ischemia
Inflammation Ischemia
Necrosis Apoptosis
Systemic inflammatory response
Multi-organ failure
Neurogenic stimulation
Mechanisms of acute pancreatitis - Pt. 1
These markers suggest that patients are dehydrated
And the guidelines suggest aggressive volume resuscitation
Remember that under resuscitation leads to a poor out come
Pancreatitis
Acute Pancreatitis
Early Indicators of Severity
Tachycardia, hypotension
Tachypnea, hypoxemia
Hemoconcentration
Oliguria
Encephalopathy
Early Diagnostic Indicators in Acute Pancreatitis
Acute Pancreatitis
Early Indicators of Severity
Tachycardia, hypotension
Tachypnea, hypoxemia
Hemoconcentration
Oliguria
Encephalopathy
Early Diagnostic Indicators in Acute Pancreatitis
Patients need 20 ml/kg in the ER as a bolus Then 3 ml/kg per hour with reassessment
every 6 hours for fluid over load
Pancreatitis
Average length of stay 3 to 5 days If longer
◦ Nutritional support is a big concern ◦ Using a nasal jejunal tube is better then TPN
Pancreatitis
Fever may develop; what to do?◦ Antibiotic ?◦ Fever develops because it is an inflammatory
condition and not an infection ◦ No antibiotic are needed
Pancreatitis
When do you need an ERCP?◦ Typically when patients have gallstone and it
appears they have cholangitis
Pancreatitis
GallstonesAcute Pancreatitis
Gallstone causing temporary obstruction of common duct
Stone obstructing both ducts
Chronic pancreatitis ◦ Consider as a SYNDROME◦ Consist of PAIN, AND LOSS OF ENDOCRINE AND
EXOCRINE FUNCTION
Pancreatitis
Breakdown◦ Early phase …. Mainly consist of PAIN ◦ Mistaken for acute pancreatitis ◦ Biggest point : clear cut evidence of chronic
pancreatitis may not be hear
Pancreatitis
Biggest risk :◦ Smoking and alcohol ◦ Alcohol is a big problem but it is NOT the cause in
most people ◦ > 5 drinks a day and smoking
Pancreatitis
What is biggest problem with Chronic pancreatitis?◦ PAIN◦ PAIN develops much sooner then changes on ct or
ultrasound or EUS ◦ Leads to a low quality of life; high disability ; and
greater use of the health care system
Pancreatitis
Where does the pain come from?◦ In the 1990’s it was thought this was from
obstruction of duct◦ And relieving the obstruction should relieve the
pain
Pancreatitis
Other Causes of Chronic Pain
Chronic Pancreatitis
Chronic cholecystitis, biliary stricture
Hepatic neoplasm
Pancreatic cancer
Peptic ulcer
Gastric cancer
Obstipation 2º narcotics
Irritable bowel syndrome
Causes of abdominal pain that can be confused with chronic pancreatitisOther Causes of Chronic Pain
Chronic Pancreatitis
Chronic cholecystitis, biliary stricture
Hepatic neoplasm
Pancreatic cancer
Peptic ulcer
Gastric cancer
Obstipation 2º narcotics
Irritable bowel syndrome
Causes of abdominal pain that can be confused with chronic pancreatitis
The changing thinking now is Pain is from the neurons
Increase in size and are surrounded by inflammatory infiltrates
And some enzymes and food stimulate the pain
Once the pathway is sensitized this goes to the spinal cord
Pancreatititis
Causes of Pain
Pseudocyst
Inflammation
Neural inflammation
Duodenal and common duct obstruction
Chronic Pancreatitis
Ischemia
PD Obstruction
with Increased PD pressure
Causes of pain in chronic pancreatitis
Once the nerve is sensitized it now can produce hyperalgesia
So pain is a wiring problem And less of a plumbing problem
Pancreatitis
Treatment◦ Opiods …◦ Pregabalin 300 mg bid has promise◦ Antioxidents… 2 studies plus and minus◦ EUS is safe but on limited effectiveness ◦ ERCP but pain may not resolve even if they have
strictures or dilated duct or stone
Pancreatitis