CC March 2016 Acute pancreatitis

echoecho's version from 2016-05-16 16:53


Question Answer
Define?sudden onset of reversible inflammation of the pancreas, often as the result of premature activation of the various digestive enzymes of the exocrine pancreatic glands (proteases, lipases and amylase)
Acute pancreatitis is estimated to result in > ____ hospital admissions annually in the US ans is associated with significant morbidity and mortality?50,000
List the 9 most common etiologies of acute pancreatitis?1) gallstones (most common, approximately 40% of all cases) 2) alcohol abuse (either chronic or episodic; approximately 35% of cases) 3) postprocedural (endoscopic retrograde cholangiopancreatography [ERCP] 4) viral (mumps, Coxsackie) 5) blunt force abdominal trauma 6) congenital (pancreas divisum) 7) medications (including azathiprine, didanosine (Videx), estrogens, furosemide (Lasix), pentamidine (Pentam), sulfonamides, tetracycline and valproic acid (Depakene) 8. Hypercalcemia 9. Hypertriglyceridemia (risk increases at levels > 500 mg/dL)
Patients with acute pancreatitis classically present with what symptoms?1) severe epigastric or periumbilical pain that radiates to the back 2) often associated with significant nausea and vomiting
Severe cases of acute pancreatitis may be associated with what s/s?1) fever 2) hypotension 3) tachcardia 4) dyspnea
In addition to tenderness and potential guarding on physical exam, what 2 physical examination signs classically described (but rarely seen) in late acute pancreatitis?1) Cullen sign (periumbilical ecchymosis) 2) Gray-Turner sign (flank ecchymosis)
What is lab testing used for?1) help dx acute pancreatitis 2) assess its severity 3) exclude other conditions
List the usual labs?1) CBC 2) lytes 3) renal function 4) hepatic function 5) glucose
Acute pancreatitis may cause elevations of what labs?amylase and lipase
Which one of the following (lipase vs. amylase) is more specific (positive likelihood ratio + LR = 24.1)? Why?1) lipase 2) because amylase is also produced in the salivary glands
*** Lipase levels greater than ___ times of upper limits of normal are consistent with acute pancreatitis? 3
*** A lipase to amylase ratio > ____ suggest alcohol?4-5
What levels, if available, can also be used to help determine severity?interleukin-6 levels
What imaging study is useful when gallstone-associated acute pancreatitis is suspected?RUQ US
What is the diagnostic test with the most clinical utility in patients with severe disease as it aids in dx and assessment of complications like necrosis??CT scan with contrast
The American College of Radiology (ACR) Appropriateness Criteria recommends what imaging at the initial presentation of acute pancreatitis? RUQ US
What is only recommended for patients wit NON-diagnostic US?CT scan with contrast
*** For severe acute pancreatitis, the ACR recommends what imaging modality as "the single best, most practical exam"?CT scan with contrast
List 4 tools proposed as predictors of severity and mortality from acute pancreatitis?1) Ranson's criteria 2) Acute Physiology and Chronic Health Evaluation (APACHE IIi) 3) CT severity index 4) BALi score
True or false? No individual prediction system has been evaluated as suprioer to the others; regional preferences determine which system is used locally?true
Regarding Ranson's Criteria, what 5 criteria are assessed on admission (1 point each)?1) age > 55 years 2) WBC > 16 3) glucose > 200 4) LDH > 350 5) AST > 250
Regarding Ranson's Criteria, what 6 criteria are assessed at 48 hours (1 point each)?1) hct decreases by 10% over admission 2) BUN increases by 5 mg/dL over admission 3) calcium < 8 mg/dL 4) base deficit > 4 mmol/L 5) fluid sequesteration 6 L 6) PA O2 < 60 mmHg
What is the scoring for Ranson's Criteria (in regards 59 predicted mortality)?Score 0-3 = 1% predicted mortality. Score 3-4 (15% predicted mortality) Score 5-6 (40 % predicted mortality) Score > 6 (100% predicted morality)
What is the scoring for the APACHE II score ( item score varying point values given within each item as follows = age, rectal temperature , mean arterial pressure, heart rate, PaO2, arterial pH, serum potassium, serum sodium, serum creatinine, hematocrit, WBC, Glasgow coma scale. Score equivalent to approx mortality rate as follows = 0-4 = 4%; 5-9 = 8%; 10-14 = 15%; 15-19 = 25%; 20-24 = 40%; 25-29 = 55%; 30-34 = 75%; < 34 = 85%
What is the CT Severity Index score?the CT severity index score is obtained by adding the CT grade to the severity score. Patients with a CT severity index core > 5 have a longer length of hospitalization and a mortality rate 15 times that of patients with a score of < 5. CT grade = normal (0 points); edematous (1 point); mild extrapancreatic changes (2 points); severe extrapancreatic changes + a fluid pocket (3 points); multiple fluid pockets (4 points). Severity score = none (0 points); > 33% involved (2 points); < 50% involved (4 points); > 50% involved (6 points)
What is the BALI score?the following are assess at admission or over the first 48 hours of admission = 1) Blood urea nitrogen > 25 mg/dL 2) Age > 65 y.o. 3) Lactate dehydrogenase > 300 units/L 4) Interleukin-6 level > 300 pg/mL. Three positive values are associated with mortality rates > 25% and 4 positive variables are associated with mortality rate > 50%
What is the initial treatment of acute pancreatitis?1) supportive 2) IV rehydration 3) bowel rest 4) pain control
Fluid resuscitation is very aggressive with a goal of keep what?renal function and urine output normal
Patients with severe pancreatitis, characterized by what s/s?1) oliguria 2) hypotension 3) tachycardia
Patients with severe pancreatitis require whatICU admission for close monitoring and frequent reassessment
Patients with mild pancreatitis are treated how?can typically take clear fluids after their pain improves
With more severe disease, prolonged periods of what may be needed?bowel rest
*** Compare total parenteral nutrition (TPN)to enteral nutrition as to hospital stays, infection rates and mortality rates?while total parenteral nutrition (TPN) was used in the past, more recent reviews suggest that enteral nutrition (nasojujunal o nasogastric feeding) results in shorter hospital stays, fewer infections and similar mortality rates when compared to TPN
In the past Meperidine (Dermerol) was considered the analgesic of choice for many years in acute pancreatitis, why? More recent studies demonstrated that at comparable doses, morphine does not cause what? Why is Meperidine used much less oftehn than other options for pain control?1) it caused less spasm of the sphincter of Oddi than morphine 2) morphine did not cause excessive spasm or worsening of symptoms 3) Meperidine has a potential for builldup of toxic metabolities, especially in the elderly, and is used much less often than other options for pain control
Pancreatic necrosis occurs in about ____% of cases and up to a ____ of these patients develop infections?20; third
Studies of prophylactic antibiotic use have been ______?mixedrosis, overal infections o
A 2010 Cochrane review concluded that there _______ (was vs. was not) a difference between the prophylaxis and no prophylaxis with respect to mortality, infected pancreatitic necrosis, overall infections or need for operative treatment?was not
What does the American Gastroenterological Association (AGA)recommend regarding prophylactic antibiotic use for patients with extensive necrosis, or those with severe acute pancreatitis without necrosis?1) restricting prophylactice antibiotic use to patients with extensive necrosis (>30%) 2) prophylaxis is NOT recommended for severe acute pancreatitis without necrosis
The AGA does recommend antibiotic treatment for what type of patients?extrapancreatic infection (cholangitis, UTI, pneumonia)
What procedure is recommended in cases of gallstone associated acute pancreatitis?cholecystectomy
*** Compare to surgery following pain resolution and enzyme normalization, surgery within ___ hours of presentation showed no increased complication rates and shorter hospital stays?48
What procedure may decrease morality in patients with GAP (gallstone associated acute pancreatitis)?ERCP with sphincterotomy
If fluid collections are seen on CT but he patient is asymptomatic, is treatment recommended?no
If fluid persists or if severe infected necrotic tissue is present, what 2 options are available and should be done?1) percutaneous CT-guided aspiration OR 2) surgical debridement
*** SUMMARY = What are the most common cause of acute pancreatitis (about 40%) ?gallstones
*** SUMMARY = While amylase and lipase are elevated in acute pancreatitis, which of the two is more specific because it only comes from the pancreas?lipase
*** SUMMARY = What imaging study is useful when gallstone-associated acute pancreatitis is suspected?RUQ US
*** SUMMARY = What is the initial treatment of acute pancreatitis?1) supportive 2) IV rehydration 3) bowel rest 4) pain control.
*** SUMMARY = Fluid resuscitation is very aggressive with what goal?of keeping renal function and urine output normal
*** SUMAMRY = The American Gastroenterological Association (AGA) recommends _______ prophylactic antibiotic use to patients with extensive necrosis (>30%)?restricting