Changing ideas about pancreatitis

Mark Lybik, MDNorthside Gastroenterology

Sept. 14, 2013

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

How do we diagnosis pancreatitis ?

Pancreatitis

Clinical features of acute disease

Acute Pancreatitis

Abdominal Pain

Pancreatic Enzymes in Serum

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

Gallstone Migration

Gallstone migration

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

Chronic Pancreatitis

Pain Calcification

Pancreatic insufficiency

Features of chronic 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

Pain is a big issue It can take years 5 to 10 to develop changes

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

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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

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Changes in a pancreatic nerve in chronic 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

Acute pancreatitis : Needs better mgmt in the first 24 hours

Chronic Pancreatitis : Pain is the biggest problem and think now of wiring and not so much plumbing

Pancreatitis