Acute-Pancreatitis-Sarah-Linson-MS4-Lambert-MD-Wang-MD-FossMD-Awdeh-MD-Feb-2021.pptx

Acute pancreatitis

1. Acute Pancreatitis Sarah Linson February 2021 RAD 4001 (Matthew Lambert, Mindy Wang, Wylie Foss)

2. Clinical presentation HPI 43 M with HTN, DM, and EtOH abuse presented to ED with nausea and 10/10 abdominal pain for past 12 hrs. Pain is at the umbilicus radiating to the back. ROS (+) subjective fever/chills (+) NBNB emesis (-) chest pain, SOB

3. Differential diagnosis Epigastric abdominal pain Acute MI AAA Acute mesenteric ischemia Perforation of GI tract Acute or chronic pancreatitis GERD PUD Early appendicitis Gastritis Nephrolithiasis Bowel obstruction Hepatobiliary disease

4. History Medical history: HTN HLD DM GERD Depression Multiple admissions this year for DKA and pancreatitis Surgical history: none Family history: DM - mother Social history: Tobacco - 0.5 ppd x 23 years Alcohol – 8 drinks/ wk Previously documented EtOH abuse, but patient now denies

5. Home medications Amlodipine 2.5 mg Lisinopril 20 mg  Atorvastatin 80 mg Fenofibrate 145 mg Sertraline 50 mg Levemir 10 U BID

6. Physical Exam Vital signs T: 99.4 F HR: 125 BP: 224/155 RR: 20 SpO2: 99% on RA

7. Physical Exam General: in distress CV: tachycardic , normal rhythm, no murmur Resp: normal respiratory effort and clear breath sounds b/l Abd: Bowel sounds normal Abdomen soft with generalized tenderness No CVA tenderness Negative signs: Murphy, Rovsing , psoas, obturator

8. Lab results 13.6 8.4 179 EKG: tachycardic; normal sinus rhythm 132 5.7 91 19 16 1.1 356 Anion gap: 22 EtOH Acetaminophen Salicylate Lactate: 2.1 AST 40 ALT 30 Tbili 0.9 ALP 45 Lipase 531 Below reference range

9. Lab results 13.6 8.4 179 EKG: tachycardic; normal sinus rhythm 132 5.7 91 19 16 1.1 356 Anion gap: 22 EtOH Acetaminophen Salicylate Lactate: 2.1 AST 40 ALT 30 Tbili 0.9 ALP 45 Lipase 531 Below reference range

10. Imaging - CXR Upright portable CXR 1/18/2021

11. Imaging - CXR Carina No IP free air Sharp costophrenic angles Lung markings extend to periphery Upright portable CXR 1/18/2021

12. Imaging - CXR Key findings: No intraperitoneal free air No fractures No PTX No pleural effusion Heart and mediastinum normal in size No airspace disease Cost to patient: $27.93 Carina No IP free air Sharp costophrenic angles Lung markings extend to periphery Upright portable CXR 1/18/2021

13. Imaging – CT A/P with contrast CT abdomen/pelvis with contrast 1/18/2021

14. Imaging – CT A/P with contrast Portal vein IVC Celiac trunk CT abdomen/pelvis with contrast 1/18/2021

15. Imaging – CT A/P with contrast

16. Imaging – CT A/P with contrast

17. Imaging – CT A/P with contrast pancreas fat stranding

18. Imaging – CT A/P with contrast

19. Imaging – CT A/P with contrast Dilation of adjacent small bowel

20. Imaging – CT A/P with contrast

21. Imaging – CT A/P with contrast

22. Imaging – CT A/P with contrast

23. Imaging – CT A/P with contrast Bowel wall thickening

24. Imaging – CT A/P with contrast Key findings: Normal enhancement of pancreatic parenchyma Peripancreatic fat stranding No necrosis, no calcifications No peripancreatic abscess or pseudocyst formation Dilated portions of adjacent small bowel and bowel wall thickening, likely reactive Cost to patient: $ 313.29

25. Differential Diagnosis Acute pancreatitis Autoimmune pancreatitis Malignancy – pancreatic ductal adenocarcinoma, pancreatic lymphoma Inflammatory/infectious enteritis

26. Differential Diagnosis Acute pancreatitis Autoimmune pancreatitis Malignancy – pancreatic ductal adenocarcinoma, pancreatic lymphoma Inflammatory/infectious enteritis

27. Discussion Pathophysiology of acute pancreatitis Acinar cells – functional unit of exocrine pancreas Damage to acinar cells or impaired secretion of proenzymes Release and activation of digestive enzymes   pancreatic autodigestion

28. Discussion Etiologies of acute pancreatitis Gallstones EtOH Metabolic (hyperlipidemia, hypercalcemia) Iatrogenic (medications, ERCP, EUS) Other causes of ductal obstruction (tumor) Autoimmune Trauma Viral Idiopathic

29. Discussion Diagnosis of acute pancreatitis Revised Atlanta Classification Need at least 2 of the following: 1) lipase or amylase levels 3 times the upper limit of normal 2) physical exam consistent with pancreatitis 3) imaging findings consistent with acute pancreatitis Two subtypes Interstitial edematous pancreatitis Necrotic pancreatitis Severity based on presence/persistence of organ failure and local or systemic complications

30. Discussion Prognostic factors/grading Many scoring systems are cumbersome and/or need 48hrs of data Ranson’s criteria, APACHE II BISAP (clinical) and CTSI (imaging) are simpler

31. Discussion Potential complications Sepsis Necrosis Hemorrhagic pancreatitis Pseudocyst Abscess ARDS

32. Complications Peripancreatic fluid collection https:// www.uptodate.com /contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis

33. Complications Pancreatic pseudocyst https:// www.uptodate.com /contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis

34. Complications Pancreatic necrosis https:// www.uptodate.com /contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis

35. https:// www.ajronline.org / doi /10.2214/ajr.183.5.1831261 CT Severity Index Our patient’s total = Total Mild 0-2 Moderate 4-6 Severe 8-10

36. https:// www.ajronline.org / doi /10.2214/ajr.183.5.1831261 CT Severity Index Our patient’s total = 4 Moderately severe interstitial edematous acute pancreatitis Total Mild 0-2 Moderate 4-6 Severe 8-10

37. Treatment Patient was admitted to MICU for treatment of DKA and acute pancreatitis. AP: NPO, fluid resuscitation , pain management DKA: Fluid resuscitation, insulin, K+ replacement Anion gap closed, started advancing diet on day 2 Early enteral feeding is preferred Transferred to floor day 3

38. Final Diagnosis Interstitial edematous acute pancreatitis Moderately severe (CTSI = 4) Outcome: discharged home on hospital day 5

39. Teaching points Acute pancreatitis is diagnosed and graded based on the Revised Atlanta Classification Imaging is not always required for a diagnosis, but it can help assess etiology, complications Common imaging findings include: Pancreatic enlargement or edema Dilation of main pancreatic duct Peripancreatic fat stranding

40. References Gapp J, Chandra S. Acute pancreatitis. In:  StatPearls . StatPearls Publishing; 2020. Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review.  JAMA . 2021;325(4):382-390. Miller D, Bhatti Z, Gandikota G. Medical imaging costs: How much do residents know? University of Michigan Dept. of Radiology. Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis.  New England Journal of Medicine . 2016;375(20):1972-1981.

41. Questions?

42. Atlanta Classification Subtypes Interstitial edematous acute pancreatitis acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis Necrotizing acute pancreatitis inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis Severity Mild absence of organ failure and local or systemic complications Moderately severe no organ failure or transient organ failure (<48 hours) and/or local complications  Severe persistent organ failure (>48 hours) that may involve one or multiple organs

43. APACHE II

44. Ranson Criteria vs. BISAP

45. CT Severity Index

46. osmosis.org Pathophysiology of acute pancreatitis