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Changing ideas about pancreatitis . Mark Lybik , MD Northside Gastroenterology Sept. 14, 2013. Pancreatitis. 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 .

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changing ideas about pancreatitis

Changing ideas about pancreatitis

Mark Lybik, MD

Northside Gastroenterology

Sept. 14, 2013

pancreatitis
Pancreatitis
  • 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
pancreatitis1
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
pancreatitis2
Pancreatitis
  • Why is this important?
  • Because it is hard to take care of patients with acute and chronic pancreatitis
pancreatitis3
Pancreatitis
  • How do we diagnosis pancreatitis ?
pancreatitis4
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
pancreatitis5
Pancreatitis
  • Who is at risk for development of pancreatitis?
  • Anyone is …. Children… Teens … adults and the elderly
pancreatitis6
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
pancreatitis7
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
pancreatitis8
Pancreatitis
  • These markers suggest that patients are dehydrated
  • And the guidelines suggest aggressive volume resuscitation
  • Remember that under resuscitation leads to a poor out come
pancreatitis9
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
p ancreatitis
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
pancreatitis10
Pancreatitis
  • Fever may develop; what to do?
    • Antibiotic ?
    • Fever develops because it is an inflammatory condition and not an infection
    • No antibiotic are needed
pancreatitis11
Pancreatitis
  • When do you need an ERCP?
    • Typically when patients have gallstone and it appears they have cholangitis
pancreatitis12
Pancreatitis
  • Chronic pancreatitis
    • Consider as a SYNDROME
    • Consist of PAIN, AND LOSS OF ENDOCRINE AND EXOCRINE FUNCTION
pancreatitis13
Pancreatitis
  • Breakdown
    • Early phase …. Mainly consist of PAIN
    • Mistaken for acute pancreatitis
    • Biggest point : clear cut evidence of chronic pancreatitis may not be hear
pancreatitis14
Pancreatitis
  • Pain is a big issue
  • It can take years 5 to 10 to develop changes
pancreatitis15
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
pancreatitis16
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
pancreatitis17
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
pancreatititis
Pancreatititis
  • 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
pancreatitis18
Pancreatitis
  • Once the nerve is sensitized it now can produce hyperalgesia
  • So pain is a wiring problem
  • And less of a plumbing problem
pancreatitis19
Pancreatitis
  • Treatment
    • Opiods …
    • Pregabalin300 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
pancreatitis20
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