Pancreas and Spleen

Biliary, EtOH

What are the most common causes of acute pancreatitis?

Gallstones are identified, LFTs are WACK

When should biliary pancreatitis be suspected?

etiology of pancreatitis, development of complications of pancreatic necrosis, comorbidities

Mortality rate of acute pancreatitis depends on…

EtOH, hyperlipidemia, hypercalcemia, drugs, genetics, bark scorpion venom

Metabolic causes of acute pancreatitis?

Cholithisais, post-op, pancreas divisum, post-trauma, ERCP, pancreatic duct obstruction, pancreatic ductal bleeding, duodenal obstruction

Mechanical causes of acute pancreatitis?

post-op after Cardiopulmonary bypass, periarteritis nodosa, atheroembolism

Vascular causes of acute pancreatitis?

mumps, coxsackie B, CMV, Cryptococcus

Infectious causes of acute pancreatitis?

CBC, UA, CMP, bilirubin panel, LFTs, CRP, Lipase, Amylase

45 y/o male with a PMHx of alcoholism presents to the ED for 10/10 abdominal pain. He notes that the pain is boring, constant, and radiates to the back. Vitals are stable with the exception of a 101.7 temp. On physical exam you note that he is lying in bed super still, scleral icterus, and a mildly distended abdomen that is diffusely tender. What labs do you want to order?

Amylase, Lipase 🥇 (3x normal)

What is the gold standard for identifying acute pancreatitis?

Cullen’s (umbilical), Grey Turner sign (flank)

Skin findings for acute pancreatitis (RARE)

Calcification/sentinel loop (KUB), RUQ U/S (for gallstone abnormality), Contrast CT 🥇 (look for phlegmon, extension, necrosis, pseudocyst), MRI/MRCP

Imaging findings for acute pancreatitis?

Abdominal pain suspicious for pancreatic origin, serum amylase or lipase activity, characteristic findings on CT/MRI

Diagnostic criteria for acute pancreatitis (need 2/3)?

APACHE II (estimates ICU mortality), Glasgow coma scale, Ranson (pancreatitis specific - repeat in 48 hours), BISAP score

Severity of Acute pancreatitis can be graded on

writhing abdominal pain, rigid abdomen, peritoneal signs

Red flags for intra-abdominal catastophe

3-6L of NS/LR over the 1st 24 hours, monitor fluid output, monitor blood glucose, pain control (narcotics 🤪), NG tube (IF there’s an ileus relieves N/V), Chemoprophylaxis in all patients (PPIs and LMWH), NPO, Elective laparoscopic chole and IOC (biliary - stabilize 1st), ERCP ± endoscopic sphincterotomy (w/ cholangitis)

Treatment plan for acute pancreatitis?

Pseudocyst (do not drain surgically), Pseudoaneurysm (heralded by acute exacerbation of abdominal pain)

What are the complications of acute pancreatitis?

Hx (penetrating or blunt), laparotomy 🥇, pseudocyst without preceding acute pancreatitis (drain vs. resection)

Pancreatic trauma should be diagnosed based on

Chronic Alcoholism (most common), gallstones, hypercalcemia, hyperlipidemia, duct obstruction, or inherited predisposition

Common causes of chronic pancreatitis

Endocrine disorders (DM), Exocrine disorders (steatorrhea), recurrent bouts to continuously disabling abdominal pain, Mid-epigastric pain that radiates to the back

Manifestations of Chronic Pancreatitis?

abdominal pain, weight loss, DM, steartorrhea

Tetrad of chronic pancreatitis

overall function (renal, hepatic) and nutritional status, Hgb A1C and fecal elastase, Hypercalcemia, hypertriglyceridemia

How do you diagnose chronic pancreatitis - rare to have evidence of active pancreatic inflammation?

MRCP/ERCO, CT MRI

What imaging is required for chronic pancreatitis?

Medical therapy, Puestow or frey (large duct); Whipple/Berger/Frey (small duct), Pancreaticoduodenectomy (traditional resection), total pancreatectomy (refractory)

Treatment plan for Chronic pancreatitis?

Ductal adenocarcinoma

Most common histology for pancreatic cancer

biliary obstruction (most common), acholic stool, dark urine, pruritus, cutaneous jaundice, Anorexia, weight loss, Courvoisier sign (painless palpable gallbladder), epigastric pain

Common manifestations of pancreatic cancer

CT w/ contrast (all patients), ERCP (no mass), Upper GI series, angiography, U/S

Diagnostics for pancreatic cancer

pancreaticoduodenectomy (Whipple)

Operative management of choice for pancreatic cancer

distal pancreatectomy, chemo, radiation

Traditional treatments for pancreatic cancer

Insulinoma

What is the most common GEP-NET?

Hypoglycemic symptoms produced by fasting, blood glucose under 50, relief of symptoms with glucose

What are the diagnostic criteria for Insulinoma (Whipple Triad)?

Weight gain, bizarre behavior, memory lapse, unconsciousness, palpitations, sweating, and tremulousness

Symptoms of an insulinoma

72 hour monitored fast (glucose, insulin, C-peptide, proinsulin, Beta-hydroxybutyrate), enucleation, open/laparoscopic distal pancreatectomy, Anatomic resection (close ductal proximity)

Diagnostics and treatment plan for Insulinoma

complete tumor extirpation

Goals of surgery for Insulinoma

neck of pancreas, junction of the 2nd/3rd portion of the duodenum, junction of the cystic and common bile duct

What is the gastrinoma triangle?

Gastrinoma (Screen’em)

What is the most common PNET in MEN-1

abdominal pain and diarrhea, refractory peptic ulcer diease

Gastrinomas present with

Fasting serum gastrin (1000+), SRS (somatostatin receptor scintigraphy)

Diagnostics for gastrinoma

Surgical resection

Treatment plan for Gastrinoma

Symptomatic relief of splenectomy, hypersplenism secondary to chronic illness, ITP, trauma (grade IV, V - ex-lap)

Splenectomy Indications

Splenomegaly

Enlargement of the spleen classified based on weight or craniocaudal length

Hypersplenism

Indicating intrinsic activities of the spleen fo unregulated - subsequent sequestration and destruction of RBCs

thug it out (non-op management)

Gameplan for a grade I spleen injury

Blunt trauma + diffuse peritonitis or hemodynamically unstable ± Kehr’s sign (pain in the left shoulder)

Signs to take a patient to the OR for trauma

IR (embolization)

If a spleen continues to bleed with no other injuries, who ya gonna call?

OPSI (overwhelming post-splenectomy infection - treat empirically with Abx), VTE

Post-op complications for Splenectomy

Total splenectomy + Abx (maybe percutaneous drainage by IR)

Gameplan for a pyogenic abscess

Strep pneumoniae, H. flu, Meningococcus (boost ‘em)

Which vaccines should you get 2 weeks prior to splenectomy or 2 weeks post emergent splenectomy?

Antiplatelet agents (ASA)

What medications should we send a patient home on post-splenectomy