Linson February 2021 RAD 4001 Matthew Lambert Mindy Wang Wylie Foss Clinical presentation HPI 43 M with HTN DM and EtOH abuse presented to ED with nausea and 1010 abdominal pain for past 12 hrs Pain is at the umbilicus radiating to the back ID: 909537
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Slide1
Acute Pancreatitis
Sarah
Linson
February 2021
RAD 4001
(Matthew Lambert, Mindy Wang, Wylie Foss)
Slide2Clinical 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
Slide3Differential 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
Slide4History
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
Slide5Home medications
Amlodipine 2.5 mg
Lisinopril 20 mg
Atorvastatin 80 mg
Fenofibrate 145 mg
Sertraline 50 mg
Levemir 10 U BID
Slide6Physical Exam
Vital signs
T: 99.4 F
HR: 125
BP: 224/155
RR: 20
SpO2: 99% on RA
Slide7Physical 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
Slide8Lab 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
Slide9Lab 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
Slide10Imaging - CXR
Upright portable CXR 1/18/2021
Slide11Imaging - CXR
Carina
No IP free air
Sharp costophrenic angles
Lung markings extend to periphery
Upright portable CXR 1/18/2021
Slide12Imaging - 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
Slide13Imaging – CT A/P with contrast
CT abdomen/pelvis with contrast
1/18/2021
Slide14Imaging – CT A/P with contrast
Portal vein
IVC
Celiac trunk
CT abdomen/pelvis with contrast
1/18/2021
Slide15Imaging – CT A/P with contrast
Slide16Imaging – CT A/P with contrast
Slide17Imaging – CT A/P with contrast
pancreas
fat stranding
Slide18Imaging – CT A/P with contrast
Slide19Imaging – CT A/P with contrast
Dilation of adjacent small bowel
Slide20Imaging – CT A/P with contrast
Slide21Imaging – CT A/P with contrast
Slide22Imaging – CT A/P with contrast
Slide23Imaging – CT A/P with contrast
Bowel wall thickening
Slide24Imaging – 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
Slide25Differential Diagnosis
Acute pancreatitis
Autoimmune pancreatitis
Malignancy – pancreatic ductal adenocarcinoma, pancreatic lymphoma
Inflammatory/infectious enteritis
Slide26Differential Diagnosis
Acute pancreatitis
Autoimmune pancreatitis
Malignancy – pancreatic ductal adenocarcinoma, pancreatic lymphoma
Inflammatory/infectious enteritis
Slide27Discussion
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
Slide28Discussion
Etiologies of acute pancreatitis
Gallstones
EtOH
Metabolic (hyperlipidemia, hypercalcemia)
Iatrogenic (medications, ERCP, EUS)
Other causes of ductal obstruction (tumor)
Autoimmune
Trauma
Viral
Idiopathic
Slide29Discussion
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
Slide30Discussion
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
Slide31Discussion
Potential complications
Sepsis
Necrosis
Hemorrhagic pancreatitis
Pseudocyst
Abscess
ARDS
Slide32Complications
Peripancreatic fluid collection
https://
www.uptodate.com
/contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis
Slide33Complications
Pancreatic pseudocyst
https://
www.uptodate.com
/contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis
Slide34Complications
Pancreatic necrosis
https://
www.uptodate.com
/contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis
Slide35https://
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
Slide36https://
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
Slide37Treatment
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
Slide38Final Diagnosis
Interstitial edematous acute pancreatitis
Moderately severe (CTSI = 4)
Outcome: discharged home on hospital day 5
Slide39Slide40Teaching 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
Slide41References
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.
Slide42Questions?
Slide43Atlanta 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
Slide44APACHE II
Slide45Ranson
Criteria
vs.
BISAP
Slide46CT Severity Index
Slide47osmosis.org
Pathophysiology of acute pancreatitis
Slide48