Case Studies II

Question 1

Drugs that can cause pancreatitis

Answer 1

Azathioprine

Corticosteroids

Didanosine

Estrogens

Lasix

HCTZ

Metronidazole

Opioids

Pentamidine

Sulfa drugs

Tetracycline

Tamoxifen

Valproate

Question 2

Rare causes of pancreatitis

Answer 2

Infection

Hereditary

Hypercalcemia

Anatomic

Hypertriglyceridemia (generally > 1000)

Tumors

Toxins

Autoimmune (rare)

Question 3

How does pancreatitis present?

Answer 3

• Low grade fever common (60%)
• Pain radiating to back (50%); worse in supine position
• 75% have N/V
• Rebound rare; guarding common (50%)
• Cullen sign is rare
• Grey Turner sign rare (but useful clue if you see it)

Question 4

What is Cullen’s Sign?

Answer 4

Cullen’s sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus.

Question 5

What is this?

Answer 5

Grey Turner Sign in pancreatitis

Question 6

What labs should be ordered for suspected pancreatitis?

Answer 6

• lipase (94% Sn; 96% Sp; LR+ 23; LR – .06)
• Amylase (less Sn and Sp than lipase)
• LFTs (100+ highly suggestive)
• Hematocrit (≥ 50 on admission predicts severe disease (LR+ 7.5))
• CRP (> 150mg/L at 48 hours predicts severe disease (LR+ 3.2-6.6))

Question 7

___% of patients with pancreatitis can develop severe disease

Answer 7

20

Question 8

What are the local complications of pancreatitis?

Answer 8

pseudocyst, necrosis, infections

Question 9

What are the systemic complications of pancreatitis?

Answer 9

hyperglycemia, hypocalcemia, ARDS, AKI, DIC

•Death more likely with infected pancreatic necrosis and in patients with MSOF

Question 10

Question 11

What is the Initial treatment of acute pancreatitis?

Answer 11

is non-operative –Fluid resuscitation, pain management, maintenance of ventilation, adequate oxygenation, and renal perfusion

Question 12

•15% of patients do not improve within 3 to 5 days. How should you procede?

Answer 12

• Order contrast-enhanced CT scan of the pancreas to rule out pancreatic necrosis
• Broad-spectrum antibiotics against enteric pathogens are indicated if necrotizing pancreatitis present
• Aggressive nutritional support and proper electrolyte replacement also important with severe pancreatitis

Question 13

How common is diverticulosis?

Answer 13

• 5-10% of persons > 45 years of age
• 50% of those > 60 years old
• 80% in those > 85 years old

Question 14

What is thought to cause diverticulosis?

Answer 14

–Low-fiber diets may cause due to decreased stool bulk

•Increases intraluminal pressure causing mucosa/submucosa to herniate through colon wall where blood vessels penetrate

Question 15

How does dievrticulitis occur?

Answer 15

•Develops secondary to microscopic or frank perforation of diverticula (e.g. vasa recta perforate muscularis externa)

Question 16

Where is diverticulitis most common?

Answer 16

85-95% in sigmoid/descending colon (LLQ pain)

Question 17

What are the complications of diverticulitis?

Answer 17

abscess, peritonitis, sepsis, colon obstruction, fistula (colovesicular most common)

Question 18

Question 19

Question 20

Question 21

CRC

Question 22