Pancreatitis Overview Quiz

Pancreatitis

• Inflammation of pancreatic parenchyma
• Types:
  • Acute:
    • Reversible emergency condition
    • Activated pancreatic enzymes leak into the pancreas, causing auto-digestion
    • Elevated pancreatic enzymes in blood and urine
  • Chronic:
    • Permanent and irreversible damage
    • Chronic inflammation, fibrosis, and destruction of exocrine and endocrine tissues

Causes of Pancreatitis

• Biliary tract diseases (gallstones)
• Alcohol intake
• Drugs (steroids, diuretics, valproic acid)
• Hypertriglyceridemia/hypercalcemia
• Idiopathic
• Traumatic injury (operative)
• Scorpion sting

Acute Pancreatitis

• Causes: Duct obstruction, acinar cell injury, defective intracellular transport
• Mechanisms: Cholelithiasis, ampullary obstruction, chronic alcoholism, ductal concretions, impaired blood flow, ischemia, alcohol, drugs, trauma, and viruses
• Release of intracellular proenzymes and lysosomal hydrolases
• Activation of enzymes (intra- or extracellular)
• Lesions: Interstitial inflammation, edema, proteolysis (proteases), fat necrosis (lipase, phospholipase), hemorrhage (elastase)

Acute Pancreatitis Stages

• Two phases: Early (1st week), Late (after 1st week)
• Severity: Mild (no organ failure), Moderate (organ failure < 48 hours), Severe (organ failure > 48 hours)
• Two types: Oedematous, Necrotizing
• Complications: Acute peripancreatic collection (< 4 wk), Acute necrotic collection (< 4 wk), Pseudocyst (> 4 wk), walled-off necrosis (> 4 wk)

Acute Pancreatitis - Symptoms

• Upper abdominal pain (sudden onset, sharp, severe, & continuous)
• Generalized abdominal pain
• Nausea, vomiting, and anorexia
• Fever and weakness
• Grey Turner's sign
• Cullen's sign
• Fox's sign
• Panniculitis (subcutaneous red nodular fat necrosis)

Acute Pancreatitis - Investigations

• Blood tests:
  • Serum amylase (elevated for 3-5 days)
  • Serum lipase (more pancreatic specific, elevated for 7 days)
  • CBC, CRP
• Imaging tests:
  • Chest X-ray
  • Abdominal ultrasound
  • CT scan
  • MRI
• ERCP (Endoscopic retrograde cholangiopancreatography)

Acute Pancreatitis - Treatment

• Treatment goals:

  • Supportive care
  • Decrease inflammation
  • Limit risk of superinfections
  • Identify and treat complications
  • Treat cause (if possible)

• Specific treatment

  • Anti-emetics (IV)
  • Opioid analgesics (IM pethidine)
  • NPO (nil per OS) until pain free (2-3 days)
  • Omeprazole or ranitidine (IV)
  • Antisecretory drugs (somatostatin- octreotide)
  • Respiratory support (O2 mask)
  • Aggressive fluid rehydration (IV fluids)
  • Antibiotic therapy (Carbapenem – Fluroquinolones)
  • (only if needle aspiration of necrotic material confirms infection)

Chronic Pancreatitis - Symptoms

• Pain in upper abdomen

• Diarrhea

• Fatty stools (loose, pale, don't flush away easily)

• Nausea and vomiting

• Shortness of breath

• Unexplained weight loss

• Excessive thirst and fatigue

• Diagnosis: Similar to acute pancreatitis cases

• Pharmacological treatment:

  • Analgesics
  • Artificial digestive enzymes (if enzyme levels are too low to digest food normally)
  • Insulin (if complicated with diabetes)
  • Steriods (if autoimmune pancreatitis)

Viral Hepatitis

• Features and classification of various types
• Management and pharmacological mechanisms of antiviral treatments
• Types of portal hypertension and their symptoms
• Pharmacological management of portal hypertension

Viral Hepatitis - Historical View

• 500 BC: Written accounts of jaundice in Babylonia
• 400 BC: Hippocrates describes "epidemic jaundice"
• 1941: Post-vaccination jaundice in >28K US soldiers
• 1947: Hepatitis A and hepatitis B designation
• 1963: Hepatitis B Surface Antigen identified
• 1973: Hepatitis A identified by electron microscopy
• Mid-1970s: Hepatitis D recognized
• Mid-1970s: Non-A, Non-B hepatitis described
• Mid-1980s: Epidemics of "non-hepatitis A" enteric hepatitis
• 1989: Hepatitis C cloned and serological tests developed
• 1990: Hepatitis E cloned and characterized

Viral Hepatitis - Common Features

• Early prodromal phase (2-3 weeks before jaundice): Arthralgias, arthritis, rash, angioneurotic edema, fever
• Preicteric phase: Gastrointestinal symptoms, malaise, myalgias, headache, fever
• Icteric phase: Fever declines, constitutional symptoms improve
• Convalescent phase: Full recovery usually within 6 months

Viral Hepatits - Differential Features (Table)

• Presents data in table format comparing various types of Hepatitis based on incubation period, transmission modes, and other aspects

Viral Hepatitis - Management

• Prophylaxis through vaccination:
  • Hepatitis A Virus (HAV):
    • Havrix, Vaqta
    • Inactive (killed) HAV
    • Two doses
    • Recommended for travelers to HAV-endemic areas, illegal drug users, HAV lab researchers
  • Hepatitis B Virus (HBV):
    • Energix B, Recombivax-HB
    • Harmless HBV surface antigen
    • Three doses
    • Recommended for infants and adolescents, people exposed to blood/body fluids, patients with kidney dialysis, and travelers to risk areas
  • Hepatitis C/D Virus (HCV/HDV):
    • No vaccines currently available

Viral Hepatitis - Treatment

• HAV, HEV: Supportive care (unless complications arise)
• HBV (Acute): Supportive care, antiviral therapy only with liver failure, avoid interferon (increased risk of hepatic necroinflammation)
• HBV (Chronic): Antiviral therapy (Interferon-alpha, either standard or pegylated) is cornerstone.
• HCV (Acute): Pegylated interferon-alpha OR Antiviral therapy, treatment can be postponed for 12 weeks if viral load spontaneously clears
• HCV (Chronic): Antiviral therapy is cornerstone; antiviral selection depends on genotype; pegylated interferon-alpha may be used.

Viral Hepatitis - Antiviral Therapy (Details)

• HBV Therapies:
  • Interferons (inducible glycoproteins, PEG-interferon) - mechanisms not fully understood
  • Lamivudine (nucleoside analogue, HBV reverse transcriptase inhibitor) - High resistance rates
  • Adefovir (nucleotide analogue)- Nephrotoxicity
  • Entecavir (nucleoside analogue targeting HBV reverse transcriptase)- adjust dose in renal failure
• HCV Therapies:
  • NS3/NS4A protease inhibitors (e.g., Paritaprevir, Grazoprevir, Glecaprevir, Voxilaprevir)
  • NS5B polymerase inhibitors (e.g., Sofosbuvir, Dasabuvir)
  • NS5A replication complex inhibitors (e.g., Ledipasvir, Ombitasvir, Elbasvir, Daclatasvir)
  • Ribavirin (guanosine analogue, improves viral clearance, decreases relapse rates)

Portal Hypertension

• Portal venous pressure: Blood pressure in hepatic portal vein (5-10 mmHg)
• Portal hypertension: Hepatic venous pressure > 10 mmol/L
• Types:
  • Pre-hepatic: Portal vein thrombosis (common), Pancreatitis
  • Intra-hepatic: Cirrhosis, fibrosis, fatty liver, malignancy
  • Post-hepatic: Hepatic vein thrombosis (Budd-Chiari syndrome), right heart failure

Portal Hypertension - Clinical Manifestations

• Ascites
• Hypersplenism
• Hemorrhoids
• Caput medusae (distended and engorged superficial epigastric veins)
• Esophageal varices
• Gynecomastia
• Jaundice

Portal Hypertension - Pharmacotherapy

• Beta-blockers: (propranolol, nadolol, timolol)

  • Decrease cardiac output → decrease portal flow
  • Decrease splanchnic vasoconstriction → decrease portal flow.
  • treatment of choice - continue for life.

• Vasopressors: (e.g., vasopressin, somatostatin, octreotide):

  • Control variceal bleeding through vasoconstrictive effects on blood vessels.
  • Mediated through V1 receptors.
  • Treat acute bleeding, IV octreotide decrease portal BP by splanchnic artery constriction reducing portal blood flow.