Good Morning! September 9, 2014

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1 Good Morning! September 9, 2014

2 Prep! A 5 day old infant was found in a trash dumpster and is brought to you for evaluation. Because you have no history on the baby, you decide to send serology specimens to test for Syphilis, HIV, Hepatitis B and C, and Rubella. One week later, all of the test results are negative, with the exception of the presence of antibodies to Rubella and HIV. Of the following, the most appropriate next step in the evaluation and treatment of this infant is to: A. Begin AZT B. Begin triple therapy with AZT, lamivudine, saquinavir C. Observe the infant D. Order HIV DNA PCR E. Repeat HIV serology in 3 months

3 14 year old female 3 day h/o abdominal pain Emesis x1 (NBNB) Intermittent constipation

4

5 Let s take a look Is her exam concerning for an acute, surgical abdomen? What are those red flags we are looking for?*** History of abdominal trauma Distension with tenderness Rigidity of the abdominal wall* Pain worsening with movement Involuntary guarding Rebound tenderness Tenderness with percussion What next?

6

7 Pancreatitis

8 Let s go to the dictionary Acute Pancreatitis An inflammatory process characterized by abdominal pain, elevated pancreatic enzymes, and radiologic evidence of pancreatic inflammation; it is reversible Chronic Pancreatitis Recurring or persisting abdominal pain, pancreatic inflammation, and progressive destruction of the pancreas; often leads to pancreatic insufficiency/failure

9 Epidemiology All ages, Male=Female Heritble Forms are most common cause of chronic pancreatitis in children SPINK 1, CFTR gene mutations

10 Etiology*** Infections, Inflammation/Vasculitis, Systemic Sepsis/Shock. Transplantation Mechanical Trauma, Anatomic, And Obstruction Structural Hyperlipidemia, Hypercalcemia, CF, Severe malnutrition, Refeeding syndrome, Drugs & Toxins Metabolic and Toxic Congenital anomaly, Idiopathic 25% Ductal Chronic fibrosis, Tumor, Pseudocyst, Trauma, AI, Heritable

11 Pathophysiology- Acute Nonphysiologic Ca signals cause premature intracellular activation of trypsinogen to trypsin Activation of other digestive enzymes Acinar cell injury ***The magnitude of the inflammatory response determines clinical severity.*** Pancretic edema, fat necrosis, and a local inflammatory response with release of inflammatory mediators Leads to systemic inflammatory response

12 Pathophysiology- Other Chronic: fibrotic parenchymal disease resulting from obstructive or calcific processes, exact mechanism unknown Hereditary: mutations in cationic trypsinogen, resulting in recurrent bouts of acute pancreatitis Autoimmune: Increased IgG levels + autoantibodies, lymphocytic infiltration of the pancreas with fibrotic changes, diffuse enlargement of pancreas, narrowing of pancreatic duct

13 Clinical Picture*** Acute Severe abd pain of acute onset +/- epigastric location NV Anorexia Can progress to coma, hypotension, renal failure, pulmonary edema, hemorrhage, shock +/- pain Chronic Some have multiple episodes of acute pancreatitis Pain decreases as pancreas burns out Endo/exocrine insufficiency Growth failure

14 How to diagnose*** Requires at least 2 of 3 criteria: 1. Abdominal pain suggestive of or compatible with acute pancreatitis (acute onset, especially in epigastric region) 2. Serum amylase or lipase activity that is at least 3xs greater than upper limit of normal 3. Imaging findings compatible with acute pancreatitis

15 How to diagnose 1. Abdominal pain seen in 80-95% of patients Epigastric pain in only 62-89% Classic epigastric radiating to back in only % 2. Labs*** Amylase value rises in 2-12 hrs, lasts 3-5 days Lipase value rises in 4-8 hrs, more specific & elevated longer Measure both!! Neither enzyme may be elevated in chronic pancreatitis

16 3. Imaging How to diagnose: Abdominal Xray- to exclude other causes US- Pancreatic inflammation, calcification, ductal dilatation, stones, pseudocysts CT- When the US is unsatisfactory CXR- eval for effusion

17 Management Treat the underlying cause NPO (if symptomatic) and aggressive hydration Pain control! Antibiotics? Only if severe systemic illness or pancreatic necrosis Cipro + Flagyl, piperacillin-tazobactam, imipenem ERCP if presence of stones/strictures Surgery for symptomatic complications

18 Complications Acute recurrent: At least 2 episodes of AP per year OR > 3 episodes over a lifetime in a patient (without CP or pancreatic pseudocysts) 10-35% have recurrence Similar pathophysiology and etiologies as single episodes

19 Noon Conference: Dr Barkemeyer Neonatal Fluids and Nutrition

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