Drugs that cause acute pancreatitis

"DEFEATS"

D: didanosine (anti-HIV drug)
E: erthyromycin
F: furosemide
E: estrogens
A: azithromycin (Imuran)
T: tetracycline
S: sulfa

Drugs Associated with Pancreatitis:

Definite Cause
·       5-Aminosalicylate ·       6-Mercaptopurine ·       Azathioprine ·       Cytosine arabinoside ·       Dideoxyinosine ·       Diuretics ·       Estrogens ·       Furosemide	·       Metronidazole ·       Pentamidine ·       Tetracycline ·       Thiazide ·       Trimethoprim-sulfamethoxide ·       Valproic acid
Probable Cause
·       Acetaminophen ·       α-Methyl-DOPA ·       Isoniazid ·       L-Asparaginase	·       Phenformin ·       Procainamide ·       Sulindac

Etiology - Acute Pancreatitis

"IT HURTS BADLY"

80-90% due to EtOH and gallstones

I: infection
T: trauma
H: hypercalcemia
U: ulcer (penetrating)
R: renal disease
T: tumor (pancreatic, biliary, duodenal)
S: structural (annular pancreas, pancreas divisum)
B: biliary gallstones
A: alcohol
D: drugs ("DEFEATS")
L: lipids
Y: "y"atrogenic

Parenteral Fluid composition

Solution	Na	K	Ca	Mg	Cl	HCO3
ECF	142	4	5	3	103	27
NS	154				154
RL	130	4	2.7		109	28
D5/0.45%NS	77				77
2/3 & 1/3	56				56

Osmolarity:
Ringer's: 275 mmol/L
Normal saline: 310 mmol/L
Plasma normal range: 300-310 mmol/L

pH:
Ringer's: 6.75
Normal saline: 5.5

Remicade vs. Humira

Adalimumab (Humira)
- human mAb to human TNF receptor
- 5-7 days until maximal serum concentration
- dosed every week 40mg I'M
- terminal half-life is 2 weeks

Infliximab (Remicade)
- Humanized mouse mAb to human TNF
- terminal half-life is 7-10 days
- dosed every 2-6 weeks 3-10 mg/kg depending on indication
- for Crohns typically 5 mg/kg

Timing after surgery.
- DMARDS can impair healing. For Remicade suggested to wait 6 weeks before elective surgery. For humira ? 2 weeks

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Hinchey 3/4 diverticulitis

ACS surgery:
- 1-2 resection and immediate anastamosis are suitable.
In setting of perforated, peritonitic diverticulitis, resection with diversion is gold standard.
- other potential options (without great evidence) include on-table lavage and primary anastamosis (more for obstructing colon lesions with minimal contamination), laparoscopic lavage and creation of loop ileostomy (and delayed laparoscopic sigmoid resection)
- one stage resection: argument is that colostomy takedown and reanastamosis associated with 4% mortality and 30-40% never go back for reversal.
In a healthy patient mortality of 4% seems too high. In an elderly and sick patient primary anastamosis would carry too high risk of leak with attendant risks of getting sicker
- diversion: loop ileostomy vs. Transverse colostomy. Higher risk of obstruction with ileostomy but transverse colostomy associated with paying problems, scar issues and harder to reverse.

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Diverticulitis: special circumstances

Cecal diverticulitis.
- 15% of north American patients. Majority are pseudodiverticula
- medical management is mainstay for uncomplicated disease
- localized diverticulotomy can be performed for very localized and mild disease

Young patients:
- patients younger than 40 yo
- current textbooks suggest treating in same fashion as in older patients.
- elective resection is individualized to the patient but generally does not follow a single attack.

Immunosuppressed patient:
- included in his group are chronic alcoholics, transplant patients, chemotherapy patients.
- incidence is not higher but consequence of a complicated attack is more significant
- corticosteroids cause thinning of colonic wall, suppressed physical exam, attenuated inflammatory response
- are RA patients on methotrexate and IBD patients on biologics considered Immunosuppressed?
- prophylactic colectomy not needed if diverticulosis found but aggressive investigation and treatment of diverticulitis warranted.

Trivia:
- diverticulitis has replaced appendicitis as most common source of liver abscess of portal origin.
- recurrence of diverticulitis after colectomy in the range of 1-10%
- level of anastamosis is only identifiable risk factor.

Classification of Wounds

Clean: 

• nontraumatic, no break in technique, no tract entered.
• Infection rate: 1.5 – 2.9%

Clean contaminated: 

• GI or resp tract entered without significant spillage, oropharynx, vagina, or noninfected GU or biliary tract entered, minor break in technique.
• Infection rate: 2.8 – 7.7%

Contaminated: 

• major break in technique, fresh traumatic wound, gross spillage from GI tract, entrance into GU or biliary tree in presence of infection.
• Infection rate: 6.4 – 15.2%

Dirty: 

• pus encountered, traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, or delayed treatment, or from a dirty source.  This definition suggests that organisms were present in the operative field before the operation.

Barrett's Esophagus - Surveillance

4 quadrant biopsies every 2 cm intervals - beginning 1 cm below GE jxn and extending 1 cm above squamocolumnar junction

In absence of dysplasia: 
- every 3 years

Low grade dysplasia: 
- every 6 months for 1st year, if no progression then every 1 yr

High grade dysplasia: 
- confirm by an independent, experienced pathologist.  Confirmation of diagnosis warrants agressive treatment
- endoscopic vs. surgical options

Mallampati Airway classification

Look for soft palate, uvula, tonsillar pillars
Class I: tonsillar pillars and all of uvula (only 0.4% were difficult)
Class II: more than base of uvula but not pillars
Class III: only base of uvula
Class IV: no uvula or soft palate

False positives and negatives do occur