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Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury

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Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury. Sankar R. Chirumamilla M.D. PGY II Physical Medicine & Rehabilitation.  An Equal Opportunity University. Anatomy.  An Equal Opportunity University. Pancreatic Secretions. Neurohumoral regulation - PowerPoint PPT Presentation

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Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain InjurySankar R. Chirumamilla M.D.PGY IIPhysical Medicine & RehabilitationAn Equal Opportunity University1

AnatomyAn Equal Opportunity University


Pancreatic SecretionsNeurohumoral regulationSecretin & CholecystokininParasympathetic predominant via vagus nerveSympathetic receptors in pancreas and 1 in sphincter of oddiAn Equal Opportunity University3

Acute Pancreatitis acute inflammation and destructive auto digestion of pancreas and peripancreatic tissue (5). Most common cause in United States (70% to 80%) Alcohol and gall stonesOther hypertriglyceridemia, drugs, iatrogenic, hereditary, and idiopathicAn Equal Opportunity University4

Abdominal pain, nausea, vomiting Serum amylase and lipase 3 times the upper normal limit Radiographic evidence of enlargement and edema of pancreasAn Equal Opportunity University5

Case 18 y/o female, restrained driver, involved in MVC. No h/o LOC, chemically paralyzed, intubated at scene. Initial GCS was 7.Trauma W/UR depressed temporal fractureICH, IVH, SAH, No midline shiftMultiple facial fracturesT3 burst fracture with 8 mm retropulsionMediastinal hematomaAn Equal Opportunity University6

Acute CareRight TP craniectomyTracheostomyPEGTLSO brace for T3 burst fractureAntibiotics for Serratia pneumoniaAn Equal Opportunity University7

Case cont.PMH & PSH: NoneHome medications: NoneAllergies: NKDAFH: HTN in motherSH: single, senior in high school, no H/O tobacco or alcohol or illegal drug use.An Equal Opportunity University8

Case cont.Admitted to Disorders of Consciousness program on day 14Rancho Los Amigos Level IIIFirst episode of dysautonomia on day 20An Equal Opportunity University9

Case cont.Hospital course/complicationsPneumoniaParoxysmal Sympathetic HyperactivityOtitis externaVomiting / elevated amylase & lipase (day 66)Electrolyte abnormalitiesAn Equal Opportunity University10

Case cont.Elevated serum amylase & lipaseAmylase 231Lipase 161US abdomen negativeCT Head - negativeBowel rest , IVF, changing TF to VivonexAmylase 57Lipase 42An Equal Opportunity University11

Pancreatitis in TBI Bouwman et al. in 1983 studied 27 patients for elevated serum amylase (1) zero our of 7 with maxillofacial traumaOne out of 10 with head trauma but without ICH (10%)Six out of 10 with head trauma but with ICH (60%)None with clinical pancreatitisAn Equal Opportunity University12

Justice et al. studied 38 patients with intracranial bleeding for elevated amylase and lipase (2)17 (44.7%) with elevated amylase & lipase25 (65.7%) with elevated lipaseNone with clinical pancreatitisAn Equal Opportunity University13

Liu et al. retrospectively studied 75 patients (3)11 (15%) patients had elevated amylase and lipaseNo clinical or radiographic evidence of pancreatitisPancreatitis in high level spinal cord injury (4)An Equal Opportunity University14

Proposed TheoriesVagal stimulation (2)Change in central control (2)Cholecystokinin release from brain (2)Sphincter of oddi dysfunction (6)Autonomic failure (6)An Equal Opportunity University15

HypothesisParoxysmal sympathetic hyperactivity or dysautonomiaSympathetic and parasympathetic mismatchHypermetabolic stateAn Equal Opportunity University16

Discussion PSH before onset clinical symptoms Serological confirmation Response to conventional treatment Normalization of serum amylase & lipaseAn Equal Opportunity University17

Discussion cont.Serum amylase & lipase testingNot indicated if there is no clinical evidenceMay be indicated if there is clinical evidenceRadiographic confirmationAn Equal Opportunity University18

Conclusion Adequate management of PSH Consider pancreatitis Pancreatitis workup Its more than just pancreatitisAn Equal Opportunity University19

Questions ?An Equal Opportunity University20

Thank YouDr . Silke Bernert M.D.Dr. Lumi Sawaki M.D.Dr. Sara Salles M.D.An Equal Opportunity University21

ReferencesBouwman D, Altshuler J, Weaver D. Hyperamylasemia: A result of intracranial bleeding. Surgery 1983;94:318- 323.Justice A, Dibenedetto R, Stanford E. Significance of elevated pancreatic enzymes in intracranial bleeding. South Med J 1994;87:889- 893.Liu K, Atten M, Lichtor T, Cho M, et al. serum amylase and lipase elevation is associated with intracranial events. Am Surg 2001;67:215-220.Nobel D, Baumberger M, Eser P,et al. Nontraumatic pancreatitis in spinal cord injury. Spine 2002;27:E228-E232.An Equal Opportunity University22

References cont.Sonnenday CJ, Simeone DM, McPhee SJ. Chapter 15. Disorders of the Exocrine Pancreas. In: McPhee SJ, Hammer GD, eds. Pathophysiology of Disease. 6th ed. New York: McGraw-Hill; 2010. Accessed May 16, 2012.Thor PJ, Goschinski I, Kolasinska-Kloch W, Madroszkiewicz D, Madroszkiewicz E, Furgala A. Gastric myoelectric activity in patients with closed head brain injury. Medical Science Monitor 2003;9:932-935.An Equal Opportunity University23

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