Pancreatitis and Paroxysmal Sympathetic Hyperactivity in

Traumatic Brain Injury

Sankar R. Chirumamilla M.D.

PGY II

Physical Medicine & Rehabilitation

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Anatomy

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Pancreatic Secretions

•Neurohumoral regulation

•Secretin & Cholecystokinin

•Parasympathetic predominant via vagus nerve

•Sympathetic – α receptors in pancreas and α1 in

sphincter of oddi

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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 stones

•Other – hypertriglyceridemia, drugs, iatrogenic,

hereditary, and idiopathic

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• Abdominal pain, nausea, vomiting

• Serum amylase and lipase 3 times the upper

normal limit

• Radiographic evidence of enlargement and

edema of pancreas

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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/U• R depressed temporal fracture• ICH, IVH, SAH, No midline shift• Multiple facial fractures• T3 burst fracture with 8 mm retropulsion• Mediastinal hematoma

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Acute Care

• Right TP craniectomy

• Tracheostomy

• PEG

• TLSO brace for T3 burst fracture

• Antibiotics for Serratia pneumonia

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Case cont.

• PMH & PSH: None

• Home medications: None

• Allergies: NKDA

• FH: HTN in mother

• SH: single, senior in high school, no H/O tobacco or

alcohol or illegal drug use.

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Case cont.

• Admitted to Disorders of Consciousness

program on day 14

• Rancho Los Amigos Level III

• First episode of dysautonomia on day 20

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Case cont.

• Hospital course/complications

• Pneumonia

• Paroxysmal Sympathetic Hyperactivity

• Otitis externa

• Vomiting / elevated amylase & lipase (day 66)

• Electrolyte abnormalities

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Case cont.

• Elevated serum amylase & lipase• Amylase – 231• Lipase – 161• US abdomen – negative• CT Head - negative

• Bowel rest , IVF, changing TF to Vivonex• Amylase – 57• Lipase – 42

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Pancreatitis in TBI• Bouwman et al. in 1983 studied 27 patients for elevated serum amylase (1)

• zero our of 7 with maxillofacial trauma

•One out of 10 with head trauma but without ICH

(10%)

•Six out of 10 with head trauma but with ICH (60%)

•None with clinical pancreatitis

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• Justice et al. studied 38 patients with intracranial bleeding for elevated amylase and lipase (2)

• 17 (44.7%) with elevated amylase & lipase

• 25 (65.7%) with elevated lipase

• None with clinical pancreatitis

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• Liu et al. retrospectively studied 75 patients (3)

• 11 (15%) patients had elevated amylase and

lipase

• No clinical or radiographic evidence of pancreatitis

• Pancreatitis in high level spinal cord injury (4)

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Proposed Theories

• Vagal stimulation (2)

• Change in central control (2)

• Cholecystokinin release from brain (2)

• Sphincter of oddi dysfunction (6)

• Autonomic failure (6)

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Hypothesis

• Paroxysmal sympathetic hyperactivity or

dysautonomia

• Sympathetic and parasympathetic mismatch

• Hypermetabolic state

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Discussion

• PSH before onset clinical symptoms

• Serological confirmation

• Response to conventional treatment

• Normalization of serum amylase & lipase

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Discussion cont.

•Serum amylase & lipase testing

•Not indicated if there is no clinical evidence

•May be indicated if there is clinical evidence

•Radiographic confirmation

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Conclusion

• Adequate management of PSH

• Consider pancreatitis

• Pancreatitis workup

• It’s more than just pancreatitis

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Questions ?

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Thank You

Dr . Silke Bernert M.D.

Dr. Lumi Sawaki M.D.

Dr. Sara Salles M.D.

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References

1. Bouwman D, Altshuler J, Weaver D. Hyperamylasemia: A result of intracranial bleeding. Surgery 1983;94:318- 323.

2. Justice A, Dibenedetto R, Stanford E. Significance of elevated pancreatic enzymes in intracranial bleeding. South Med J 1994;87:889- 893.

3. 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.

4. Nobel D, Baumberger M, Eser P,et al. Nontraumatic pancreatitis in spinal cord injury. Spine 2002;27:E228-E232.

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References cont.

5. 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. http://www.accessmedicine.com/content.aspx?aID=5370194. Accessed May 16, 2012.

6. 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.

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