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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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