1. Sankar R. Chirumamilla M.D. PGY II Physical Medicine & Rehabilitation
Pancreatitis and Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury
Sankar R. Chirumamilla M.D.
PGY II
Physical Medicine & Rehabilitation
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2. Anatomy
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3. 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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4. 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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5. 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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6. 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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7. Acute Care Right TP craniectomy Tracheostomy PEG
TLSO brace for T3 burst fracture
Antibiotics for Serratia pneumonia
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8. 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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9. 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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10. Case cont. Hospital course/complications Pneumonia
Paroxysmal Sympathetic Hyperactivity
Otitis externa
Vomiting / elevated amylase & lipase (day 66)
Electrolyte abnormalities
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11. Case cont. Elevated serum amylase & lipase
US abdomen – negative
CT Head - negative
Bowel rest , IVF, changing TF to Vivonex
Amylase – 57
Lipase – 42
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12. 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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13. 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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14. 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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15. 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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16. Hypothesis Paroxysmal sympathetic hyperactivity or dysautonomia
Sympathetic and parasympathetic mismatch
Hypermetabolic state
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17. Discussion PSH before onset clinical symptoms Serological confirmation
Response to conventional treatment
Normalization of serum amylase & lipase
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18. 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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19. Conclusion Adequate management of PSH Consider pancreatitis
Pancreatitis workup
It’s more than just pancreatitis
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20. Questions ?
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21. Dr . Silke Bernert M.D. Dr. Lumi Sawaki M.D. Dr. Sara Salles M.D.
Thank You
Dr . Silke Bernert M.D.
Dr. Lumi Sawaki M.D.
Dr. Sara Salles M.D.
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22. References
Bouwman D, Altshuler J, Weaver D. Hyperamylasemia: A result of intracranial bleeding. Surgery 1983;94:
Justice A, Dibenedetto R, Stanford E. Significance of elevated pancreatic enzymes in intracranial bleeding. South Med J 1994;87:
Liu K, Atten M, Lichtor T, Cho M, et al. serum amylase and lipase elevation is associated with intracranial events. Am Surg 2001;67:
Nobel D, Baumberger M, Eser P,et al. Nontraumatic pancreatitis in spinal cord injury. Spine 2002;27:E228-E232.
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23. 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; 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:
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