1 Exocrine Pancreas

Question 1

Why is hypocalcemia a bad prognostic indicator in pancreatitis?

Answer 1

This means the necrosis has already spread to the peripancreatic fat

-Ca deposits in fat tissue as part of fat necrosis

Question 2

chronic pancreatitis

• mech
• most common cause in adults
• most common in children

Answer 2

• fibrosis of pancreatic parenchyma, usu secondary to recurrent acute pancreatitis
  1. alcohol (adults)
  2. cystic fibrosis (children)
• also can be idiopathic

Question 2

pancreatic carcinoma

• clinical presentation (4)
• what other symptom commonly occurs in tumors in pancreatic head?
• what other symptom occurs in tumors in body/tail?
• serum tumor marker?

Answer 2

1. epigastric pain
2. weight loss
3. pancreatitis
4. migratory thrombophlebitis (Trousseau sign)–10% of pts have swelling, tenderness in extremities

• obstructive jaundice (if head of pancreas involved)–pale stools, palpable gallbladder
• secondary diabetes mellitus (assoc with body/tail tumors)
• CA 19-9

Question 3

chronic pancreatitis

• clinical presentation (3)
• late complications (2)

Answer 3

1. epigastric pain, radiates to back
2. pancreatic insufficiency–steatorrhea, DEAK malabsorption
3. Dystrophic calcification of pancreas on imaging. ‘chain of lakes’ pattern from dilation of pancreatic ducts
4. diabetes mellitus (destruction of islets)
5. increased risk of pancreatic carcinoma

Question 4

acute pancreatitis

• mech
• types of necrosis
• most common causes (2)

Answer 4

• inflamm, hemorrhage of pancreas
• autodigestion of pancreatic parenchyma–premature activation of trypsin leads to activation of other enzymes
• results in liquefactive hemorrhagic necrosis of pancreas, and fat necrosis of peripancreatic fat
  1. gallstones, alcohol

Question 5

annular pancreas

-risk of what?

Answer 5

• developmental malformation in which pancreas form a rings around duodenum
• risk of duodenal obstruction

Question 5

Your pt is a 70 year old thin, elderly woman who presents with new onset diabetes. Suspect what?

Answer 5

• suspect pancreatic carcinoma/chronic pancreatitis
• diabetic usu present as obese in middle age

Question 6

chronic pancreatitis

-what to expect on blood test levels

Answer 6

• serum amylase and lipase are NOT good indicators of chronic pancreatitis. Acute, yes.
• can be normal levels, but that’s because much of pancreas already destroyed

Question 8

acute pancreatitis

-elevated serum amylase typically decreases after acute attack. Suspect what if persistently elevated? (2)

Answer 8

1. pseudocyst
2. pancreatic abscess

Question 10

acute pancreatitis

• clinical symptoms (3)
• what blood lab results abnormal? (3)

Answer 10

1. epigastric abdominal pain, radiates to back
2. nausea, vomiting
3. periumbilical and flank hemorrhage (necrosis spreads to retroperitoneum)
4. elevated serum lipase (more specific)
5. elevated amylase
6. hypocalcemia (Ca consumed during saponification in fat necrosis–Ca deposited in fat)

Question 11

pancreatic carcinoma

• carcinoma of what cells
• major risk factors (2)
• population

Answer 11

• adenocarcinoma from pancreatic ducts
• 1. smoking
     
     2. chronic pancreatitis
• elderly (avg age 70)

Question 12

acute pancreatitis

-complications (4)

Answer 12

1. shock–peripancreatic hemorrhage, fluid sequestration
2. pancreatic pseudocyst–fibrous tissue surrounding liquefactive necrosis and enzymes. (presents as abdominal mass with persistantly elevated serum amylase. Rupture assoc with enzyme release into abdominal cavity and hemorrhage!)
3. pancreatic abscess (often E Coli)
4. DIC (enzymes destroy coag factors in blood), ARDS (enzymes damage alveolar/capillary interface)