160. Clinical Features of Pancreatic Disorders

Question 1

What do you need to diagnose pancreatitis?

Answer 1

2/3 of

sx: severe epigastric pain radiating to back
labs: high lipase/amylase (amylase may be elevated in other conditions)
radiology: imaging suggests pancreatitis (not always needed)

Question 2

Acute Pancreatitis

• types
• etiology
• tx

Answer 2

Type 1: Interstitial Edematous - inflammation of pancreatic parenchyma + peripancreatic tissues WITHOUT necrosis
2. Necrotizing - inflammation with parenchymal or peripancreatic NECROSIS

Etiology: Biliary (stones, microlithiasis), Alcohol Use (dose dependent, sole cause and increases susceptibility), Tobacco, Post ERCP, Pancreatic Obstruction (tumor, stricture), elevated TG, infection, trauma, pancreas divisum (buds don’t fuse - minor papillae increased flow)
Hereditary: PRSS1 gene AD mutation (encodes trypsinogen), CFTR/SPINK1 mutations AR and disease-modifiers
Autoimmune: Type 1 - IgG4 mediated (high serum Levels); Type 2 - IBD assoc
Meds

tx: early dx of cause - imaging of US RUQ BEST! (Avoid CT for unknown cause! MRCP too much!) ERCP for recurrent AP only
IV hydration (lots quickly)
Nutrition: controversial in avoiding oral nutrition, nasojejunal feedings better than TPN, timing of nutrition does not matter
Analgesia

Question 3

Complications of the types of acute pancreatitis

Answer 3

Interstitial Pancreatitis - Acute Pancreatic Fluid Collections (self-resolve, don’t intervene until progress to) - Pseudocyst (mature, walled collections of pancreas juice, may need drainage)

Necrotizing Pancreatitis - Acute Necrotic Collections (no tx acute, wait til) - Walled Off Pancreatic Necrosis (tx if infected/sx - drainage + DEBRIDEMENT - of necrotic tissue)

Question 4

Chronic pancreatitis

• causes
• CP
• tx

Answer 4

Causes: alcohol, hereditary, tobacco (progresses chronic inflammation, increases risk of cancer), previous severe acute pancreatitis, autoimmune, anatomic (divisum)
CP: pancreatic pain, neuropathic pain, exocrine insufficiency (malabsorption), endocrine insufficiency (DM)
Tx: meds - pancreas enzyme replacement for exocrine fx (AVOID OPIATES!)

Question 5

Pancreas Adenocarcinoma

• epidemiology
• RF
• Tumor presentation depending on location
• Tx
• Prognosis

Answer 5

3rd leading cause of cancer death
RF: M > F, +FamHx, Smoking, Chronic Pancreatitis, Obesity, Genetic Syndromes (Puetz-Jaghers - STK11 gene, Familial Atypical Multiple Myeloma - CDK2NA gene, BRCA1/2, Lynch Syndrome (HCCS))
in head of pancreas: blocks bile ducts earlier, causes jaundice
in body/tail - presents very advanced - grows lots before sx
tx: surgical resection only cure
Prognosis: poor - 9% 5 year survival (trend: growing prevalence and improving survival rates)

Question 6

Pancreatic Endocrine Tumors

-types and sx of each

Answer 6

Named after hormone they secrete - insulinoma, gastrinoma, non-functioning
functioning found at early stage due to sx

Insulinoma: fasting hypoglycemia, high levels of insulin and c-peptide (insulin precursor), even after prolonged fast

Gastrinoma: 70% in duodenum, 30% in pancreas/LNs
- high gastrin = abd pain, diarrhea, high gastric folds, PUD
Dx: high fasting serum gastrin w/ acidic stomach pH
Secretin Stim test: gastrin rises 200x after secretin use (normally inhibits gastrin)

Question 7

Compare the following Cyst neoplasms

1. Mucinous Cyst Neoplasms
2. Intraductal Papillary Mucinous Neoplasms
3. Serous Cystademona

• pt characteristics
• dx histo
• location w/in pancreas
• prognosis

Answer 7

Mucinous Cyst Neoplasms

• 40 year old women (“mother cyst”)
• ovarian-like stroma
• Macrocystic lesion in pancreas body/tail
• prog: more aggressive than other cysts (precancerous) - needs surgical resection

IPMN

• elderly men (“grandfather cyst”)
• mucin producing cells in papillary pattern
• communicates w/pancreatic duct (MUCIN THROUGH MAJOR PAPILLAE PATHOGNOMONIC)
• prognosis: common and low risk

Serous Cystadenoma

• middle-age to elderly women
• prognosis: low malignant potential, only resect if sx/rapidly growing