2- Pancreatic Disease Flashcards
Pathophys for pancreatitis involves high pancreatic levels of activated trypsin → pancreatic auto-digestion, injury, and inflammation → increased inflammation → ??
Multi-organ injury/ failure, systemic inflammatory response, death
What type of pancreatitis is defined as acute inflammation of the pancreatic parenchyma and peripancreatic tissues without necrosis?
Interstitial edematous acute pancreatitis
What type of pancreatitis is defined as inflammation a/w pancreatic parenchymal necrosis and/ or peripancreatic necrosis?
Necrotizing acute pancreatitis
What are the 2 most common etiologies of acute pancreatitis?
Gallstones and chronic alcohol abuse
What is included in the mneumonic “I get smashed” for the causes of acute pancreatitis?
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion/ snakes
Hyperlipidemia/ hypercalcemia
ERCP
Drugs
Pt presents with acute, persistent, boring and severe abd/ epigastric pain that radiates to his back. He also presents with N/V and decreased satiety/ anorexia. What are you concerned for?
Acute pancreatitis
When is acute pancreatitis typically aggravated and alleviated?
Worse w/ intake or lying supine
Better leaning forward with knees flexed
What will VS show for a pt with acute pancreatitis?
Tachycardia, tachypnea, hypotension, fever
Acute pancreatitis due to ileus will likely show what specific PE finding?
Abd distension, hypoactive bowels
Acute pancreatitis due to choledocholithiasis or edema of pancreatic head will likely show what specific PE finding?
Scleral icterus
Acute pancreatitis due to alcoholic abuse will likely show what specific PE finding?
Hepatomegaly
Acute pancreatitis due to hyperlipidemia will likely show what specific PE finding?
Xanthomas
Acute pancreatitis due to mumps will likely show what specific PE finding?
Parotid swelling
What 3 PE findings are specifically a/w severe necrotizing pancreatitis?
Cullen sign (periumbilical), Grey-Turner (flanks), Panniculitis (erythematous nodules)
What will lab studies for pancreatic enzymes show for a pt with acute pancreatitis?
3x ULN- amylase and lipase
Lipase more specifc to pancreatic injury
What will CRP reflect if severe pancreatitis?
> 150 mg/dL @ 48 hours
When should genetic testing for acute pancreatitis be performed?
Strong FH, < 35 at age of onset
(should have genetic counseling before and after)
What will be seen on abd XR of a pt with acute pancreatitis?
Calcified gallstones and sentinel loop
(gallstones also seen on US)
The following things should be evaluated for if dx of acute pancreatitis is not clear on what dx study?
Pancreatic ductal abns, tumors involving ampulla, pancreatic CA, microlithiasis in GB or common bile duct (CBD), early chronic pancreatitis
Endoscopic US (EUS)
When evaluating for acute pancreatitis, if the EUS (endoscopic US) is abnormal, what should you consider?
ERCP
What will a contrast enhanced CT of the abdomen show if acute pancreatitis and what does this help with?
Enlargement of pancreas, identifies severity/ complications of disease
What are some possible complications of acute pancreatitis that can be seen on abdominal CT?
Necrosis, pseudocyst, abscess, hemorrhage
Is an early CT recommended for a pt meeting clinical and laboratory criteria for acute pancreatitis?
NO
(most uncomplicated, complications appreciated 3 days post onset, IV contrast may worsen pancreatitis)
What are the advantages of using an MRCP over CT when evaluating acute pancreatitis?
Lower risk of nephrotoxicity, increased characterization, better view of biliary and pancreatic ducts
What diagnostic test is used for acute pancreatitis to visualize biliary and pancreatic ductal antomy, to obtain cytology or biopsy, and is therapeutic?
ERCP
(can remove stones or insert stent)
For suspected pancreatitis, what is the appropriate order of dx tests that should be ordered?
Abd US, EUS, MRCP
Unexplained acute pancreatitis is concerning for what? And should therefore be eval’d with contrast abd CT (pancreas protocol), MRI w/ MRCP and EUS?
Concerning for malignancy
Pt presents with recurrent pancreatitis and EUS is negative. What is the next step?
Check bile for microscopic cholesterol or bilirubinate crystals → if negative then MRCP
Diagnosis for pancreatitis requires 2 of what 3 criteria? (general)
Clinical presentation, elevated serum lipase or amylase, consistent imaging findings
What is the tx for pancreatits?
Admit, supportive/ sx, meds (pain control, abx, N/V), NPO, hydration, monitor
When monitoring a pt with pancreatis, what conditions would indicate a CT if > 72 hours after sx onset? (4)
- Persistent/ recurrent abd pain
- Increase in pancreatic enzymes after initial decrease
- New/ worsening organ dysfunction
- Sepsis (fever/ increased WBCs)
What complications are a/w pancreatits?
Local complications, systemic inflammatory response syndrome (SIRS), organ failure
(local complications: peripancreatic fluid collection, pancreatic pseudocyst, necrosis, gastric outlet dysfunction, splenic and portal vein thrombosis)
What complication of acute pancreatitis is a localized collection of fluid, can present as a palpable mass in the mid-epigastric area (+/- sxs), and may spontaneously resolve or continue to enlarge?
Pancreatic pseudocyst
What conditions will complicate a pancreatic pseudocyst?
Rupture, hemorrhage, infection
(surgery vs drainage if sx or infected)
How is mild acute pancreatitis classified?
No organ failure, local complications, or systemic complications
How is moderately severe pancreatitis classified?
Transient organ failure, local complications, and systemic complications < 48 hours
How is severe pancreatitis classified?
Organ failure > 48 hrs, ≥ local complication, and ≥ systemic complication
There are multiple scoring systems and many data points involved in the prediction of disease severity for acute pancreatits. What are the most commonly used?
Presence of systemic inflammatory response syndrome (SIRS) on admission and persisting > 48 hours
Ranson criteria (findings at initial assesement a/w severe disease)
What is the mortality rate a/w severe acute pancreatitis?
Up to 30%
What are likely causes of death if w/i first 2 weeks of acute pancreatitis?
SIRS/ organ failure
What are likely causes of death if after 2 weeks of acute pancreatitis?
Sepsis and other related complications
How can recurrence of acute pancreatitis be prevented?
Treat underlying cause
What is defined as progressive inflammatory changes and long term structural damage of the pancreas?
Chronic pancreatitis
Chronic pancreatitis (repeated episodes of acute inflammation) leads to a gradual loss of pancreatic function that then leads to what?
Exocrine and endocrine insufficiency
What are the effects of exocrine insufficiency a/w chronic pancreatitis?
Malapsorption → steatorrhea (increased excretion of fecal fat, greasy, foul smelling stool) and weight loss
Endocrine insufficiency a/w chronic pancreatitis leads to what?
Diabetes (“poly’s”, insulin dependency, brittle cells affected)
Pt presents with epigastric pain that is chronic, unrelenting, debilitating and persistent. They state it is aggravated by alcohol and large/ high fat meals. He Also reports N/V and weight loss. What are you concerned for?
Chronic pancreatitis
What is the classic triad a/w chronic pancreatitis?
DM, steatorrhea, calcifications
Secretin stimulation test (can be used for chronic pancreatitis but not often) is abnormal if what?
60% of exocrine function lost
What labs are considered gold standard for eval of chronic pancreatitis?
Increased fecal fat testing
- 72 hr quantitative fecal fat preferred over qualitative testing of a spot sample
- Fecal elastase = test of choice for steatorrhea
What imaging is ordered is suspicion of chronic pancreatitis?
Abd XR (scattered calcifications), contrast abd CT (calcifications, dustal dilation, pseudocyst), MRCP, ERCP
Although more invasvie and therefore used less often, what gold standard finding will be seen on ERCP if chronic pancreatitis?
Chain-of-lakes
What is included in the management for chronic pancreatitis? (general)
Behavior mod, pain relief, lithotripsy, endoscopic procedures, decompression/ drainage, resection and denervation
Aside from general measures such as alcohol and smoking cessation, small meals, and hydration, what other methods of pain relief are used for chronic pancreatitis?
Pancreatic enzyme supplements, consider Amitriptyline or SSRI, referral to interventional pain specialist (opioids and nerve blocks)
What are the following complications a/w?
DM and malabsorption management, chronic pain, pseudocyst, abscess formation, fistula formation, pancreatis ascites, mesenteric venous thrombosis
Chronic pancreatitis
What are the common etiologies of pancreatic CA? (4)
Abn glucose metabolism, insulin resistance, obesity, chronic pancreatitis
Is exocrine or endocrine pancreatic CA more common?
Exocrine (85% present with locally advanced or metastatic disease)
What is the most common type of exocrine pancreatic CA?
Ductal adenocarcinoma of the pancreas
Majority of cases of pancreatic CA involve what anatomical location?
Head of pancreas
What are the major RFs a/w pancreatic CA? (5)
Cigarette smoking, high body mass, lack of physical activity, nonhereditary chronic pancreatitis, pancreatic cysts
What is the most common clinical presentation of pancreatic CA?
Epigastric pain, jaundice, weight loss
In addition of abd pain, hepatomegaly, RUQ/ epigastric mass, ascites, and jaundice/ icterus, what sign of PE is indicative of pancreatic CA?
Courvoisier sign = nontender palpable gallbladder
If pt suspicious for pancreatic CA presents with jaundice or epigastric pain, what should you look for on labs?
Cholestasis
What tumor marker is used in pancreatic CA and displays elevations relative to tumor size?
CA 19-9
What initial imaging should be performed for suspicion of pancreatic CA if pt presents with jaundice?
Abd US preferred
MRCP/ ERCP if suspicious for choledocholithiasis
(US detects biliary tract/ CBD dilation, level of obstruction, mass)
What initial imaging should be performed for suspicion of pancreatic CA if pt presents with epigastric pain and weight loss without jaundice?
Triple phase thin sliced enhanced helical CT of abd w/ 3D reconstruction (preferred)
For a pt that presents with epigastic pain and weight loss but no jaundice and you are suspicious for pancreatic CA, why is an US not preferred?
Lacks sensitivity for small tumors < 3cm and cannot clearly ID necrosis
For pt with suspicion for pancreatic CA, if mass on US, you should proceed with what?
Abd CT
(confirms presence of mass, extent of disease)
Pt with suspicion for pancreatic CA → mass on US → proceed with abd CT → no further test if what? (3)
- Mass appears typical
- Enough info to assess resectability
- Pt is fit for major surgery
- (If in doubt, may need additional imaging)
Pt with suspicion for pancreatic CA → mass on US → proceed with abd CT → if in doubt, what additional imaging might you order?
ERCP if therapeutic, MRCP, EUS, contrast enhanced helical CT
When additional imaging would be indicated for eval of possible pancreatic CA under the following circumstances:
- Choledocholithiasis remains a ddx
- Biliary decompression is required
- Double duct sign
ERCP
When additional imaging would be indicated for eval of possible pancreatic CA under the following circumstances:
- Pt cannot undergo ERCP
MRCP
When additional imaging would be indicated for eval of possible pancreatic CA under the following circumstances:
- No bx needed if resectable disease and typical imaging
- Histology can be made at time of excision
EUS
(EUS guided FNA best for tissue dx)
What is test of choice for staging and ID eligibility for resection of pancreatic CA?
Contrast enhanced helical CT
What is the only potential cure for pancreatic CA?
Resection (Whipple procedure)
What is management for pancreatic CA if biliary obstruction?
Biliary stent and decompress bile duct
What is management for pancreatic CA if gastric obstruction- N/V, anorexia?
Decompress stomach, surgical palliation
What is included in pain management for pancreatic CA?
Narcotics, chemo vs radiation
What is the prognosis for a pt with pancreatic CA?
POOR :(
(5 yr survival < 5%, w/ resectable lesions ~20%,)
