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Clin Med III Unit 2 > 3 Pancreatic Disease > Flashcards

3 Pancreatic Disease Flashcards

1
Q

What are the endocrine cells of the pancreas?

A

Islet of Langerhans

Composed of Alpha and Beta Cells

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2
Q

What hormones are produced by the Islets of Langerhans?

A

Insulin - released in response to increased blood glucose

Glucagon - released in response to low blood glucose

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3
Q

What are the primary exocrine cells of the pancreas?

A

Acinar cells

Synthesize and secrete digestive enzymes into the duodenum

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4
Q

Which digestive enzymes are produced by the acinar cells of the pancreas?

A

Amylase - breakdown of starch
Lipase - breakdown of fat
Protease - breakdown of protein

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5
Q

What is pancreatic juice?

A

Electrolytes, bicarbonate, and digestive enzymes

Neutralizes gastric acid

Provides a basic environment for pancreatic enzymes

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6
Q

Inflammatory condition of the pancreas

A

Acute pancreatitis

Can be mild to severe, life-threatening illness

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7
Q

Alcohol induced pancreatitis is more common in _______

Gallstone induced pancreatitis is more common in _______

A

Men

Women

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8
Q

Pancreatitis is more common in _______ countries

A

Developed countries (b/c of our diet)

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9
Q

Most common etiologies of pancreatitis

A

Gallstones (35-40%)

Chronic alcohol abuse (25-35%)

Idiopathic (10-20%)

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10
Q

Other less common causes of pancreatitis

A 
Smoking
Hypertriglyceridemia
Hypercalcemia
Meds
Abdominal trauma
Infection
Vascular disease
Tumor
Genetics
Toxins
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11
Q

What is the stupid mnemonic Ms. Black had on her slides that has the causes of acute pancreatitis but they aren’t in fucking order?

A 
“I get smashed”
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion/Snakes
Hyperlipidemia/hypercalcemia
ERCP
Drugs
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12
Q

Instead of memorizing some dumb list of all the fucking meds that can cause acute pancreatitis, just know this…

A

If you suspect a patient has acute pancreatitis, ask what drugs they are taking and if any are new

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13
Q

What is the pathophysiology of pancreatitis?

A

High pancreatic levels of activated trypsin

—> Pancreatic auto-digestion, injury, and inflammation

—> Increased inflammation

—> Potentially leads to:
• Remote organ injury and failure
• Systemic inflammatory response
• Multi-organ failure
• DEATH
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14
Q

Clinical presentation of acute pancreatitis

A

Acute, persistent, and severe postprandial epigastric pain, radiating to the back

Worse with intake or laying supine

Better sitting, leaning forward with knees flexed

N/V

Anorexia

+/- abdominal swelling, diaphoresis, hematemesis, SOB

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15
Q

Physical exam findings for acute pancreatitis

A

Tachycardia
Tachypnea
Fever
Hypotension

Epigastric or upper quadrant pain
Guarding
Decreased bowel sounds (esp if the inflammation is causing an ileus)

Occasionally jaundice, pallor, diaphoresis

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16
Q

Name the cause of your patient’s pancreatitis:

Abdominal distention, hypoactive bowels

A

Ileus

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17
Q

Name the cause of your patient’s pancreatitis:

Scleral icterus

A

Choledocholithiasis or edema of the pancreatic head

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18
Q

Name the cause of your patient’s pancreatitis:

Hepatomegaly

A

Alcohol abuse

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19
Q

Name the cause of your patient’s pancreatitis:

Xanthomas

A

Hyperlipidemia

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20
Q

Name the cause of your patient’s pancreatitis:

Parotid swelling

A

Mumps

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21
Q

Physical signs of severe necrotizing pancreatitis

A

Cullen’s sign

Grey-Turner’s sign

Panniculitis

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22
Q

Ecchymosis in the periumbilical region

A

Cullen’s sign

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23
Q

Ecchymosis of the flanks

A

Grey-Turner’s sign

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24
Q

Erythematous nodules in SQ fat

A

Panniculitis

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25
Q

DDx for pancreatitis

A 
Biliary colic
Acute cholecystitis
Acute cholangitis
Acute hepatitis
MI
Perforated ulcer
SBO
AAA
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26
Q

Pancreatitis lab findings:

CBC

A

Will show elevated WBC

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27
Q

Pancreatitis lab findings:

CMP

A 
Glucose - hyper or hypo
Hypercalcemia
Creatinine
Bilirubin elevated
LFTs - ALT elevated
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28
Q

Pancreatitis lab findings:

Amylase

A

Rises in 6-12 hours, peaks in 48 hours and normalizes in 3-5 days

20% will have normal level

Sensitivity 67-83%, specificity 85-98%

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29
Q

Pancreatitis lab findings:

Lipase

A

Rises in 4-8 hours, peaks at 24 hours, normalizes in 8-14 days (earlier peak but longer to normalize than amylase)

MORE SPECIFIC to pancreatic injury

Sensitivity/specificity 82-100%

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30
Q

Pancreatitis lab findings:

Urine trypsinogen-2 dipstick test

A

Rapid, non-invasive

High sensitivity (82%) and specificity (94%)

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31
Q

Pancreatitis lab findings:

Alanine Aminotransferase (ALT)

A

> 150 U/L in the first 48 hours of symptom onset = >85% PPV of gallstone pancreatitis

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32
Q

Who should get genetic testing for pancreatitis?

A

Strong family history of pancreatitis

<35 years of age at onset

All patients having genetic testing should have genetic counseling before and after

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33
Q

What is a sentinel loop?

A

Small bowel inflammation/air from ileus formation, seen on abdominal xray in cases of pancreatitis

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34
Q

What are the different imaging modalities used for pancreatitis?

A

Abd xray - gallstones, sentinel loop

Abd US - gallstones

Abd CT - inflammation, calcification, pseudocyst, necrosis, abscess

MRCP

ERCP

Endoscopic US

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35
Q

If you suspected pancreatitis, what is a good initial imaging to r/o other things?

A

Ultrasound

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36
Q

If your patient has unexplained pancreatitis, what imaging should you get

A

Risk for malignancy so important to get DETAIL

Abdominal CT with IV contrast (“pancreas protocol”)***
- can show inflammation, calcification, pseudcysts, necrosis, abscess

MRI with MRCP

Endoscopic ultrasound

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37
Q

What is the preferred imaging for recurrent pancreatitis?

A

Endoscopic US preferred initially

ERCP if neoplasm or stricture - also therapeutic to remove stones if present

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38
Q

Why is an early CT not recommended for patients with suspected pancreatitis?

A

Most cases are uncomplicated
No evidence it improves clinical outcomes
Complications appreciated 3 days after onset
IV contrast may worsen pancreatitis***

Only patients meeting clinical and lab criteria get one

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39
Q

When is MRCP used over CT?

A

Lower risk of nephrotoxicity

Increased characterization - so if you know there are fluid collections, necrosis, abscess, or pseudocyst, you can use to better see what’s going on

Better view of biliary and pancreatic ducts - use if CBD stone not visualized on CT or US***

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40
Q

What is ERCP?

A

Endoscopic Retrograde Cholangiopancreatography

Used to visualize biliary and pancreatic ductal anatomy

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41
Q

How is ERCP used in pancreatitis?

A

To obtain cytology or biopsy

Therapeutic for stone removal or stent insertion

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42
Q

How is endoscopic ultrasound (EUS) used in pancreatitis?

A 
If cause is not clear, then it evaluates for:
Pancreatic ductal anomalies
Tumors involving the ampulla
Pancreatic cancer
Microlithiasis in GB or CBD
Early chronic pancreatitis

If abnormal, consider ERCP

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43
Q

What are the diagnostic criteria for pancreatitis?

A

At least 2 of the following:

Clinical presentation:
• Acute persistent, severe, epigastric pain
• Often radiating to the back

Elevated serum lipase or amylase
• 3x or greater than normal

Consistent imaging findings (if the two above are not met)
• CT with contrast, MRI or US

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44
Q

Almost all patients with pancreatitis are treated…

A

Inpatient, with supportive and symptomatic care

Aggressive hydration
Monitor vitals, I&amp;Os, Labs
NPO if severe N/V
Pain control
Antiemetics

Abx if infective necrosis

45
Q

When should you give abx to pancreatitis patients?

A

If infective necrosis

Use Imipenim (Primaxin) - good pancreas penetration

46
Q

How do you monitor for complications of pancreatitis?

A

Decreased urinary output or rising creatinine

Respiratory failure

Worsening condition (increased pain, fever, leukocytosis)

47
Q

Local complications of pancreatitis

A 
Peripancreatic fluid collection
Pancreatic pseudocyst
Necrosis
Gastric outlet dysfunction
Splenic and portal vein thrombosis
48
Q

What are some more serious complications of pancreatitis?

A

SIRS

Organ failure
• CV
• Respiratory
• Renal

49
Q

When should you perform a CT on a pancreatitis patient?

A

If you suspect complications >72 hours of symptoms onset

Signs:
• Persistent or recurrent abdominal pain
• Inc in pancreatic enzyme level after initial decrease
• New or worsening organ dysfunction
• Sepsis (inc fever and inc WBCs)
50
Q

Peripancreatic fluid collection walled off by endothelial cells

A

Pancreatic pseudocyst

51
Q

Palpable mass in the mid-epigastric area is suggestive of…

A

Pancreatic pseudocyst

10% of patients

May cause symptoms:
• Abdominal pain
• Early satiety
• N/V

52
Q

What happens to a patient with pancreatic pseudocyst?

A

Can spontaneously resolve or continue to enlarge

Complicated by rupture, hemorrhage, or infection

Surgery or drainage indicated if symptomatic or infected

53
Q

What are the two types of pancreatitis?

A

Interstitial edematous acute pancreatitis

Necrotizing acute pancreatitis

54
Q

What type of pancreatitis is this:

Acute inflammation of the pancreatic parenchyma and peripancreatic tissues without necrosis

A

Interstitial edematous acute pancreatitis

55
Q

What type of pancreatitis is this:

Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis

A

Necrotizing acute pancreatitis

56
Q

What severity classification is this (pancreatitis):

No organ failure
No local complications
No systemic complications

A

Mild acute

57
Q

What severity classification is this (pancreatitis):

Transient organ failure <48h (resolves)
No local complications
No systemic complications

A

Moderately severe

58
Q

What severity classification is this (pancreatitis):

Organ failure >48h
≥ 1 local complication
≥ 1 systemic complication

A

Severe

59
Q

Findings at initial assessment associated with severe pancreatitis

A 
>55 years old
Obesity
AMS
Comorbidities
BUN >20mg/dL or rising
Hematocrit >44% or rising
Increased creatinine
Many or large extrapancreatic fluid collections
Pleural effusions
Pulmonary infiltrates
60
Q

What is the Ranson Criteria?

A

Used to predict mortality in pancreatitis patients

One point each for…

Initial signs:
• Age >55
• WBC >16,000
• Glucose >200mg/ml
• AST >250 IU/L
• LDH >350 IU/L
Delayed signs (next 48 hrs)
• HCT drop >10%
• BUN increase >5mg/dL
• Calcium <8 mg/dL
• pO2 <60 mmHg
• Serum albumin <3.2 mg/dL
• Fluid sequestration 4-5 L
61
Q

What is the APACHE score for pancreatitis

A

Acute Physiology and Chronic Health Examination Score

More in depth and takes longer

Decreasing values in first 48 hours = mild
Increasing values in first 48 hours = severe

Does not differentiate between interstitial and necrotizing

62
Q

A ranson criteria score of <3

A

0-3% mortality

63
Q

A ranson criteria score ≥3

A

11-15% mortality

64
Q

A ranson criteria score of ≥6

A

40% mortality

65
Q

What is the most likely cause of death from severe pancreatitis in the first 2 weeks?

A

Systemic Inflammatory Response Syndrome (SIRS) or organ failure

66
Q

What is the most likely cause of death from severe pancreatitis after 2 weeks?

A

Sepsis and other related complications

67
Q

How do you prevent recurrence of pancreatitis?

A

Treat the underlying cause

Gallstone pancreatitis:
• ERCP if CBD stone
• Elective cholecystectomy (w/in 7 days if mild)

Alcoholic pancreatitis
• Abstain

Hypertriglyceridemia
• Dietary mods
• Lipid lowering meds

Drug induced
• D/c offending meds

68
Q

Progressive fibrotic inflammatory changes —> long term structural damage of the pancreas

A

Chronic pancreatitis

69
Q

_____% of patients with acute pancreatitis develop chronic pancreatitis

A

5-20%

Repeated episodes of acute —> chronic

70
Q

______ is generally lower with chronic pancreatitis than with acute

A

Mortality

But attacks are similar

71
Q

Gradual loss of pancreatic function in chronic pancreatitis leads to…

A

Exocrine and endocrine insufficiency

72
Q

Exocrine insufficiency in chronic pancreatitis leads to…

A

Malabsorption

Steatorrhea
• Inc excretion of fecal fat
• greasy, foul smelling stool

Weight loss
• Fear of eating
• Malabsorption

73
Q

Endocrine insufficiency in chronic pancreatitis leads to…

A

Diabetes

Sx of da ‘betes (The “polys”)
Typically insulin dependent (b/c destruction of beta cells)
Brittle DM - so glucose hard to control

74
Q

What type of diabetes is more likely in patients with chronic pancreatitis?

A

Insulin dependent

Destruction of Beta cells

More likely to have hypoglycemic events b/c of insulin use

75
Q

Most common etiology of chronic pancreatitis

A

Alcohol induced disease (70-80%)

76
Q

Other etiologies of chronic pancreatitis besides alcohol

A

Cystic Fibrosis
Hereditary
Idiopathic
SMOKING

77
Q

Classic triad associated with chronic pancreatitis

A

Diabetes
Steatorrhea
Calcifications on imaging

78
Q

SSx of chronic pancreatitis

A

Epigastric pain

Early - episodic similar to acute pancreatitis
Late - may be continuous

Aggravators - alcohol and large high fat meals

79
Q

What labs do you order for chronic pancreatitis?

A

Amylase and lipase (normal or slightly increased)

Bilirubin and alk phos (mildly elevated)

INCREASED GLUCOSE

Secretin stimulation test (not common)

Fecal fat testing
• 72 hr quantitative fecal fat > qualitative testing of a spot sample
• Fecal Elastase = test of choice for steatorrhea

80
Q

Test of choice for steatorrhea

A

Fecal elastase

81
Q

What will you see on CT for patients with chronic pancreatitis?

A

Calcifications
Ductal dilation
Pseudocyst

82
Q

What imaging study provides better view of the pancreatic and biliary ducts and is being used with increased frequency for evaluation and diagnosis

A

MRCP

83
Q

What is the pathognomonic sign of chronic pancreatitis seen on ERCP?

A

“Chain-of-lakes”

But ERCP is more invasive so used less often

84
Q

How do you manage chronic pancreatitis?

A

Behavior mods (alcohol, smoking, low fat meals)

Early ID of complications

Treatment of complications (ie DM, malabsorption)

Pain Relief
• Pancreatic enzyme supplements
• Amitriptyline or SSRI
• Refer to interventional pain specialist —> opioids, nerve blocks, celiac plexus etc

Endoscopic procedures (dilation, stenting)

Resection

85
Q

If a patient has their pancreas surgically respected for chronic pancreatitis, how much do they keep?

A

You only really need 20% remaining pancreatic tissue to function

86
Q

Complications of chronic pancreatitis

A 
Chronic pain
Pseudocyst
Abscess formation
Fistula formation
Pancreatic ascites
Mesenteric venous thrombosis
87
Q

Describe acute pancreatitis in a few bullet points

A

Acute, severe, boring epigastric pain that often radiates to the back

Worse in supine position, better sitting or leaning forward

Meets 2 of these 3:
• Clinical presentation
• Increased lipase or amylase 3x normal
• Radiographic findings (not needed if first 2 criteria met)

88
Q

Chronic pancreatitis in a few bullet points

A

Classic Triad - DM, Steatorrhea, Calcifications

ERCP —> “chain of lakes” from alternating stenosis and dilation of pancreatic duct

Progressive inflammation with long term structural damage = insufficiency

89
Q

4the leading cause of cancer related deaths

A

Pancreatic cancer

90
Q

Is pancreatic cancer more common in men or women?

A

Men

91
Q

Pancreatic cancer is rare before age _____

A

45

92
Q

What is the etiology of pancreatic cancer

A

Abnormal glucose metabolism
Insulin resistance
Obesity
Chronic pancreatitis

93
Q

95% of pancreatic cancer is ________

A

Exocrine

vs 5% endocrine

94
Q

85% of all pancreatic neoplasms are this kind

A

Ductal adenocarcinoma of the pancreas

95
Q

60-70% of pancreatic cancers involve the _____ of the pancreas

A

Head

96
Q

Only _____% of pancreatic cancer patients present with resectable disease

A

15-20%

85% present with locally advanced or metastatic disease

97
Q

Major risk factors for pancreatic cancer

A 
Cigarette smoking
High body mass
Lack of physical activity
Nonhereditary chronic pancreatitis
Pancreatic cysts

Others:
EtOH
Advanced age

98
Q

Most common Sx of pancreatic cancer

A

Epigastric pain
Jaundice (incl scleral icterus)
Weight loss

Other Sx:
Asthenia, anorexia, nausea, back pain, dark urine, steatorrhea, hepatomegaly, RUQ/epigastric mass, ascites

99
Q

PE findings for pancreatic cancer

A

Abdominal pain
Nontender palpable gallbladder (Courvoisier’s sign)
Jaundice and icterus

100
Q

What labs do you want for pancreatic cancer

A

If jaundice or epigastric pain, start search for cholestasis

Assay of serum aminotransferases

Alkaline phosphatase

Bilirubin

Serum lipase - if epigastric pain

**CA 19-9** tumor marker used in pancreatic cancer

101
Q

What is the tumor marker used in pancreatic cancer?

A

CA 19-9

Sensitivity/specificity 80-90%

Elevations relative to tumor size

102
Q

Preferred initial imaging for suspected pancreatic cancer if presenting with Jaundice

A

Abdominal ultrasound
• Detects biliary tract/CBD dilation
• Levels of obstruction
• Mass

MRCP and/or ERCP if suspicious for choledocholithiasis

103
Q

If a patient with epigastric pain and weight loss (but no jaundice) is suspected of having pancreatic cancer, what imaging do you want?

A

Triple phase thin sliced enhanced helical CT of abdomen with 3D reconstruction

US lacks sensitivity for small tumors and cannot clearly ID necrosis

104
Q

If you ID a pancreatic mass on US, what do you do next?

A

Abdominal CT

Confirms presence of mass and assess extent of disease

No further testing if mass appears typical, enough info to assess respectability, and patient is fit for major surgery

105
Q

Additional imaging you probably don’t need for pancreatic cancer but we need to know about anyway

A

ERCP if stones or biliary decompression needed (look for Double Duct sign)

MRCP for patients who can’t have ERCP

EUS - best for tissue diagnosis but might not be necessary if surgery is happening

Contrast enhanced helical CT - test of choice for staging and ID eligibility for resection

FNA for histology

106
Q

What is the only potential cure for pancreatic carcinoma?

A

Surgical resection

“Whipped” procedure (pancreaticoduodenectomy)

107
Q

How do you manage a patient with pancreatic cancer?

A

If biliary obstruction - biliary stent and decompress bile duct

If gastric obstruction (N/V/anorexia) - decompress stomach, surgical palliative

Pain - narcotics, chemo vs radiation

108
Q

What is the prognosis for pancreatic cancer

A

Overall, pretty poor - five year survival <5%

Five year survival for resectable lesions ~20%

Clin Med III Unit 2 (6 decks)

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