3 Pancreatic Disease Flashcards
1
Q
What are the endocrine cells of the pancreas?
A
Islet of Langerhans
Composed of Alpha and Beta Cells
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
3
Q
What are the primary exocrine cells of the pancreas?
A
Acinar cells
Synthesize and secrete digestive enzymes into the duodenum
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
5
Q
What is pancreatic juice?
A
Electrolytes, bicarbonate, and digestive enzymes
Neutralizes gastric acid
Provides a basic environment for pancreatic enzymes
6
Q
Inflammatory condition of the pancreas
A
Acute pancreatitis
Can be mild to severe, life-threatening illness
7
Q
Alcohol induced pancreatitis is more common in _______
Gallstone induced pancreatitis is more common in _______
A
Men
Women
8
Q
Pancreatitis is more common in _______ countries
A
Developed countries (b/c of our diet)
9
Q
Most common etiologies of pancreatitis
A
Gallstones (35-40%)
Chronic alcohol abuse (25-35%)
Idiopathic (10-20%)
10
Q
Other less common causes of pancreatitis
A
Smoking Hypertriglyceridemia Hypercalcemia Meds Abdominal trauma Infection Vascular disease Tumor Genetics Toxins
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
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
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
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
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
16
Q
Name the cause of your patient’s pancreatitis:
Abdominal distention, hypoactive bowels
A
Ileus
17
Q
Name the cause of your patient’s pancreatitis:
Scleral icterus
A
Choledocholithiasis or edema of the pancreatic head
18
Q
Name the cause of your patient’s pancreatitis:
Hepatomegaly
A
Alcohol abuse
19
Q
Name the cause of your patient’s pancreatitis:
Xanthomas
A
Hyperlipidemia
20
Q
Name the cause of your patient’s pancreatitis:
Parotid swelling
A
Mumps
21
Q
Physical signs of severe necrotizing pancreatitis
A
Cullen’s sign
Grey-Turner’s sign
Panniculitis
22
Q
Ecchymosis in the periumbilical region
A
Cullen’s sign
23
Q
Ecchymosis of the flanks
A
Grey-Turner’s sign
24
Q
Erythematous nodules in SQ fat
A
Panniculitis
25
DDx for pancreatitis
```
Biliary colic
Acute cholecystitis
Acute cholangitis
Acute hepatitis
MI
Perforated ulcer
SBO
AAA
```
26
Pancreatitis lab findings:
CBC
Will show elevated WBC
27
Pancreatitis lab findings:
CMP
```
Glucose - hyper or hypo
Hypercalcemia
Creatinine
Bilirubin elevated
LFTs - ALT elevated
```
28
Pancreatitis lab findings:
Amylase
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%
29
Pancreatitis lab findings:
Lipase
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%
30
Pancreatitis lab findings:
Urine trypsinogen-2 dipstick test
Rapid, non-invasive
High sensitivity (82%) and specificity (94%)
31
Pancreatitis lab findings:
Alanine Aminotransferase (ALT)
>150 U/L in the first 48 hours of symptom onset = >85% PPV of gallstone pancreatitis
32
Who should get genetic testing for pancreatitis?
Strong family history of pancreatitis
<35 years of age at onset
All patients having genetic testing should have genetic counseling before and after
33
What is a sentinel loop?
Small bowel inflammation/air from ileus formation, seen on abdominal xray in cases of pancreatitis
34
What are the different imaging modalities used for pancreatitis?
Abd xray - gallstones, sentinel loop
Abd US - gallstones
Abd CT - inflammation, calcification, pseudocyst, necrosis, abscess
MRCP
ERCP
Endoscopic US
35
If you suspected pancreatitis, what is a good initial imaging to r/o other things?
Ultrasound
36
If your patient has unexplained pancreatitis, what imaging should you get
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
37
What is the preferred imaging for recurrent pancreatitis?
Endoscopic US preferred initially
ERCP if neoplasm or stricture - also therapeutic to remove stones if present
38
Why is an early CT not recommended for patients with suspected pancreatitis?
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
39
When is MRCP used over CT?
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***
40
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography
Used to visualize biliary and pancreatic ductal anatomy
41
How is ERCP used in pancreatitis?
To obtain cytology or biopsy
Therapeutic for stone removal or stent insertion
42
How is endoscopic ultrasound (EUS) used in pancreatitis?
```
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
43
What are the diagnostic criteria for pancreatitis?
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
44
Almost all patients with pancreatitis are treated...
Inpatient, with supportive and symptomatic care
```
Aggressive hydration
Monitor vitals, I&Os, Labs
NPO if severe N/V
Pain control
Antiemetics
```
Abx if infective necrosis
45
When should you give abx to pancreatitis patients?
If infective necrosis
Use Imipenim (Primaxin) - good pancreas penetration
46
How do you monitor for complications of pancreatitis?
Decreased urinary output or rising creatinine
Respiratory failure
Worsening condition (increased pain, fever, leukocytosis)
47
Local complications of pancreatitis
```
Peripancreatic fluid collection
Pancreatic pseudocyst
Necrosis
Gastric outlet dysfunction
Splenic and portal vein thrombosis
```
48
What are some more serious complications of pancreatitis?
SIRS
Organ failure
• CV
• Respiratory
• Renal
49
When should you perform a CT on a pancreatitis patient?
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
Peripancreatic fluid collection walled off by endothelial cells
Pancreatic pseudocyst
51
Palpable mass in the mid-epigastric area is suggestive of...
Pancreatic pseudocyst
10% of patients
May cause symptoms:
• Abdominal pain
• Early satiety
• N/V
52
What happens to a patient with pancreatic pseudocyst?
Can spontaneously resolve or continue to enlarge
Complicated by rupture, hemorrhage, or infection
Surgery or drainage indicated if symptomatic or infected
53
What are the two types of pancreatitis?
Interstitial edematous acute pancreatitis
Necrotizing acute pancreatitis
54
What type of pancreatitis is this:
Acute inflammation of the pancreatic parenchyma and peripancreatic tissues without necrosis
Interstitial edematous acute pancreatitis
55
What type of pancreatitis is this:
Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis
Necrotizing acute pancreatitis
56
What severity classification is this (pancreatitis):
No organ failure
No local complications
No systemic complications
Mild acute
57
What severity classification is this (pancreatitis):
Transient organ failure <48h (resolves)
No local complications
No systemic complications
Moderately severe
58
What severity classification is this (pancreatitis):
Organ failure >48h
≥ 1 local complication
≥ 1 systemic complication
Severe
59
Findings at initial assessment associated with severe pancreatitis
```
>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
What is the Ranson Criteria?
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
What is the APACHE score for pancreatitis
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
A ranson criteria score of <3
0-3% mortality
63
A ranson criteria score ≥3
11-15% mortality
64
A ranson criteria score of ≥6
40% mortality
65
What is the most likely cause of death from severe pancreatitis in the first 2 weeks?
Systemic Inflammatory Response Syndrome (SIRS) or organ failure
66
What is the most likely cause of death from severe pancreatitis after 2 weeks?
Sepsis and other related complications
67
How do you prevent recurrence of pancreatitis?
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
Progressive fibrotic inflammatory changes —> long term structural damage of the pancreas
Chronic pancreatitis
69
_____% of patients with acute pancreatitis develop chronic pancreatitis
5-20%
Repeated episodes of acute —> chronic
70
______ is generally lower with chronic pancreatitis than with acute
Mortality
But attacks are similar
71
Gradual loss of pancreatic function in chronic pancreatitis leads to...
Exocrine and endocrine insufficiency
72
Exocrine insufficiency in chronic pancreatitis leads to...
Malabsorption
Steatorrhea
• Inc excretion of fecal fat
• greasy, foul smelling stool
Weight loss
• Fear of eating
• Malabsorption
73
Endocrine insufficiency in chronic pancreatitis leads to...
Diabetes
Sx of da ‘betes (The “polys”)
Typically insulin dependent (b/c destruction of beta cells)
Brittle DM - so glucose hard to control
74
What type of diabetes is more likely in patients with chronic pancreatitis?
Insulin dependent
Destruction of Beta cells
More likely to have hypoglycemic events b/c of insulin use
75
Most common etiology of chronic pancreatitis
Alcohol induced disease (70-80%)
76
Other etiologies of chronic pancreatitis besides alcohol
Cystic Fibrosis
Hereditary
Idiopathic
SMOKING
77
Classic triad associated with chronic pancreatitis
Diabetes
Steatorrhea
Calcifications on imaging
78
SSx of chronic pancreatitis
Epigastric pain
Early - episodic similar to acute pancreatitis
Late - may be continuous
Aggravators - alcohol and large high fat meals
79
What labs do you order for chronic pancreatitis?
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
Test of choice for steatorrhea
Fecal elastase
81
What will you see on CT for patients with chronic pancreatitis?
Calcifications
Ductal dilation
Pseudocyst
82
What imaging study provides better view of the pancreatic and biliary ducts and is being used with increased frequency for evaluation and diagnosis
MRCP
83
What is the pathognomonic sign of chronic pancreatitis seen on ERCP?
“Chain-of-lakes”
But ERCP is more invasive so used less often
84
How do you manage chronic pancreatitis?
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
If a patient has their pancreas surgically respected for chronic pancreatitis, how much do they keep?
You only really need 20% remaining pancreatic tissue to function
86
Complications of chronic pancreatitis
```
Chronic pain
Pseudocyst
Abscess formation
Fistula formation
Pancreatic ascites
Mesenteric venous thrombosis
```
87
Describe acute pancreatitis in a few bullet points
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
Chronic pancreatitis in a few bullet points
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
4the leading cause of cancer related deaths
Pancreatic cancer
90
Is pancreatic cancer more common in men or women?
Men
91
Pancreatic cancer is rare before age _____
45
92
What is the etiology of pancreatic cancer
Abnormal glucose metabolism
Insulin resistance
Obesity
Chronic pancreatitis
93
95% of pancreatic cancer is ________
Exocrine
vs 5% endocrine
94
85% of all pancreatic neoplasms are this kind
Ductal adenocarcinoma of the pancreas
95
60-70% of pancreatic cancers involve the _____ of the pancreas
Head
96
Only _____% of pancreatic cancer patients present with resectable disease
15-20%
85% present with locally advanced or metastatic disease
97
Major risk factors for pancreatic cancer
```
Cigarette smoking
High body mass
Lack of physical activity
Nonhereditary chronic pancreatitis
Pancreatic cysts
```
Others:
EtOH
Advanced age
98
Most common Sx of pancreatic cancer
Epigastric pain
Jaundice (incl scleral icterus)
Weight loss
Other Sx:
Asthenia, anorexia, nausea, back pain, dark urine, steatorrhea, hepatomegaly, RUQ/epigastric mass, ascites
99
PE findings for pancreatic cancer
Abdominal pain
Nontender palpable gallbladder (Courvoisier’s sign)
Jaundice and icterus
100
What labs do you want for pancreatic cancer
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
What is the tumor marker used in pancreatic cancer?
CA 19-9
Sensitivity/specificity 80-90%
Elevations relative to tumor size
102
Preferred initial imaging for suspected pancreatic cancer if presenting with Jaundice
Abdominal ultrasound
• Detects biliary tract/CBD dilation
• Levels of obstruction
• Mass
MRCP and/or ERCP if suspicious for choledocholithiasis
103
If a patient with epigastric pain and weight loss (but no jaundice) is suspected of having pancreatic cancer, what imaging do you want?
Triple phase thin sliced enhanced helical CT of abdomen with 3D reconstruction
US lacks sensitivity for small tumors and cannot clearly ID necrosis
104
If you ID a pancreatic mass on US, what do you do next?
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
Additional imaging you probably don’t need for pancreatic cancer but we need to know about anyway
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
What is the only potential cure for pancreatic carcinoma?
Surgical resection
“Whipped” procedure (pancreaticoduodenectomy)
107
How do you manage a patient with pancreatic cancer?
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
What is the prognosis for pancreatic cancer
Overall, pretty poor - five year survival <5%
Five year survival for resectable lesions ~20%
