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Gastroenterology > 341 Pancreas > Flashcards

341 Pancreas Flashcards

1
Q

What stimulates the secretion of water and electrolytes from the pancreas

A

Gastric acid stimulates the release of secretin from the duodenal mucosa which stimulates the release of water and electrolytes from the pancreas

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2
Q

What cells release CCK

A

Ito cells of the duodenal and jejunal mucosa

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3
Q

Exerts significant control over pancreatic secretions

A

Parasympathetic nervous system (via the vagus nerve)

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4
Q

Ion of primary physiologic importance within pancreatic secretion

A

Bicarbonate

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5
Q

Where is 93% of bicarbonate derived

A

ductal cells secrete bicarbonate predominantly derived from plasma (93%)

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6
Q

General types of enzyme secreted by the pancreas

A

amylolytic, lipolytic and proteolytic enzymes

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7
Q

Examples of amylolytic enzymes and what does it do

A

amylase; hydrolyzes startch to oligosaccharides and disaccharide to maltose

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8
Q

Examples of lipolytic enzymes

A

lipase, phospholipase A2, and cholesterol esterase

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9
Q

Examples of proteolytic enzymes and what does it do

A

endopeptidases, exopeptidases, elastase; act on internal peptide bonds of protein and polypeptides

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10
Q

Enzymes found in doudenal mucosa which cleaves trypsinogen to trypsin

A

enterokinase

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11
Q

Stimulatory neurotransmitters of the pancreas

A

acetylcholine and gastrin releasing peptide

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12
Q

extrinsic innervation of the pancreas

A

vagus nerve

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13
Q

How is autodigestion in the pancreas mantained

A

pancreatic proteases are in proenzyme form;intracellular calcium homeostasis, acid-base balance, synthesis of protective protease inhibitors

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14
Q

Accounts for 80-90% of acute pancreatitis cases in the US

A

gallstones and alcohol

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15
Q

Leading cause of pancreatitis in 30-60% of cases

A

gallstones

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16
Q

What size of the gallstone has a 4x greater risk of acute pancreatitis

A

one gallstone less than 5 mm

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17
Q

Causes pancreatitis in 1.3-3.8% of cases

A

hypertriglyceridemia

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18
Q

What is the level of triglycerides that will trigger acute pancreatitis

A

serum triglyceride level of more than 1000 mg/dl

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19
Q

what does apolipoprotein CII do

A

activates lipoprotein lipase which clears chylomicrons from the blood strea

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20
Q

currently accepted pathogenic theory for acute pancreatitis

A

autodigestion

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21
Q

What happens in autodigestions

A

pancreatic enzymes are activated in the pancreas acinar cell than than in the intestinal lumen

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22
Q

How many phases of pancreatitis

A

3 phases

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23
Q

Pathophysiology of acute pancreatitis. Characterized by intrahepatic digestive enzyme activation and acinar cell injury

A

Initial phase

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24
Q

Pathophysiology of pancreatitis. Activation, chemoattraction, and sequestration of leukocytes and macrophages in the pancreas

A

Second phase

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25
Q

Pathophysiology of pancreatitis. Effects of activated proteolytiz enzymea and cytokines released by inflamed pancreas to distant organs

A

Third phase

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26
Q

Major symptom of acute pancreatitis

A

abdominal pain

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27
Q

Mechanisms that lead to shock in patient with pancreatitis

A

hypovolemia from extravasaation of blood and plasma into the retroperitoneal space; increased formation and release of kinin peptides leading to increased vascular permeability; systemic effects of proteolytic and lipolytic enzymes released into the circulation

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28
Q

What leads to jaundice in pancreatitis? Is it common

A

Jaundice is uncommon. It is due to compression of the intrapancreatic portion of the CBD or passage of biliary stone or slude brought about by the edema of the head of the pancreas

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29
Q

What is Cullen sign

A

Bluish discoloration around the umbilicus as a result of hemoperitoneum

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30
Q

What is Turner sign

A

Blue red purple or green brown discoloration of the flanks

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31
Q

Perfect test for acute pancreatitis.

A

Lipase. It is more specific than amylase.

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32
Q

When does amylase return to normal

A

3-7 days even if patients still have clinical signs of pancreatitis

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33
Q

Until how many days does lipase remain elevated

A

lipase remains elevated for 7-14 days

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34
Q

True or false. Serum amylase can increase in cases of acidemia when blood pH is less than 7.32

A

True.

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35
Q

True or false. Patients with DKA can have elevated serum amylase even without evidence of pancreatitis

A

True

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36
Q

Harbinger of more severe disease in acute pancreatitis

A

hemoconcentration. Hct more than 44%

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37
Q

True or false. Hypoglycemia in common in acute pancreatitis

A

False. Hyperglycemia is common from decreased insulin release and increased glucagon release

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38
Q

Definition. Acute inflammation of the pancreatic parenchy and peripancreatic tissues but without recognizable tissue necrosis.

A

interstitial pancreatitis

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39
Q

Definition. Inflammation associated with pancreatic parenchymal necrosis and or peripancreatic necrosis

A

necrotizing pancreatitis

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40
Q

Definition. Encapsulated collection of fluid with a well defined inflammatory wall outside the pancreas with minimal or no necrosis.

A

pancreatic pseudocysts

41
Q

When does pancreatic pseudocyts appear

A

more than 4 weeks after onset of interstitial pancreatitis

42
Q

Definition. Peripancreatic fluid associated with interstitial edemaous pancreatitis with no associated peripancreatic necrosis

A

Acute pancreatic fluid collection

43
Q

When does acute pancreatic fluid collection occur

A

within the 4 weeks after onset of intersitial pancreatitis

44
Q

Definition. A collection containing cariable amounts of both fluid and necrosis associated with necrotizing pancreatitis

A

Acute pancreatic necrotic collection

45
Q

When does walled off necrosis (WON) occur?

A

Occurs more than 4 weeks after onset of necrotizing pancreatitis

46
Q

Definition. Mature encapsulated collection of pancreatic and or peripancreatic necrosis that has developed a well defined inflammatory wall

A

Walled-off necrosis (WON)

47
Q

When does serum bilirubin levels result to normal in acute pancreatitis

A

normal in 4-7 days

48
Q

True or false. Jaundice in acute pancreatitis is transient

A

True.

49
Q

How is acute pancreatitis diagnosed

A

2 out of 3. typical abdominal pain in epigastrium which radiate to the back, 3x or greater elevation of serum lipase and or amylase, confirmatory findings of acute pancreatitis on abdominal imaging

50
Q

True or false. It may be difficult to differentiate acute cholecystitis from acute pancreatitis as both can present with elevated amylase.

A

True.

51
Q

Test to differentiate DKA from acute pancraetitis

A

Serum lipase is normal in DKA

52
Q

Define organ failure and what systems must be assessed

A

Organ failure in 2 or more sytems: respiratory, cardiovascular, renal

53
Q

Most important clinical finding in regard to severity of the acute pancreatitis

A

persistent organ failure of more than 48 hours

54
Q

When is late phase in acute pancreatitis

A

Protracted course illness

55
Q

Phases of acute pancreatitis

A

early less than 2 weeks hospital course and late more than 2 weeks

56
Q

True or false. CT imaging is done as early as possible.

A

False. CT imaging not needed or recommended during the first 48 hours of acute pancreatitis. After the 48 hours, it is done to evaluate for local complications

57
Q

Greatest importance during the late phase of acute pancreatitis

A

CT imaging

58
Q

Severity classes of acute pancreatitis

A

Mild, moderate, severe

59
Q

When is acute pancreatitis mild

A

Without local complications or organ failure. Disease is self limited and subsides spontaneously in 3-7 days

60
Q

When is acute pancreatitis moderate

A

there is transient organ failure than resolves in less than 48 hours

61
Q

when can oral intake be resumed in acute pancreatitis

A

when patient is hungry, has normal bowel function and no nausea and vomiting

62
Q

When is acute pancreatitis severe

A

when organ failure persists for more than 48 hours

63
Q

Types of pancreatitis based on imaging

A

intersitial and necrotizing

64
Q

Imaging of interstitial pancreatitis

A

diffuse gland enlargement with homogenous contrast enhancement

65
Q

Imaging of necrotizing pancreatitis

A

lack of pancreatic parenchymal enhancement by contrast and presence of peripancreatic necrosis

66
Q

How is fluid resuscitation done in acute pancreatitis

A

15-20 ml/kg bolus then 2-3 ml/kg per hour to maintaine urine output more than 0.5 ml/kg per hour

67
Q

Preferred IV fluid in acute pancreatitis and why

A

Lactated Ringers; shown to decrease inflmmation than normal saline

68
Q

Recommended to ensure adequate fluid resuscitationn

A

Hematocrit and BUN every 8-12 hours

69
Q

Strong evidence that sufficient fluids are being administered

A

Decrease in hematocrit and BUN during the first 12- 24 hours

70
Q

How to respond to rise in hematocrit or BUN on serial measurement

A

repeat volume challenge of 2 Liters then followed by increasing fluid rate at 1.5 ml/kg/hr

71
Q

If still despite repeat volume challenge, Hct and BUN continues to rise, what to do

A

for ICU for hemodynamic monitoring

72
Q

What to do in patient with evidence of ascending cholangitis on top of gallstone pancreatitis

A

ERCP within 24-48 hours of admission

73
Q

When should cholecystectomy be done in patient with gallstone pancreatitis

A

during admission or 4-6 weeks after discharge

74
Q

Effective at decreasing pancreatitis after ERCP

A

pancreatic duct stenting and rectal indomethacin

75
Q

When should feeding be considered in acute pancreatitis

A

enteral feeding considered 2-3 days after adminsion after abdominal pain has resolved

76
Q

True or false. Patients with necrotizing pancreatitis should be given prophylactic antibiotics

A

False. No role. If patient appear septic, antibiotics may be given and discontinued when cultures turned negative

77
Q

True or false. Acute pancreatitis may present with sterile necrosis and managed conservatively without antibiotics

A

True. No antibiotics if no growth on culture to avoid opportunistic and fungal infection

78
Q

Presents with increasing abdominal pain or shortness of brath in setting of enlarging fluid collection on MRCP or ERCP

A

Pancreatic duct disruption

79
Q

How is pancreatic duct disruption managed

A

Bridging pancreatic stent for at least 6 weeks

80
Q

Most common etiologic factor for recurrent pancreatitis

A

alcohol and cholelithiasis

81
Q

Why is there an increased incidence of pancreatitis in patients with AIDS

A

high incidence of infection involving the pancreas such as CMV, cryptosporidium and MAC; medication induced such as TMP SMX, pentamidine, protease inhibitors

82
Q

True or false. In chronic pancreatitis, the damage is irreversible.

A

True.

83
Q

Strongly linked to chronic pancreatitis and why

A

smoking increases susceptibility to pancreatic autodigestion and predispose to CFTR dysfunction

84
Q

Most common cause of chronic pancreatitis in adults. In children?

A

Adult: alcoholism. Children: cystic fibrosis

85
Q

Marker for autoimmune pancreatitis

A

Elevated serum levels of IgG4; ANA and RF may be positive

86
Q

How is AIP diagnosed

A

Mayo Clinic HISORt criteria 1 or more of the following. Histology. Imaging: mass in head of pancreas. Serology: elevated IgG4; other organ inolvment; response to glucocorticoid therapy

87
Q

How is AIP treated

A

Prednisone 40 mg/d for 4 weeks followed by taper dose of 5 mg/wk

88
Q

Has been shown to be effective at inducing and maintaining remission in AIP

A

rituximab

89
Q

True or false. Just like acute pancreatitis, amylase and lipase strikingly elevated in chronic pancreatitis

A

false.

90
Q

Initial modality of choice in diagnosing chronic pancreatitis

A

Abdominal CT

91
Q

Imaging findings in chronic pancreatitis

A

calcification, dilated ducts or an atrophic pancreas

92
Q

Diagnostic test with best sensitivity and specificity in chronic pancreatitis

A

hormone stimulation using secretin. Abnormal results seen when 60% of pancretic exocrine function is lost

93
Q

Cornerstone therapy of steatorrhea

A

enzyme therapy

94
Q

How much of lipase should be taken during a meal

A

80,000-100,000 units

95
Q

Can improve pain in chronic pancreatits

A

pregabalin

96
Q

Ventral pancraetic anlage fails to migrate resulting to a ring of pancreatic tissue circling the duodenum

A

Annular pancreas

97
Q

Radiographic findings of annular pancreas

A

symmetric dilation of the proximal duodenum with bulging of the recesses on either side of the annular band

98
Q

Embyronic ventral and dorsal pancreatic anlagen fail to fuse so that pancreatic drainage is accomplished throuh the accessory papillar

A

pancreas divisum

99
Q

Condition where amylase circulating the blood is in polymer form too large to be excreted by the kidney. There is elevated serum amylase and low urinary amylase.

A

Macroamylasemia

Gastroenterology (13 decks)

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