6. Acute/Chronic Pancreatitis & Pancreatic Cancer Flashcards by Bria Schurke

Risk of pancreatitis is _______x higher for blacks than whites

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Most common cause of acute pancreatitis.

Gallstones

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What is the main digestive function of the pancreas?

Break down the macromolecules in food, producing smaller nutrient molecules for intestinal absorption.

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What stimulates pancreatic acinar cells?

Secretagogues

Acetylcholine (Vagus)
Cholecystokinin (small intestines)

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What does alkaline fluid do in the pancreas?

Neutralizes the acidic chyme that enters the small intestine.

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Besides alkaline fluid, what else does the pancreas secrete?

Insulin and glucagon

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What stimulates the pancreatic duct cells?

Secretin

*Duct cells secrete bicarbonate via calcium/bicarbonate exchange channel

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“Enzymatic precursors” produced by acinar cells

Zymogens

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Where are zymyogens produced?

In vesicles w/in acinar cells

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In what phase of acute pancreatitis are proteolytic enzymes w/in pancreas activated? (causing acinar cell injury)

Initial Phase

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In what phase of AP does an inflammatory reaction occur?

Second phase

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What happens in the third phase of acute pancreatitis?

Proteolytic enzymes and cytokines start to digest surrounding tissues and organs. Can cause a systemic inflammatory response

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What happens when pancreatic enzymes starts to digest surrounding tissues?

Proteolytic
Edema
Interstitial hemorrhage
Vascular damage
Coagulation necrosis
Fat necrosis
Parenchymal cell necrosis

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5 known genetic factors for ACUTE pancreatitis

1) Cationic trypsinogen gene (PRSS1)
2) Pancreatic secretory trypsin inhibitor (SPINK1)
3) The cystic fibrosis transmembrane conductance regulator gene (CFTR)
4) The chymotrypsin C gene (CTRC)
5) The calcium-sensing receptor (CASR)

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A patient presents with a sudden onset of abdominal pain, vomiting, diarrhea, and anorexia. They describe the pain as “dull and steady in the back and lower abdomen.”

Acute pancreatitis

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What might cause muscle spasms in acute pancreatitis?

Hypocalcemia

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A fain blue discoloration around the umbilicus?

Cullen’s sign

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A blue-red-purple or green-brown discoloration of the flanks.

Grey-Turner’s sign

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Serum amylase in acute pancreatitis.

Elevated-not specific

P-Amylase-more specific

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Serum Lipase results for AP

Elevated-more specific

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The ALT level in gallstone pancreatitis is generally_________

Higher than 150

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Hyperglycemia in acute pancreatitis is caused by__________

B cell injury

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What would you see in CRP w/ acute pancreatitis at 24 hours? 48 hours?

> 6

>7=more severe pancreatitis

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What is the initial imaging choice in ER for acute pancreatitis?

Abdominal Ultrasound-look for GALLSTONES and visualize PANCREATIC head

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When are abdominal CT’s best done in acute pancreatitis?

3-5 days into hospitalization

How is the EARLY phase defined in the Atlanta Classification?

<2 weeks. Clinical parameters-I.e. organ failure

How is the LATE phase of the Atlanta Classification defined?

> 2 weeks. Longer course may require imaging to evaluate for necrosis

How is MILD acute pancreatitis defined?

W/OUT local complications or organ failure. Subside w/in 3-7 of tx

How is MODERATELY SEVERE acute pancreatitis defined?

Transient organ failure that resolves in <48 hr. OR LOCAL or SYSTEMIC complications w/out organ failure.

How is SEVERE acute pancreatitis defined?

Persistent organ failure > 48 hr

What would you find in imaging of interstitial pancreatitis?

Blood is still flowing. Gland enlargement, homogenous contrast enhancement and mild inflammatory changes. (Resolve w/in a week). 90-95% admissions

What would you find in imaging of necrotizing pancreatitis?

Lack of pancreatic parenchymal enhancement. Variable course (necrosis may remain solid, liquefy etc). 5-10% of admissions. *It’s what you DON’T see!

Ranson’s criteria on admission: age.

>55

Ranson’s criteria on admission: WBC

>16,000 uL

Ranson’s criteria on admission: blood glucose

>200mg/dL

Ranson’s criteria serum on admission: LDH

>350 IU/L

Ranson’s criteria on admission: AST

>250

Ranson’s (48hr) criteria: Hematocrit

> 10%

Ranson’s (48hr) criteria: BUN level

Inc. more than 8 mg/dL

Ranson’s (48hr) criteria: Serum calcium level

Lower than 8 mg/dL

Ranson’s (48hr) criteria: PaO2

<60mm Hg

Ranson’s (48hr) criteria: Base deficit

>4 mEq/L

Ranson’s (48hr) criteria: Established fluid sequestration

>6 L

_________% cases of acute pancreatitis are self-limited and subside w/in _________days of tx.

85-90 | 3-7

Tx of Acute pancreatitis?

Pain Control I.V. Rehydration Time

What triage would you use in the hospital for acute pancreatitis?

The Bedside Index of Severity in Acute Pancreatitis

What are the 5 clinical and laboratory parameters obtained w/in first 24 hrs of hospitalization for acute pancreatitis?

``` BUN>25 Glasgow < 15 SIRS >60 yrs Pleural effusion on CXR ```

First thing you would do in ER for pt. with AP?

Aggressive fluid resuscitation

What would do asap if patient presenting to ER with AP is hemodynamically unstable?

SEND TO ICU!

What solution has been shown to decrease systemic inflammation?

Lactated Ringers

In the hospital, when would you measure hematocrit and BUN?

Every 8-12 hr

A rising BUN during hospitalization for AP is associated with what?

Inadequate hydration Higher in-hospital mortality

How would you treat a rising BUN for pt. with AP during hospitalization?

Bolus Challenge

The bolus challenge is ________L crystalloid bolus followed by inc. fluid rate by _______mg/kg/hr.

2 | 1.5

What is considered STRONG evidence that SUFFICIENT fluids are being administered in hospitalized AP pt.?

Dec. in HEMATOCRIT and BUN during the first 12-24 hrs

If there is evidence of ASCENDING CHOLANGITIS (rising WBC, inc. liver enzymes) what should you do?

ERCP w/in 24-48 hrs

What should a pt. with gallstone causing AP receive w/in 4-6 weeks of hospital admission?

Cholecystectomy

Tx for post-ERCP pancreatitis

Prophylactic pancreatic duct stent + rectal NSAIDS after ERCP

What does the initial therapy for hypertriglyceridemia include?

Insulin, heparin, or plasmapherisis

Outpatient therapies for hypertriclyceridemia AP

Control of diabetes Admin of Lipid-lowering agent Weight loss Avoidance of drugs that elevate lipids

How would you manage a pancreatic duct disruption?

Bridge pancreatic stent for at least 6 weeks (>90% effective at effecting leak)

Hospital-acquired infections occur in up to _____% of pt’s with AP

Overall mortality for AP

10-15%

Mortality for severe AP

30%

What % of AP pt’s have recurrence?

25%

Is chronic pancreatitis reversible?

What is the most common cause of CP in adults?

Alcohol

What is the most common cause of CP in children?

Cystic fibrosis

A pt presents with mid-back and abdominal pain that is exacerbated by eating, says she has lost a lot weight w/out trying. Consider:

What is a characteristic positioning found during a CP attack?

Lying on the left side, flexing the spine, and drawing the knees up toward the chest. (fetal position)

What might you see in advanced CP?

Temporal wasting or cachexia

What kind of test is a direct stimulation of the pancreas to assess the remaining functional ability?

Secretin Test

What test might you conduct in high advanced chronic pancreatitis?

Fecal Fat test

This test can detect calcifications, pancreatic duct dilatation, chronic pseudo cysts, focal pancreatic enlargement, and biliary ductal dilatation.

Abdominal CT (Useful in planning surgical or endoscopic intervention)

GOLD standard fo diagnosing CP

ERCP (most accurate visualization of pancreatic duct system)

An alternative SAFE and noninvasive test to ERCP

MRCP (secretin used to enhance pancreatogram)

What is an endoscopic tx used for in CP?

Spincterotomy Ductal Stenting-pain relief Stone extraction Drainage of pseudo cyst

What type of surgery would provide the most likely chance of pain relief for CP?

Whipple procedure

What kind of diet would you put a CP pt on?

Reduced fat, high protein, and carb diet. *Vit. A, D, E, K, B12

Pancreatic cancer is the ____leading cause of cancer deaths in U.S.

4th

Majority of pancreatic cancers are caused by _________

Ductal carcinoma

Most common location for pancreatic cancer

Head of Pancreas

5 yr survival rate for pancreatic cancer

6-7%

Pancreatic cancer occurs in _________year olds.

65-84

This syndrome carries a 123x increased lifetime risk of pancreatic cancer.

Peutz-Jeghers Syndrome

This syndrome carries an inc. risk of colon and pancreatic cancer

Lynch syndrome

What screening tools would you use in pancreatic cancer?

EUS or MRCP

A patient presents with “constant mid back pain” and says they are itching all the time...Consider:

Pancreatic cancer

Virchow’s node

Left supraclavicular lympadenopathy

Sister Mary Joseph’s nodes

Periumbilical nodules

Trousseau’s Sign

Migratory thrombophlebitis

Courvoisier’s Sign

Palpable gallbladder

The gold standard diagnostic imaging for pancreatic cancer.

Dual-base, contrast-enhanced spiral CT

This imaging test is highly sensitive in detecting lesions less than 3 cm

Endoscopic Ultrasound

This test is useful as a local staging tool for assessing vascular invasion and lymph node involvement in pancreatic cancer.

Endoscopic ultrasound

This test is useful for revealing small pancreatic lesions and to id stricture or obstruction in pancreatic or common bile ducts.

ERCP or MRCP

Useful for detecting distant metastasis in pancreatic cancer

FDG-PET

T1 size

<2cm

T2 size

>2 cm

What tumor classification invades into the duodenum, bile duct, major VEINS, or peripancreatic tissues?

T4 invades what?

Stomach, Spleen, Colon, or Large ARTERIES

_____% of pt’s with pancreatic cancer present with localized tumors

Procedure if resectable tumors are in the pancreatic head.

Pylorus-preserving pancreaticoduodenectomy (modified Whipple’s procedure)

Procedure if resectable tumors are in the pancreatic body and tail.

Distal pancreatectomy and splenectomy

Adjuvant chemo of six cycles of ______is common worldwide for resectable pancreatic cancer

Gemcitabine

Gemcitabine + _______ is used for bulky resectable tumors

5-FU based CRT

______% pt’s present with unresectable pancreatic cancer

Median survival of unresectable pancreatic cancer with Gemcitabine is ________

9 mo

_______% of pancreatic cancer pt’s present with metastatic disease.

Standard tx of metastatic pancreatic cancer

Gemcitabine (6 mo survival)

What addition to gemcitabine has improved 1-yr survival in metastatic pancreatic cancer?

Nab-paclitaxel