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FUN MED SPRING 2018 > 6. Acute/Chronic Pancreatitis & Pancreatic Cancer > Flashcards

6. Acute/Chronic Pancreatitis & Pancreatic Cancer Flashcards

1
Q

Risk of pancreatitis is _______x higher for blacks than whites

A

3

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2
Q

Most common cause of acute pancreatitis.

A

Gallstones

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3
Q

What is the main digestive function of the pancreas?

A

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

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4
Q

What stimulates pancreatic acinar cells?

A

Secretagogues

  • Acetylcholine (Vagus)
  • Cholecystokinin (small intestines)
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5
Q

What does alkaline fluid do in the pancreas?

A

Neutralizes the acidic chyme that enters the small intestine.

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6
Q

Besides alkaline fluid, what else does the pancreas secrete?

A

Insulin and glucagon

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7
Q

What stimulates the pancreatic duct cells?

A

Secretin

*Duct cells secrete bicarbonate via calcium/bicarbonate exchange channel

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8
Q

“Enzymatic precursors” produced by acinar cells

A

Zymogens

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9
Q

Where are zymyogens produced?

A

In vesicles w/in acinar cells

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10
Q

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

A

Initial Phase

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11
Q

In what phase of AP does an inflammatory reaction occur?

A

Second phase

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12
Q

What happens in the third phase of acute pancreatitis?

A

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

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13
Q

What happens when pancreatic enzymes starts to digest surrounding tissues?

A 
Proteolytic
Edema
Interstitial hemorrhage
Vascular damage
Coagulation necrosis
Fat necrosis
Parenchymal cell necrosis
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14
Q

5 known genetic factors for ACUTE pancreatitis

A

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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15
Q

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.”

A

Acute pancreatitis

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16
Q

What might cause muscle spasms in acute pancreatitis?

A

Hypocalcemia

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17
Q

A fain blue discoloration around the umbilicus?

A

Cullen’s sign

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18
Q

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

A

Grey-Turner’s sign

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19
Q

Serum amylase in acute pancreatitis.

A

Elevated-not specific

P-Amylase-more specific

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20
Q

Serum Lipase results for AP

A

Elevated-more specific

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21
Q

The ALT level in gallstone pancreatitis is generally_________

A

Higher than 150

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22
Q

Hyperglycemia in acute pancreatitis is caused by__________

A

B cell injury

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23
Q

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

A

> 6

>7=more severe pancreatitis

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24
Q

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

A

Abdominal Ultrasound-look for GALLSTONES and visualize PANCREATIC head

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25
Q

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

A

3-5 days into hospitalization

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26
Q

How is the EARLY phase defined in the Atlanta Classification?

A

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

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27
Q

How is the LATE phase of the Atlanta Classification defined?

A

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

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28
Q

How is MILD acute pancreatitis defined?

A

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

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29
Q

How is MODERATELY SEVERE acute pancreatitis defined?

A

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

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30
Q

How is SEVERE acute pancreatitis defined?

A

Persistent organ failure > 48 hr

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31
Q

What would you find in imaging of interstitial pancreatitis?

A

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

90-95% admissions

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32
Q

What would you find in imaging of necrotizing pancreatitis?

A

Lack of pancreatic parenchymal enhancement. Variable course (necrosis may remain solid, liquefy etc).

5-10% of admissions.

*It’s what you DON’T see!

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33
Q

Ranson’s criteria on admission: age.

A

> 55

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34
Q

Ranson’s criteria on admission: WBC

A

> 16,000 uL

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35
Q

Ranson’s criteria on admission: blood glucose

A

> 200mg/dL

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36
Q

Ranson’s criteria serum on admission: LDH

A

> 350 IU/L

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37
Q

Ranson’s criteria on admission: AST

A

> 250

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38
Q

Ranson’s (48hr) criteria: Hematocrit

A

> 10%

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39
Q

Ranson’s (48hr) criteria: BUN level

A

Inc. more than 8 mg/dL

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40
Q

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

A

Lower than 8 mg/dL

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41
Q

Ranson’s (48hr) criteria: PaO2

A

<60mm Hg

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42
Q

Ranson’s (48hr) criteria: Base deficit

A

> 4 mEq/L

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43
Q

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

A

> 6 L

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44
Q

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

A

85-90

3-7

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45
Q

Tx of Acute pancreatitis?

A

Pain Control
I.V. Rehydration
Time

46
Q

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

A

The Bedside Index of Severity in Acute Pancreatitis

47
Q

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

A 
BUN>25
Glasgow < 15
SIRS
>60 yrs
Pleural effusion on CXR
48
Q

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

A

Aggressive fluid resuscitation

49
Q

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

A

SEND TO ICU!

50
Q

What solution has been shown to decrease systemic inflammation?

A

Lactated Ringers

51
Q

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

A

Every 8-12 hr

52
Q

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

A

Inadequate hydration

Higher in-hospital mortality

53
Q

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

A

Bolus Challenge

54
Q

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

A

2

1.5

55
Q

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

A

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

56
Q

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

A

ERCP w/in 24-48 hrs

57
Q

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

A

Cholecystectomy

58
Q

Tx for post-ERCP pancreatitis

A

Prophylactic pancreatic duct stent + rectal NSAIDS after ERCP

59
Q

What does the initial therapy for hypertriglyceridemia include?

A

Insulin, heparin, or plasmapherisis

60
Q

Outpatient therapies for hypertriclyceridemia AP

A

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

61
Q

How would you manage a pancreatic duct disruption?

A

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

62
Q

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

A

20

63
Q

Overall mortality for AP

A

10-15%

64
Q

Mortality for severe AP

A

30%

65
Q

What % of AP pt’s have recurrence?

A

25%

66
Q

Is chronic pancreatitis reversible?

A

No

67
Q

What is the most common cause of CP in adults?

A

Alcohol

68
Q

What is the most common cause of CP in children?

A

Cystic fibrosis

69
Q

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:

A

CP

70
Q

What is a characteristic positioning found during a CP attack?

A

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

71
Q

What might you see in advanced CP?

A

Temporal wasting or cachexia

72
Q

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

A

Secretin Test

73
Q

What test might you conduct in high advanced chronic pancreatitis?

A

Fecal Fat test

74
Q

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

A

Abdominal CT (Useful in planning surgical or endoscopic intervention)

75
Q

GOLD standard fo diagnosing CP

A

ERCP (most accurate visualization of pancreatic duct system)

76
Q

An alternative SAFE and noninvasive test to ERCP

A

MRCP (secretin used to enhance pancreatogram)

77
Q

What is an endoscopic tx used for in CP?

A

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

78
Q

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

A

Whipple procedure

79
Q

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

A

Reduced fat, high protein, and carb diet.

*Vit. A, D, E, K, B12

80
Q

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

A

4th

81
Q

Majority of pancreatic cancers are caused by _________

A

Ductal carcinoma

82
Q

Most common location for pancreatic cancer

A

Head of Pancreas

83
Q

5 yr survival rate for pancreatic cancer

A

6-7%

84
Q

Pancreatic cancer occurs in _________year olds.

A

65-84

85
Q

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

A

Peutz-Jeghers Syndrome

86
Q

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

A

Lynch syndrome

87
Q

What screening tools would you use in pancreatic cancer?

A

EUS or MRCP

88
Q

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

A

Pancreatic cancer

89
Q

Virchow’s node

A

Left supraclavicular lympadenopathy

90
Q

Sister Mary Joseph’s nodes

A

Periumbilical nodules

91
Q

Trousseau’s Sign

A

Migratory thrombophlebitis

92
Q

Courvoisier’s Sign

A

Palpable gallbladder

93
Q

The gold standard diagnostic imaging for pancreatic cancer.

A

Dual-base, contrast-enhanced spiral CT

94
Q

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

A

Endoscopic Ultrasound

95
Q

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

A

Endoscopic ultrasound

96
Q

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

A

ERCP or MRCP

97
Q

Useful for detecting distant metastasis in pancreatic cancer

A

FDG-PET

98
Q

T1 size

A

<2cm

99
Q

T2 size

A

> 2 cm

100
Q

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

A

T3

101
Q

T4 invades what?

A

Stomach, Spleen, Colon, or Large ARTERIES

102
Q

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

A

10

103
Q

Procedure if resectable tumors are in the pancreatic head.

A

Pylorus-preserving pancreaticoduodenectomy (modified Whipple’s procedure)

104
Q

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

A

Distal pancreatectomy and splenectomy

105
Q

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

A

Gemcitabine

106
Q

Gemcitabine + _______ is used for bulky resectable tumors

A

5-FU based CRT

107
Q

______% pt’s present with unresectable pancreatic cancer

A

30

108
Q

Median survival of unresectable pancreatic cancer with Gemcitabine is ________

A

9 mo

109
Q

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

A

60

110
Q

Standard tx of metastatic pancreatic cancer

A

Gemcitabine (6 mo survival)

111
Q

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

A

Nab-paclitaxel

FUN MED SPRING 2018 (14 decks)

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