Acute and chronic pancreatitis

Question 1

Chronic pancreatitis is a chronic inflammatory condition resulting from ongoing damage (i.e. alcohol use) to the pancreas over time, and is characterized by _______ with resultant destruction of pancreatic exocrine and endocrine tissue

Answer 1

fibrosis

Question 2

The greatest difference between acute and chronic pancreatitis is that is that _________ can result in progressive and permanent change to the morphology and function of the pancreas.

Answer 2

chronic pancreatitis

Question 3

What are the top three causes of acute pancreatitis

Answer 3

gallstones
alcohol
idiopathic

Question 4

Describe the three general phases of acute pancreatitis

Answer 4

1. Activation of zymogen granules within acinar cells, fusion with the basolateral membrane, and release into the interstitial space
2. Recruitment of activated neutrophils
3. Digestion of pancreatic and peripancreatic tissue by activated proteolytic enzymes such as trypsin.

Question 5

In normal pancreatic functioning activated zymogens
such as trypsin are released through the _____ membrane into the ductal lumen.
However, in pancreatitis activated zymogens are released through the _______ membrane into the interstitial space.

Answer 5

normal- apical

pancreatitis- basolateral

Question 6

Activated neutrophils are capable of converting _____ into ____

Answer 6

trypsinogen into trypsin

Question 7

______ is capable of activating elastase and phospholipase, which cause proteolysis, third spacing, hemorrhage, and necrosis

Answer 7

Trypsin

Question 8

Decreased intravascular volume in acute pancreatitis from third spacing leads to hypoperfusion of the pancreas, which in turn promotes:

Answer 8

additional inflammation, pancreatic necrosis

Question 9

In acute pancreatitis, the cascade of increased vascular permeability, third spacing, and vasodilation can lead to ________________ and multiorgan failure

Answer 9

systemic inflammatory response syndrome (SIRS)- extrapancreatic inflammation

Question 10

How do patients with acute pancreatitis present?

Answer 10

sudden onset epigastric pain which radiates to the back and is more intense when supine
Nausea, vomiting

Patients may sit flexing their trunk and pulling knees up to get relief from pain

Question 11

In acute pancreatitis, both ____ and _____ are elevated but ___ is elevated in many conditions

Answer 11

amylase and lipase

amylase is elevated in many other conditions, lipase is more specific for pancreatitis

Question 12

Which remains elevated longer in acute pancreatitis, amylase or lipase?

Answer 12

lipase- elevated for 7-14 days

amylase returns to normal within 72 hours

Question 13

______ is not usually visible on CT until 48-72 hours after the onset of symptoms of acute pancreatitis

Answer 13

necrosis

Question 14

Though there are number of grading systems available to approximate the severity of acute pancreatitis, the two most important values are:

Answer 14

hematocrit (measure of hemoconcentration)

creatinine (measure of renal function)

Question 15

List two local complications of acute pancreatitis

Answer 15

necrosis

pseudocysts

Question 16

The most important determinant of overall outcome in acute pancreatitis is the presence of necrosis and whether it is _____ or ______

Answer 16

sterile or infected

Infected necrosis needs surgical debridement and antibiotics

Question 17

When in the course of acute pancreatitis do pseudocysts develop?

Answer 17

4-6 weeks after symptoms

Question 18

List some systemic complications of acute pancreatitis

Answer 18

respiratory failure (ARDS/ pleural effusion)
acute kidney injury (acute tubular necrosis)
hypotension, shock
coagulopathy if DIC
GI bleeding
hyperglycemia, hypocalcemia

Question 19

List treatments for acute pancreatitis

Answer 19

Don’t eat- possible nasojejunal feeding
Pain relief
Aggressive IV fluids to prevent hypoperfusion and necrosis
Antibiotics if infected necrosis, debate about role of antibiotics in sterile necrosis

Question 20

Gallstone pancreatitis results from a gallstone being impacted in the distal common bile duct and subsequent inflammation and impaired flow of the pancreatic duct.
Treatment is with ____________________. After recovery, cholecystectomy is recommended to prevent additional episodes

Answer 20

endoscopic sphincterotomy and stone extraction via ERCP

Question 21

Other than alcohol, what other substances may cause a toxic etiology of acute pancreatitis?

Answer 21

sulfa
azathioprine
metronidazole

Question 22

Laboratory measurements of amylase and lipase greater than ____ x normal values is usually diagnostic for acute pancreatitis

Answer 22

3x

Question 23

Elevated ALT suggests _____ as the cause of acute pancreatitis

Answer 23

gallstones

Question 24

_____ or ____ pancreatitis is milder than necrotizing pancreatitis and is often self limiting with low mortality

Answer 24

interstitial or edematous

Question 25

Enteral nutrition in acute pancreatitis has been shown to improve the following outcomes

Answer 25

infectious complications
hospital stay
mortality
organ failure

Patients are in a catabolic state, have increased caloric needs

Question 26

Chronic pancreatitis is a chronic inflammatory process that leads to ____ fibrosis and scarring throughout the pancreas and leads to both ______ and _____ dysfunction

Answer 26

patchy

endocrine and exocrine dysfunction

Question 27

What are major causes of chronic pancreatitis

Answer 27

alcohol
idiopathic including hereditary pancreatitis
CF
autoimmune pancreatitis

Question 28

How do patients with chronic pancreatitis present?

Answer 28

Asymptomatic
epigastric pain that radiates to the back and is worse wiht food
nausea and vomiting
new onset diabetes

Question 29

Amylase and lipase levels are often _____ in chronic pancreatitis

Answer 29

normal

Question 30

______ will develop in chronic pancreatitis once there is <10% of normal endocrine function

Answer 30

Diabetes

Question 31

______ will occur as there is loss of exocrine function of the pancreas

Answer 31

Malabsorption

Question 32

How does alcohol contribute to the etiology of chronic pancreatitis

Answer 32

• pancreatic juice rich in viscous protein precipitates in ductules
• decreased production of lithostatin–> stone and plug formation
• EtOH is a direct pancreatic toxin

Question 33

How is a diagnosis of chronic pancreatitis made?

Answer 33

Combination of clinical symptoms with imaging studies
CT and ERP can show dilation of pancreatic duct, heterogeneity of the parenchyma, calcifications with high sensitivity
Can be difficult dx in early stages, lab values may be normal

Question 34

The gold standard of pancreatic function is the ______ test

Answer 34

secretin

Secretin, a stimulant to the pancreas is given intravenously; then the levels of duodenal bicarbonate, lipase, and trypsin are measured. All will be significantly decreased in chronic pancreatitis

Question 35

List complications of chronic pancreatitis

Answer 35

pseudocyst
bile duct obstruction
splenic vein thrombosis
pseudoaneurysm
pancreatic cancer

Question 36

How is chronic pancreatitis treated?

Answer 36

pain management, incl celiac plexus block
correction of pancreatic insufficiency- synthetic enzymes
management of complications
advise smaller meals, low fat, decreased EtOH and tobacco