Acute and chronic pancreatitis Flashcards
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
fibrosis
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.
chronic pancreatitis
What are the top three causes of acute pancreatitis
gallstones
alcohol
idiopathic
Describe the three general phases of acute pancreatitis
- Activation of zymogen granules within acinar cells, fusion with the basolateral membrane, and release into the interstitial space
- Recruitment of activated neutrophils
- Digestion of pancreatic and peripancreatic tissue by activated proteolytic enzymes such as trypsin.
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.
normal- apical
pancreatitis- basolateral
Activated neutrophils are capable of converting _____ into ____
trypsinogen into trypsin
______ is capable of activating elastase and phospholipase, which cause proteolysis, third spacing, hemorrhage, and necrosis
Trypsin
Decreased intravascular volume in acute pancreatitis from third spacing leads to hypoperfusion of the pancreas, which in turn promotes:
additional inflammation, pancreatic necrosis
In acute pancreatitis, the cascade of increased vascular permeability, third spacing, and vasodilation can lead to ________________ and multiorgan failure
systemic inflammatory response syndrome (SIRS)- extrapancreatic inflammation
How do patients with acute pancreatitis present?
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
In acute pancreatitis, both ____ and _____ are elevated but ___ is elevated in many conditions
amylase and lipase
amylase is elevated in many other conditions, lipase is more specific for pancreatitis
Which remains elevated longer in acute pancreatitis, amylase or lipase?
lipase- elevated for 7-14 days
amylase returns to normal within 72 hours
______ is not usually visible on CT until 48-72 hours after the onset of symptoms of acute pancreatitis
necrosis
Though there are number of grading systems available to approximate the severity of acute pancreatitis, the two most important values are:
hematocrit (measure of hemoconcentration)
creatinine (measure of renal function)
List two local complications of acute pancreatitis
necrosis
pseudocysts
The most important determinant of overall outcome in acute pancreatitis is the presence of necrosis and whether it is _____ or ______
sterile or infected
Infected necrosis needs surgical debridement and antibiotics
When in the course of acute pancreatitis do pseudocysts develop?
4-6 weeks after symptoms
List some systemic complications of acute pancreatitis
respiratory failure (ARDS/ pleural effusion)
acute kidney injury (acute tubular necrosis)
hypotension, shock
coagulopathy if DIC
GI bleeding
hyperglycemia, hypocalcemia
List treatments for acute pancreatitis
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
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
endoscopic sphincterotomy and stone extraction via ERCP
Other than alcohol, what other substances may cause a toxic etiology of acute pancreatitis?
sulfa
azathioprine
metronidazole
Laboratory measurements of amylase and lipase greater than ____ x normal values is usually diagnostic for acute pancreatitis
3x
Elevated ALT suggests _____ as the cause of acute pancreatitis
gallstones
_____ or ____ pancreatitis is milder than necrotizing pancreatitis and is often self limiting with low mortality
interstitial or edematous
Enteral nutrition in acute pancreatitis has been shown to improve the following outcomes
infectious complications
hospital stay
mortality
organ failure
Patients are in a catabolic state, have increased caloric needs
Chronic pancreatitis is a chronic inflammatory process that leads to ____ fibrosis and scarring throughout the pancreas and leads to both ______ and _____ dysfunction
patchy
endocrine and exocrine dysfunction
What are major causes of chronic pancreatitis
alcohol
idiopathic including hereditary pancreatitis
CF
autoimmune pancreatitis
How do patients with chronic pancreatitis present?
Asymptomatic
epigastric pain that radiates to the back and is worse wiht food
nausea and vomiting
new onset diabetes
Amylase and lipase levels are often _____ in chronic pancreatitis
normal
______ will develop in chronic pancreatitis once there is <10% of normal endocrine function
Diabetes
______ will occur as there is loss of exocrine function of the pancreas
Malabsorption
How does alcohol contribute to the etiology of chronic pancreatitis
- pancreatic juice rich in viscous protein precipitates in ductules
- decreased production of lithostatin–> stone and plug formation
- EtOH is a direct pancreatic toxin
How is a diagnosis of chronic pancreatitis made?
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
The gold standard of pancreatic function is the ______ test
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
List complications of chronic pancreatitis
pseudocyst bile duct obstruction splenic vein thrombosis pseudoaneurysm pancreatic cancer
How is chronic pancreatitis treated?
pain management, incl celiac plexus block
correction of pancreatic insufficiency- synthetic enzymes
management of complications
advise smaller meals, low fat, decreased EtOH and tobacco
