All Things Pancreas

Question 1

3 MCCs of Acute Pancreatitis with percentages (excluding idiopathic causes).

Answer 1

Gallstones are responsible for 40%. EtOH is 30%. Hypertriglyceridemia is 3%. Idiopathic accounts for 20% of pts.

Question 2

What is the pathogenesis of acute pancreatitis?

Answer 2

Pressure or activation of the pancreatic zymogens that normally cleave and break down protein, fat in the intestine are now doing self autolysis - leading to damage and inflammation.

Question 3

How does a pt with pancreatitis present and how do we diagnose it?

Answer 3

Pt presents with the universal symptoms of epigastric pain with nausea and vomiting that is worse after eating. Sometimes pt will say it radiates to the back (retroperitoneal) or increased tenderness on palpation.

Question 4

SAD PUCKER is a mnemonic for what?

Answer 4

Retroperitoneal organs. Suprarenal glands, aorta/ivc, 2nd and 3rd parts of duodenum. Pancreas (except the tail), ureters, colon (ascending and descending), Kidneys, Esophagus, Rectum.

Question 5

If pancreatitis is suspected, how do I diagnose?

Answer 5

Requires 2/3 of the following: 1. Epigastric pain is a no brainer. 2. Elevated amylase or lipase by 3x normal. 3. CT or MRI with contrast imaging.

Question 6

Treatment of Acute Pancreatitis.

Answer 6

If gallstone related - remove it. Otherwise, Supportive with careful observation of electrolytes and concern for distributive shock in first week. Do not allow pt to eat until they are improved.

Question 7

I GET SMASHED is a mnemonic for…

Answer 7

Causes of Acute Pancreatitis. Idiopathic. Gallstones, EtOH, Triglycerides/Trauma share the T.

Steroids, Mumps, Autoimmune, Scorpion sting, Hypercalcemia, ERCP (which should never have to be spelled out), Drugs (Sulfa and HIV meds).

Question 8

What does ERCP stand for and what complications could it cause besides acute pancreatitis?

Answer 8

endoscopic retrograde cholangiopancreatography. Can cause bowel perforation and or bleeding. Gastroenterologist puts flexible tube until it reaches the sphincter of oddi to look at the biliary and pancreatic system.

Question 9

Where is the Ampulla of Vater?

Answer 9

It is where the CBD enters the intestine releasing bile and pancreatic enzymes. It is surrounded by the musculature of SoD.

Question 10

Where would the obstruction of the gallstone need to be to lead to acute pancreatitis?

Answer 10

Ampulla of Vater/Sphincter of Oddi.

Question 11

Aggressive fluid resuscitation in Acute Pancreatitis is due to the concern for what 3 complications?

Answer 11

Fluid loss occurs from Pancreatic capillary edema. Or Leakage into peritoneum aka Peripancreatic fluid collection. Or most famously and more late of a complication - Pseudocyst.

Question 12

Why is a pancreatic Pseudocyst called a Pseudocyst?

Answer 12

It does not have any epithelium on the inside - merely granulation tissue.

Question 13

What kind of vascular damage can acute pancreatitis cause?

Answer 13

Neighboring Splenic vasculature can be disrupted and lead to hemorrhage from erosion and varied patches of necrosis with secondary infection bc difficult to remove the necrosis.. May require debridement.

Question 14

What other Cxs may occur in Acute Pancreatitis?

Answer 14

Hemorrhage from splenic vasculature. Patchy necrosis that is hard to filter out thereby leading to infection. It can move on to be Chronic Pancreatitis if acute never resolves.

1. Hemorrhage. 2. Necrosis 3. Infection (in 1/3rd of necrotic cases) 4. Chronic pancreatitis.

Question 15

What metabolites are affected systemically from pancreatic inflammation which is dangerous for the pt in the first week and requires constant supervision?

Answer 15

Calcium and Glucose. Calcium can drop abruptly and Glucose may rise abruptly.

Question 16

What is SIRS? What are the 4 Dx criteria?

Answer 16

Systemic Inflammatory Response Syndrome.

Tachycardia, Tachypnea (respiratory rate >20 breaths/min), fever or hypothermia, and leukocytosis, leukopenia, or bandemia. Eventually leads to Shock.

Question 17

Inflammatory cascade leading to distributive shock from Acute Pancreatitis targets which 2 organs most?

Answer 17

Lungs (ARDS) and Kidneys ( AKI from fluid loss from distributive shock rerouted to brain and heart)

Question 18

Why keep pt from eating during acute pancreatitis?

Answer 18

We do not want to stimulate the pancreas to secrete anything else.

Question 19

What occurs in chronic pancreatitis? 2 MCCs?

Answer 19

Pancreas tired of abuse fibroses and shrivels up.

Ethanol and Cystic Fibrosis gunking up the ducts.

Question 20

What are the 2 classic radiographic features of Chronic Pancreatitis?

Answer 20

Atrophy of the pancreas and granular calcifications.

Question 21

What are the severe Sxs of Pancreatic Insufficiency from Chronic Pancreatitis?

Answer 21

Destruction of beta cells - leading to a insulin-dependent diabetes prone to hypoglycemia from overtreatment (not as bad as Type 1), chronic stomach pain, recurrent pseudocysts. Loss of Somatostatin and Glucagon aren’t as obvious. Delta cells are still found in the antrum of the stomach.

Loss of fat digestion is especially prominent causing steatorrhea + consequential fat soluble vitamin deficiencies.

Question 22

Why can we not use Amylase and Lipase to diagnose Chronic Pancreatitis?

Answer 22

Like in cirrhosis, if the pancreas is too insufficient it will not be releasing the two in high quantities. High levels of Amylase and Lipase are just like AST and ALT in the liver…they are a function of how rapidly the cells are dying.

Often caught late if ever.

Question 23

Deadliest cancer of all. Found esp in what region of the organ?

Answer 23

Pancreatic Adenocarcinoma - particularly the ductal adenocarcinoma type. Very aggressive even as a small cancer. Highly invasive and metastatic.

Question 24

Risk Factors for Pancreatic Adenocarcinoma.

Answer 24

Tobacco, Age (mean age is 70 yo), Jewish and African Americans, DM, Chronic pancreatitis.

Question 25

While Pancreatic cancer is so lame about showing itself…what symptoms would you notice?

Answer 25

Weight loss, chronic abdominal pain, weakness. All these are sooooooooo nonspecific.

Question 26

Most common location of Pancreatic cancer is in which of the 3 parts?

Answer 26

Head of the pancreas - and can cause gall bladder dilation.

Question 27

What’s a life-saving complication which only could occur if your pancreatic adenocarcinoma is in the head of the pancreas vs body and tail?

Answer 27

Biliary obstruction. This leads to a strangely painless gall bladder dilation that you can feel but doesn’t hurt them. Also causes Sxs you can see from the bile reflux…jaundice, acolic stools, dark urine which can help detect the cancer earlier.

Question 28

What is Trousseau Sign and what is Trousseau Syndrome?

Answer 28

Trousseau sign and Chvostek sign indicate tetany from hypocalcemia. Trousseau involves the BP and cuff, while Chvostek involves tapping facial nerve causing a weird twitch.

These signs are not related to Trousseau Syndrome which is the tendency for pts with pancreatic or GI cancers to get recurrent MIGRATING thrombophlebitis much more than occurs in other cancers!

Question 29

What Lab antigen is related to Pancreatic Cancer?

Answer 29

CA-19. really only used to detect tumor recurrence as it is not a great test.

Question 30

What is the name of the sign involving painless jaundice and a distended gall bladder indicating the problem is not gallstones?

Answer 30

Pass the Courvoisier! You can usually palpate the gallbladder but they don’t feel pain. This means a biliary or pancreatic neoplasm.

Question 31

What are the treatments for pancreatic adenocarcinoma once detected?

Answer 31

Usually only Palliative because Chemo and Radiation are non-curative for these pts. ERCP can be used for biliary stenting as palliative care.

Whipple Procedure is an option in rare cases.

Question 32

What exactly is a Whipple Procedure?

Why is the duodenum involved in this mess? Why is the whole biliary thing being removed?!?!

Answer 32

Pancreaticoduodenectomy.

Blood supply of pancreas and duodenum is so interlinked that removing the pancreatic blood supply would put the duodenum at a dangerously high risk for ischemia. Hepatic duct is connected to jejunum and stomach is connected distally to this point in the jejunum. Weird anatomically.

You so need the duodenum to make the gall bladder do its work. Because I cells of the duodenum are required to even make the gall bladder squeeze (Cholecystikinin).