approach to pancreatitis

Question 1

pancreas: surrounded by ____ but no ____? mixed functions by %?

Answer 1

surrounded by fine connective tissue but no capsule. 80% exocrine, 20% endocrine.

Question 2

what stimulates H2O/bicarb vs. digestive enzyme release from pancreas?

Answer 2

food stimulates S cells to make secretin = duct cells secrete bicarb. food stimulates I cells to make CCK = acinar cells secrete enzymes.

Question 3

up to ___% of healthy pancreas can be removed before exocrine dysfunction seen?

Answer 3

90%

Question 4

physiology of trypsin secretion and activation?

Answer 4

calcium –> trypsinogen production –> then secreted; CFTC important –> converted into trypsin by enterokinase

Question 5

basic steps of pancreatitis

Answer 5

irritation of pancreas. pain. confirm with lipase blood test. give pain killers and IV fluid. most get better, if not go to ICU.

Question 6

how does pancreatitis happen?

Answer 6

trypsin within acinar cells is activated = autodigestion of pancreas, activates kinin/complement systems = inflammatory complications, systemic response, sepsis

Question 7

acute pancreatitis: defined clinically by?

Answer 7

patient with 2 out of 3: pain, serum lipase 3X normal. radiological imaging (usually CT/MRI)

Question 8

grades/severity of acute pancreatitis?

Answer 8

mild acute = no organ failure/local or systemic complications. moderately severe = transient organ failure + complications but not persistent. severe = peristent organ failure > 48 h

Question 9

criteria for organ failure in pancreatitis?

Answer 9

O2 requirement. SBP<90, pH <7.3, creat > 170

Question 10

etiology of pancreatitis (5)

Answer 10

gallstones/biliary sludge. alcohol. meds/ERCP,hypercalcemia/hypertriglyc/surgery/traumua. autoimmune IgG 4. unclear.

Question 11

embryological condition for pancreas?

Answer 11

pancreas divisum - the two buds swing together but union not complete. annular pancreas = duodenal stenosis. less likely to result in pancreatitis.

Question 12

alcohol and pancreatitis?

Answer 12

alcohol weakens sphincter = reflux of gut contents can damage acinae. also stimulates large amounts of enzymes. also thickens fluids produced. maybe also a direct toxin to acinar cells.

Question 13

auto immune pancreatitis

Answer 13

type 1 = IgG 4 related disease. treat with steroids. type 2 = normal IgG4

Question 14

pancreatitis: acute management?

Answer 14

pain control + fluid resuscitation: ringers lactate. ERCP if cholangitis. don’t need antibiotics unless extra pancreatic infection. can start oral feeding once pain resolved.

Question 15

pancreatitis: post acute management?

Answer 15

cholecystectomy. but wait until fluid resolves or is walled off before intervening - might take months. alcohol + cigarette abstinence. be aware of endocrine + excocrine insufficiencies = diabetes + malabsoprtion

Question 16

3 complications of pancreatitis

Answer 16

jaundice, shock, necrosis

Question 17

chronic pancreatitis: results from?

Answer 17

progressive inflamm + fibrotic changes = permanent structural damage = impaired function +
irreversible damage.
(recurrent acute can cause chronic pancreatitis)

Question 18

chronic pancreatitis dx: triad? confirm with?

Answer 18

pancreatic calcifications, steatorrhea, diabetes mellitus. CT/abdo x ray shows calcifications; beading of main pancreatic duct

Question 19

clinical findings of chronic pancreatitis

Answer 19

mid epigastric pain radiating to back that is worse with food + associated with nausea/vomiting. relieved by sitting upright or leaning forward. exocrine def = malabsp = steatorrhea. endocrine def = diabetes

Question 20

suspect pancreatic cancer in chronic pancreatitis pt when? (5)

Answer 20

older age. absence of alcohol abuse. weight loss. protracted flare of symptoms. significant constitutional symptoms.