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Nutrition > Biliary and pancreatic function > Flashcards

Biliary and pancreatic function Flashcards

1
Q

list the effects of pancreatic insufficiency

A

maldigestion (causing wt loss and malnutrition especially in vitamins ADEK and steatorrhoea)

Diabetes

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2
Q

list some causes of pancreatic insufficiency

A

1) chronic pancreatitis - usually alcohol
2) cystic fibrosis- children
3) Duct obstruction -Ca
4) pancreatic atrophy - elderly

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3
Q

what might be used to test pancreatic function?

A

1) faecal elastase
2) serum amylase (^x3 suggestive of acute pancreatitis)
3) tubeless function tests - poor sensitivity and specificity (urinary metabolites, pancreolauryl)

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4
Q

what is the imaging of choice for the pancreas

A

CT -> good for parenchyma
US -> quick and cheap good for masses and biliary obstruction (bad if gas)
ERCP -> best for ducts but invasive, MR also used but not first line

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5
Q

what is the average daily bile flow

A

600ml/day

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6
Q

name 4 bile acids which are ionized forms of bile salts (conjugated with taurine or glycine 3:1)

A

1) glycocholic acid
2) glycochenodeoxycholic acid
3) taurocholic acid
4) taurocendodeoxycholic acid

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7
Q

where is taurine and glycine removed from the bile

A

by bacteria in the intestine

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8
Q

what are the two essential fatty acids

A

linoleum acid

linolenic acid

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9
Q

what do the products of degraded lipids aggregate into and then what are the transferred into

A

multilamellar vesicles

to mixed micelles

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10
Q

where are bile salts ionised into acids

A

the duodenum

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11
Q

where and how are bile acids degraded

A

by the flora in the duodenum

they are converted from primary to secondary acids

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12
Q

what are the functions of bile acids

A

excretion route for cholesterol
emulsify lipids
form mixed micelles

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13
Q

where are bile acids reabsorbed and how are they transported back to the liver

A

95% in the terminal ileum

transported back to liver by albumin

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14
Q

what are the functions of the pancreas

A

endocrine –> metabolic control

Exocrine –> digestive enzyme secretion and neutralisation of the duodenum

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15
Q

what controls the exocrine function of the pancreas

A

1) cephalic phase –> vagus
2) in response to lipids, proteins and secretin –> CCK
3) low pH –> HCO3
4) inhibitory hormones –> amylin, pancreatic polypeptide, somatostatin/ghrelin

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16
Q

what is the cephalic phase of pancreas stimulation

A

sight/taste/smell of food
stimulates hypothalamus
vagus nerve
stimulates 40% of max secretion

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17
Q

what is the duodenal phase of pancreatic function

A

endocrine cells secrete secretin in response to low pH; and CCK in response to lipids and proteins

pH is monitored by vagal nerve afferents

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18
Q

what are the hormonal actions of secretin

A

causes duct cells to secrete HCO3

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19
Q

what are the hormonal actions of CCK

A

causes gall bladder contraction, oddi relaxation and acing cell excretion

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20
Q

what are the hormonal actions of amylin secreted by beta cells

A

slow gastric emptying and pancreatic secretions

inhibits glucagon production

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21
Q

what are the hormonal actions of pancreatic polypeptide produced in islets

A

inhibit gall bladdr and pancreatic secretion

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22
Q

what are the endocrine cells of the pancreas

A

alpha -> glucagon
beta -> insulin and amylin
delta -> somatostatin

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23
Q

what is the aetiology of acute pancreatitis

A 
Gallstones
Alcohol
post ERCP complication
Pregnancy
Autoimmune (rare)
24
Q

how does acute pancreatitis present

A 
sudden or gradual onset of severe epigastric pain
radiates to the back
relieved by sitting forwards
vomiting
bruising (if severe cullers sign or grey-turners sign)
tenderness
guarding
shock is severe
25
Q

what are cullens and grey-turners signs

A

cullens -> periumbilical bruising
grey-turners -> flank bruising
both suggest necrotising pancreas +/- haemorrhage

26
Q

what blood tests would you investigate in acute pancreatitis

A 
serum amylase
serum lipase
U+Es
BM
ABG
FBC
27
Q

why might hypovolaemia show on U+Es in response to acute pancreatitis

A

renal failure can occur due to inflammatory response causing increased capillary permeability and third space sequestration

28
Q

what type of imaging would you use to investigate acute pancreatitis

A

Erect CXR to exclude perforation
AXR looking for calcifications
abdo US to exclude gallstones
CT/MRI show parenchyma (oedema/necrosis)

29
Q

what is the PANCREAS scoring system?

>3 = severe pancreatits

A 
P= PaO2 55
N = neutrophillia
C = calcium < 2.0mmol/L
R= raised urea >16mmol/L
E= enzymes: LDH>600ui/L; AST >iu/L
A= albumin 10 mmol/L
30
Q

how would you manage mild pancreatitis

A

supportive care and analgesia

31
Q

how do you treat severe pancreatitis

A

ITU
pre-emptive abx
surgical intervention
ERCP

32
Q

what is the aetiology for chronic pancreatitis?

A

alcohol
malnutrition
hereditary
Cystic fibrosis

33
Q

what is the pathophysiology of chronic pancreatitis

A

hyper secretion of proteins –> plug formation
blockage of duct and premature activation of enzymes
loss of pancreatic tissue and insufficiency
fibrosis, scarring and calcification occur

34
Q

what is the presentation of chronic pancreatitis

A 
epigastric pain
pancreatic insufficiency
wt loss
steatorrhoea
flatus
diabetes
jaundice
35
Q

investigations of chronic pancreatitis

A 
low faecal elastase
low PABA (urine)
USS
CT
MRI/endoscopic USS
36
Q

how is chronic pancreatitis managed

A

analgesia
enzyme supplements
diabetic control
surgery if req

37
Q

risk factors for carcinoma of the pancreas

A

> 60s
smoking/alcohol
chronic pancreatitis
FHx (BRAC2)

38
Q

what are the different presentations of carcinoma of the head and the tail of the pancreas

A

Head: early presentation, obstructive jaundice, painless

Tail: late presentation, epigastric pain, wt loss

39
Q

what tumour markers can be used for carcinoma of the pancreas

A

CA19-9

CA125

40
Q

how is pancreatic carcinoma managed

A

usually palliatively
stunting of CBD
chemo/radiotherapy

only 10% suitable for attempted curative surgery

41
Q

what are the most common type of gall stone and how are they formed

A

cholesterol

formed by supersaturation, reduced bile salt, stasis and promoting factors

42
Q

describe two types of pigment stone

A

black -> calcium bilirubinate (a/w/ haemolytic disease)

brown -> Ca/FA salts -> from stasis or infection

43
Q

predisposing factors of gall stones

A 
FAT- obesity diabetes
FEMALE
FERTILE
FAIR
FORTY/age
 also Crohn's
44
Q

what is biliary colic

A

gallstone lodged in cystic duct/CBD

causes mucocele of GB -> gall bladder distension

45
Q

what is acute cholecystitis

A

obstruction of the cystic duct

causes inflammation/infection
complications: empyema of GB and perforation

46
Q

what is obstructive jaundice

A

hepatic duct obstruction

caused by stone or mass in head of pancreas causing bilirubin in the blood

47
Q

what is ascending cholangitis

A

infection spreading up from the duodenum in static bile

48
Q

what is gallstone ileus

A

large gallstone erodes from GB to duodenum and can occlude the ileocaecal junction

49
Q

how does biliary colic present

A 
crescendo pain in RUQ radiating to shoulder/scapula
restless
precipitated by fatty food
N&V
jaundice
50
Q

investigations for biliary colic

A

bloods
US
MRCP
HIDA scan

51
Q

how does acute cholecystitis present

A 
RUQ pain
N&V
guarding and tenderness
fever
positive Murphy's sign
52
Q

what are the treatments for acute cholecystitis

A

cefuroxime

cholecystectomy

53
Q

what is charcots triad

A

fever
jaundice
RUQ pain
in obstructive jaundice/cholangitis

54
Q

what would you find on investigation for obstructive jaundice

A

raised bilirubin ALP and gamma GT

on images: dilation/masses in the CBD/pancreas

55
Q

how is obstructive cholangitis/jaundice treated

A

cefuroxime

ERCP for drainage, stone removal or stenting

Nutrition (11 decks)

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