Ch. 19-1 (Dobson) Flashcards
The adult pancreas is a transversely oriented retroperitoneal organ extending from the C-loop of the duodenum to the hilum of the spleen. It is a complex lobulated organ with distinct _______ and _______ components.
Endocrine
Exocrine
The (EXOCRINE/ENDOCRINE) pancreas constitutes 80-85% of the organ and is composed of acinar cells that secrete enzymes needed for digestion (zymogens), including trypsinogen, chymotrypsinogen, procarboxypeptidase, proelastase, kallikreinogen, and prophospholipase A and B.
Exocrine
The (EXOCRINE/ENDOCRINE) pancreas is composed of about 1 million clusters of cells, the islets of Langerhans, scattered throughout the gland. The islet cells secrete insulin, glucagon, and somatostatin and constitute only 1-2% of the organ.
Endocrine
This congenital anomaly of the pancreas is the most common and is due to a failure of ventral and dorsal bud fusion. It may be associated with chronic pancreatitis.
Pancreas divisum
***The ducts in the pancreas don’t come together into the bile duct, they are separate!
This congenital anomaly of the pancreas is an abnormal rotation that can produce a duodenal obstruction.
Annular pancreas
This disorder occurs when the pancreas is in an abnormal place or position, but histologically normal. Favored sites are the stomach and duodenum, followed by the jejunum, Meckel diverticula, and ileum. Usually asymptomatic, but may cause pain from localized inflammation, or rarely, mucosal bleeding.
Ectopic pancreas
Pancreatitis is divided into two forms, _______ and _______, each with its own characteristic pathologic and clinical features. Both are initiated by injuries that lead to _________ of the pancreas by its own enzymes when the protective mechanism are disrupted or overloaded.
Acute
Chronic
Autodigestion
Most digestive enzymes are synthesized as inactive proenzymes, called ________, and packaged within secretory granules. These are typically activated by ________, which itself is activated by duodenal enterokinase in the small bowel. As a result, intrapancreatic activation of proenzymes is normally minimal. This is what messes up to cause pancreatitis.
Zymogens
Trypsin
Acinar and ductal cells secrete trypsin inhibitors, including _______, which further limits intrapancreatic trypsin activity.
SPINK1 (serine protease inhibitor Kazal type I)
Severe acute pancreatitis is a medical emergency. Patients usually present with an acute abdomen and systemic findings caused by the release of toxic enzymes, cytokines, and other mediators into the circulation. These activate a systemic inflammatory response and can result in…
- Leukocytosis
- DIC
- Edema
- ARDS
- Shock
- Acute renal tubular necrosis
This is the cardinal manifestation of the acute pancreatitis. Characteristically, it is constant, intense, and referred to the upper or mid back and occasionally the left shoulder. Severity ranges from mild discomfort to incapacitating.
Abdominal pain
***Anorexia, N/V also common.
Laboratory findings of acute pancreatitis include elevation of serum _______ and _______ levels during the first 4-12 hours following the onset of pain. Serum _______ is the most specific and sensitive marker of acute pancreatitis due to its longer elevation for 8-14 days, as serum _______ has a short half-life and may return to normal in 3-5 days.
Amylase
Lipase
Lipase
Amylase
In acute pancreatitis, _______ occurs in 10% of cases, and ________ may result from saponification of necrotic fat.
Glycosuria
Hypocalcemia
Direct visualization of the enlarged inflamed pancreas by ______ scanning is useful in the diagnosis of pancreatitis.
CT
For acute pancreatitis, periumbilical ecchymosis is called _______ _______ and ecchymosis of the flank is called _______ _______ _______. These discolorations are a result of liberated pancreatic enzymes causing the diffusion of fat necrosis and inflammation with retroperitoneal or intraabdominal bleeding.
Cullen’s Sign
Grey Turner’s Sign
For Cullen’s Sign (periumbilical ecchymosis), the diffusion occurs from the retroperitoneum to the umbilicus through the…
Round Ligament
For Grey Turner’s Sign (flank eccymosis) the diffusion occurs from the retroperitoneum to the _________ tissues of the flanks.
Subcutaneous
Cullen’s and Grey Turner’s signs, although not specific, are associated with severe acute pancreatitis and high ________.
Mortality
For acute pancreatitis, the male-to-female ratio is 6:1 in those with _________ and 1:3 in patients with _______ ______ ______.
Alcoholism
Biliary tract disease
These are present in 35-60% of acute pancreatitis cases.
Gallstones
***Can cause “gallstone pancreatitis”
For acute pancreatitis, once tissue damage commences, trypsin can also directly or indirectly activate factors found in the blood, including components of the coagulation, complement, kallikrein, and fibrinolytic pathways. The resulting inflammation and small-vessel _________ causes further damage to ________ cells, amplifying intrapancreatic enzyme activation.
Thrombosis
Acinar
Hereditary factors are increasingly recognized as causes of pancreatitis. The feature shared by most forms of hereditary pancreatitis is a defect that increases or sustains the activity of ________. Affected individuals have recurrent attacks of severe acute pancreatitis, which often begin in childhood, and can ultimately lead to chronic pancreatitis.
Trypsin
This gene will have a protein product of Cystic Fibrosis Transmembrane Conductance Regulator. The function of this is an epithelial anion channel. LOF mutations of it can alter fluid pressure and limit bicarbonate secretion, leading to inspissation of secreted fluids and duct obstruction.
CFTR
This gene will have a protein produce of Serine Protease 1 (Trypsinogen 1). It is a cationic trypsin, and with a GOF mutation it will prevent self-inactivation of the trypsin.
PRSS1
This gene will have a protein product of Serine Peptidase Inhibitor, Kazal Type 1. It is an inhibitor of trypsin, and mutations can cause loss of function resulting in increased trypsin activity.
SPINK1
This gene will have a protein product called Calcium-Sensing Receptor. It is a membrane-bound receptor that senses extracellular calcium levels and controls luminal calcium levels. Mutations may alter calcium concentrations and activate trypsin.
CASR
This gene will have a protein product called Chymotrypsin C (caldecrin). It degrades trypsin and protects the pancreas from trypsin-related injury.
CTRC
This gene will have a protein product called Carboxypeptidase A1, and it is an exopeptidase involved in regulating zymogen activation.
CPA1
The morphology of acute pancreatitis ranges from limited inflammation and edema to extensive necrosis and hemorrhage. The basic alterations are…
1) Microvascular leak and edema
2) Fat necrosis
3) Acute inflammation
4) Autodigestion of pancreatic parenchyma
5) Blood vessel destruction with interstitial hemorrhage
***Extent of these depends on duration and severity of disease!
_______ _______ may also occur in the omentum and the mesentery of the bowel adjacent to the pancreas and beyond the abdominal cavity, such as in the subcutaneous fat, as a result of systemic lipase release.
Fat necrosis
Treatment of acute pancreatitis centers on “resting” the pancreas by total elimination of _______ _______ and supportive therapy with _______ _______ and _______. Most individuals recover fully but about 5% with severe forms die in the first week of illness.
Oral intake
Intravenous fluid
Analgesia
