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Chapter 14 Flashcards

1
Q

From which two endodermal tissues does the pancreas develop?

When in development does this begin?

A

Dorsal and ventral pancreatic buds

4th wk of gestation

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2
Q

Position of the pancreas

A

Lies retroperitoneal, posterior to the stomach at the level of the first and second lumbar vertebrae

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3
Q

Composition of the pancreas

A 
Head
Uncinate process
Neck
Body
Tail
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4
Q

Position of head of the pancreas

A

Rests within the C-loop of the duodenum to the right of the midline

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5
Q

Uncinate process

A

An inferior projection of the head, which curves posterior to the superior mesenteric vessels and anterior to the IVC

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6
Q

Neck of the pancreas

A

The portion of the pancreas that lies anterior to the portal vein and superior to mesenteric vessels

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7
Q

Body of the pancreas

A

To the left of the mesenteric vessels

Lies superior to the fourth portion of the duodenum and forms the floor of the lesser sac

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8
Q

Tail of the pancreas

A

The smallest portion of the pancreas

Lies in proximity to the splenic hilum

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9
Q

Blood supply of head and uncinate process

A

Vast majority is supplied by anterior and posterior superior and inferior pancreaticoduodenal arteries

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10
Q

Superior pancreaticoduodenal artery branches

A

Branches off the gastroduodenal artery, which emanates from the celiac axis

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11
Q

Inferior pancreaticoduodenal artery pathway

A

Arises from the SMA

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12
Q

Blood supply to body and tail of the pancreas

A

Branches of the splenic and left gastroepiploic arteries supply the distal body and tail of the pancreas
Within the posterosuperior and posteroinferior aspect of the body of the pancreas lie the superior and inferior pancreatic arteries, respectively

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13
Q

Venous drainage of the pancreas

A

Parallels its arterial supply
All drainage ultimately enters the portal vein, which is formed posterior to the neck of the pancreas by the confluence of the splenic and SMVs

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14
Q

Sympathetic pathway of the pancreas

A

Preganglionic sympathetic axons arise from cell bodies withint he thoracic sympathetic ganglia and travel as splanchnic nerves terminating within the celiac ganglia
Postganglionic sympathetic fibers traverse retroperitoneal tissue to innervate the pancreas and serve as the principal pathways for pain of pancreatic origin

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15
Q

Parasympathetic innervation

A

Preganglionic fiber cell bodies that reside within the vagal nuclei and travel through the posterior vagal trunk.
These axons traverse the celiac plexus and terminate in parasympathetic ganglia within the pancreatic parenchyma
Short postganglionic parasympathetic fibers then innervate the pancreatic islets, acini, and ducts, serving an exclusively efferent function

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16
Q

What are the two general categories of cellular components of the pancreas?

A

Exocrine

Endocrine

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17
Q

What are the primary exocrine units of the pancreas?

A

Acinar cells

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18
Q

How are acinar cells connected?

A

Connected to each other by a network of tubules and ducts, which eventually drain into the duodenum

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19
Q

Types of islet cells

A

Alpha
Beta
Delta

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20
Q

What does each islet consist of?

A

A core composed of beta cells

A peripheral mantle composed of alpha, delta, and pancreatic polypeptide cells

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21
Q

How much does the exocrine pancreas produce?

A

Up to 20 g of digestive enzymes and 2.5 L of bicarb-rich fluid each day.

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22
Q

Purpose of the acinar cells

A

Responsible for the production of enzymes

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23
Q

Purpose of the ductal cells

A

Secrete fluid and electrolytes under both vagal and humoral control

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24
Q

Sodium and potassium concentrations and exocrine physiology

A

Remain constant and are approximately equivalent to plasma concentrations

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25
Anion concentration of pancreatic exocrine secretion
Dependent on secretory rate
26
What is the most potent endogenous stimulant of pancreatic bicarb secretion?
Secretin
27
Where is secretin synthesized?
In the mucosal S cells of the crypts of Lieberkuhn of the proximal small bowel and is released int he presence of luminal acid and bile
28
Physiology of secretin
Circulates in the blood and binds to secretin receptors on pancreatic ductal cells, effecting signal transduction through the intracellular adenylate cyclase system The resultant bicarb secretion serves to neutralize stomach acid that enters the duodenum
29
What are the other components of exocrine pancreatic juice?
Digestive enzymes, which aid in amino acid, lipid, and complex carbohydrate breakdown
30
What are the three phases of the contribution of the pancreas to digestion?
Cephalic phase Gastric phase Intestinal phase
31
Cephalic phase
Stimuli (smell and taste) activate vagal efferent signals, which stimulate pancreatic enzyme release The net effect of cephalic phase stimulation is the secretion of an enzyme-rich, bicarb-poor fluid
32
Gastric phase
Antral distention and protein delivery stimulate the release of gastrin Gastrin promotes gastric acid secretion from parietal cells and also serves as a weak stimulant for pancreatic enzyme secretion Acidification of the duodenum in turn leads to secretin release, which stimulates pancreatic bicarb secretion.
33
Intestinal phase
Secretin and CCK serve a major function in mediating pancreatic exocrine secretion Duodenal acid and bile stimulate secretin release, in turn stimulating pancreatic bicarb secretion from ductal cells Duodenal fat and protein stimulate CCK release, stimulating the secretion of pancreatic enzymes from acinar cells
34
General purpose of endocrine cells
Whole body metabolism and energy utilization
35
Endocrine hormone associated with alpha cells
Glucagon
36
Primary functions of alpha cells
Glycogenolysis Gluconeogenesis Lipolysis Increase blood sugar
37
Endocrine hormone associated with beta cells
Insulin
38
Primary functions of beta cells
Glucose uptake at cellular level | Protein synthesis
39
Endocrine hormone associated with delta cells
Somatostatin
40
Primary functions of delta cells
General inhibitor of acid production, pancreatic and biliary secretion Helps regulate pancreatic endocrine function in a paracrine manner
41
Characteristics of acute pancreatitis
Diffuse inflammation of the pancreas and encompasses a wide spectrum of clinical dz
42
_____ of cases of acute pancreatitis resolve without complications
80%
43
Complications of acute pancreatitis
``` Hemorrhage Pancreatic necrosis Infection Shock Multisystem organ failure ```
44
Goals of management of acute pancreatitis
Early dx Supportive therapy Tx of the underlying cause
45
Presentation of acute pancreatitis
Sudden onset of epigastric pain that radiates to the back, usually accompanied by nausea and vomiting
46
PE of acute pancreatitis
Epigastric tenderness Retroperitoneal hemorrhage may manifest as Turner's sign (flank ecchymosis), Cullen's sign (periumbilical ecchymosis), or Fox's sign (ecchymosis below the inguinal ligament and/or involving the scrotum) Left pleural effusion may be present
47
A systemic inflammatory response in acute pancreatitis may lead to...
Tachycardia Edema Hypovolemic shock
48
Causes of early complications of acute pancreatitis
Usually related to massive fluid sequestration
49
Early complications of acute pancreatitis
Pulmonary edema Circulatory collapse Renal failure
50
Causes of late complications of acute pancreatitis
Infection or hemorrhage
51
What are the vast majority of causes of acute pancreatitis?
Gallstones or alcohol
52
What types of gallstones are likely to lead to acute pancreatitis?
Small stones <5 mm
53
Pathophysiology of acute pancreatitis
Autodigestion and inflammation caused by unregulated release of pancreatic enzymes within the organ
54
What are the end points of acute pancreatitis?
Organ edema Peripancreatic inflammation with severe fluid loss Multiorgan dysfunction secondary to circulating toxins
55
What are the primary diagnostic markers of pancreatitis?
Amylase and lipase
56
Difference between amylase and lipase in pancreatitis
Amylase levels peak early in the dz process and do not stay elevated beyond 5 days of ongoing inflammation Lipase peaks later, but remains elevated for a longer period of time
57
Imaging in pancreatitis-plain films
May show a dilated, air-filled duodenal loop in the RUQ, focal jejunal ileus (sentinal loop sign), or transverse colonic ileus (colon cutoff sign)
58
Imaging in pancreatitis-abdominal u/s
Sensitivity is as low as 70%
59
What is the imaging modality of choice for pancreatitis?
CT scan- computerized with contrast
60
What are some contemporary systems for grading pancreatitis?
``` APACHE II Sequential Organ Failure Assessment (SOFA) Marshall Balthazar score Atlanta classification ```
61
Tx of mild acute pancreatitis
Aggressive fluid resuscitation with crystalloid solution | Correction of metabolic and electrolyte derangements
62
Tx of mild-moderate acute pancreatitis
In initial phase, restriction of oral intake Consider nasogastric tube placement for ileus Supplementary nutrition if prolonged inflammation or complications H2 receptor antagonists or antacids for prophylaxis against upper GI tract hemorrhage in critically ill pts
63
When is early cholecystectomy recommended for pancreatitis?
In all cases of gallstone pancreatitis and most cases of idiopathic pancreatitis
64
What may be definitive therapy for pts considered too infirm to tolerate cholecystectomy for pancreatitis?
ERCP
65
Tx of severe acute pancreatitis
Fluid resuscitation Apply a low threshold for invasive monitoring Antibiotic therapy if infected pancreatic necrosis is strongly suspected or documented
66
Antimicrobials effective for acute pancreatitis
``` Imipenem 3rd gen cephalosporins Piperacillin Mezlocillin FQs Metronidazole ```
67
Three life-threatening infectious complications of acute pancreatitis
Pancreatic abscess Infected pancreatic pseudocyst Infected pancreatic necrosis
68
Cause of pancreatic infection
Most are polymicrobial and may arise from transmural migration of bacteria from adjacent inflamed bowel or from hematogenous seeding
69
Who is susceptible to fungal superinfection?
Pts subjected to long courses of powerful antibiotics
70
When should one suspect septic complications in pancreatic infection?
In pts with severe pancreatitis Documented bacteremia Clinical deterioration Failure of resolution of pancreatitis within 7-10 days
71
Clinical manifestations of pancreatic infection
Fever Tachycardia Abdominal pain Abdominal distention

Surgery (30 decks)

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