Chapter 20: Pancreatic Flashcards by Lisa Conticello

The pancreas is located in the abdomen, behind the _________

Stomach

How well did you know this?

Not at all

Perfectly

Endocrine pancreatic cells produce these 2 hormons

Insulin & glucagon

How well did you know this?

Not at all

Perfectly

Exocrine pancreatic cells produce _______ to neutralize stomach acid & ________ enzymes

Bicarbonate
Digestive (lipase, amylase, protease)

How well did you know this?

Not at all

Perfectly

What does Trypsin & Chymotrypsin do?

Break down proteins into amino acids

How well did you know this?

Not at all

Perfectly

What is the ampulla of vater?

The emptying point of bile& pancreatic juices into the small intestine (duodenum)

How well did you know this?

Not at all

Perfectly

The majority of pancreatic cancers arise from the _______ cells, making this called __________

Exocrine cells
Adenocarcinoma

How well did you know this?

Not at all

Perfectly

7% of pancreatic cancers arise from the ____________ cells, the most common being ___________

Endocrine
Pancreatic neuroendocrine

How well did you know this?

Not at all

Perfectly

Pancreatic adenocarcinoma is AKA

Ductal cell carcinoma or ductal adenocarcinoma

How well did you know this?

Not at all

Perfectly

These are nonmalignant tumors of the pancreas that require a similar treatment d/t the location

“Cyst” or “Pseudo” neoplasms

How well did you know this?

Not at all

Perfectly

7 risk factors for pancreatic adenocarcinoma

Smoking
Obesity
Family history
Chronic pancreatitis
DM
Heavy drinking (limited evidence)
Poor diet (saturated fat, fructose)

How well did you know this?

Not at all

Perfectly

This marker is elevated in most patients with pancreatic cancer

CA 19-9

(Carbohydrate antigen 19-9)

How well did you know this?

Not at all

Perfectly

Pancreatic tumors are divided into these 3 categories and this is often the staging method:

Resectable (potentially curable)
Bordeline resectable (potentially curable) - requires neoadjuvant chemo
Unresectable (locally advanced or metastatic)

How well did you know this?

Not at all

Perfectly

Why isn’t traditional staging method used for pancreatic tumors?

Requires surgery to determine, thus defining it by resectability is typically used

How well did you know this?

Not at all

Perfectly

T/F: Systemic therapy is used with all stages of pancreatic cancer

True

*if radiation is given, it’s typically given with

How well did you know this?

Not at all

Perfectly

When might single chemo agents be used with pancreatic cancer? (Rather than combo)

Poor performance status

How well did you know this?

Not at all

Perfectly

Combo therapy for pancreatic cancer w/ patients that have good performance status

FOLFIRINOX

fluoroacil, leucovorin, irnotecan, oxaliplatin

How well did you know this?

Not at all

Perfectly

A total of ______ months of systemic treatment (for pancreatic cancer- before after or both from surgery) is recommended

How well did you know this?

Not at all

Perfectly

Adjuvant chemotherapy should commence within ______ weeks post-op, specifically for pancreatic cancer

8-12 weeks

How well did you know this?

Not at all

Perfectly

Pancreatic tumors found in the _______ or _____ may require pts may be asked to come to treatment on an empty stomach, then drink a specific volume of fluid to aid in mimicking simulation anatomy

Body
Tail

How well did you know this?

Not at all

Perfectly

Concurrent chemoRT typically includes 1 of the following 3 chemo agents

Fluorouracil
Capectiabine
Gemecitabine

How well did you know this?

Not at all

Perfectly

3 surgeries for resectable pancreatic cancer

Whipple (pancreaticoduodenectomy (PD),
pylorus preserving pancreaticodueodenectomy (PPPD), distal pancreatectomy

How well did you know this?

Not at all

Perfectly

PPDD doesn’t modify any of the _______

stomach

How well did you know this?

Not at all

Perfectly

5 organs removed w/ whipple

Head of pancreas
Duodenum
Distal stomach (pylorous)
Bile duct
Gallbladder (sometimes saved)

How well did you know this?

Not at all

Perfectly

5 side effects of Whipple

PEI
DM
Lactose intolerence
Dumping syndrome
Delayed gastric emptying

How well did you know this?

Not at all

Perfectly

What is NOT a side effect or PPPD

Dumping syndrome

These are the 2 main side effects of distal pancreatectomy

PEI, DM (no GI issues)

Why may you see jaundice w/ pancreatic cancer?

If the head of the pancreas obstructs the bile duct

Why may the hallmark sign of pancreatic insufficiency (loose or frequent BMs) be masked with pancreatic cancer?

Narcotics ghat slow gut motility

Are tests or judgment better indicators of PEI?

Judgement/clinical signs the tests often underdiagnose and are expensive

What are some tests that may be used to diagnose PEI?

Fecal elastase - most common Fecal chymotrypsin Fecal fat excretion Coefficient of fat absorption Carbon 13- labeled mixed tryglyceride breath test

Signs of PEI

Excess gas Abdominal bloating Cramping after meals Stool changes (oily/foamy, frequent, floating, clay colored, loose) Smelly gas Unexplained wt loss

What are pancreatic enzyme main ingredient

Pancrealipase

The most common dosing of PERT is ________- based

Meal

May dose of pancreatic enzymes (per day and per meal)

2,500 g/kg lipase units per meal (4x/day) 10,000 g/kg lipase units per day

Starting dose for PERT

1-3 capsules with meals and snacks 10,000-15,000 lipase units per capsule

6 steps for optimizing PERT if initial dose doesn't work

1. Acid-reducing therapy (H2 or PPI) 2. Educate to space with meals 3. Increase dosage 4. Open capsules or change to non-enteric coated tablet 5. Change brand 6. Consider other issues (i.e. lactose intolerence, c diff)

Fat-based dosing for pancreatic enzymes

500-1000 per g fat No more than 4000 per g fat

Do not sprinkle pancreatic enzymes or acidic or basic foods? What PH?

Basic, nothing with ph> 4 (like milk)

Regardless of the indication, those with suspected or known PEI on EN should be placed on a ___________ formula, high in _________

Semi-elemental MCT *severe PEI may still require PERT

PERT with EN frequency

q3 hours for continuous with each feeding for gravity/bolus

How to deliver PERT through feeding tube

If you have a large bore feeding tube, put the microspheres in a thickened acidic liquid For small bore or j tube, crush and dissolve w/ bicarb

Studies in humans with ___________ condition demonstrate that in-line digestive cartridges (like Relizorb) may help enhance lipid absorption

Cystic fibrosis

Fat restriction recommendation for severe steatorrhea

Possible use/benefit of MCT oil?

For those having difficulty consuming adequate kcal d/t fat intolerance. Do not require enzymatic action or bile salts for digestion & absorption. Not very palatable PO, but coconut oil may be a good substitution. MCT shouldnt be the ONLY form of fat though d/t risk for essential FA deficiency

Liberalize A1c goal for those with progressive pancreatic cancer or advanced disease to

What is the ligament of trietz?

separation between the duodenum & jejunum

Gastric outlet obstruction is AKA

Duodenal obstruction

What is gastric outlet obstruction? How is it treated?

When the pancreatic tumor evades the duodenum. Surgery is needed to create a bypass Other options include a duodenal stent or g tube for drainage. J tube for feeding may be placed at the same time

Difference between gastric outlet obstruction and small bowel obstruction?

Small bowl = beyond ligament of trietz Gastric outlet = duodenum

MNT for duodenal stent & vented g tube

Liquids then low fiber foods chewed very well. Plenty of liquid with meals *some institutions will require blended foods before progressing to solids likely also need laxatives to prevent obstruction

What is serum ascites albumin gradient? (SAAG)

Used to determine the etiology of ascites. If high (>/= 1g/dL), no-salt-added diet may be appropriate

Kcal recommendations for pancreatic cancer pre & post op

25 kcal/kg 30 kcal/kg

EN vs PO post-pancreatic surgery

Really depends on the surgeon but no evidence found to support use of EN - PO is preferred

Immunonutrition w/ pancreatic cancer surgery?

Likely benefit found on outcomes with these products

Diet progression post-whipple

Low fat/fiber ~1-2 weeks post op Regular ~4-8 weeks, low fat if needed

Should you drink fluid with or without meals for delayed gastric emptying?

With do the opposite w/ dumpong

MNT for delayed gastric emptying

Low fat, low fiber liquid with meals 6-8 eating occasions/day good BG control potential nutrition support potential liquid diet prokiniteic agents (metoclopramide, erythromycin)

Recommendations for absorptive fiber

psyllium or methyllcellulose take after a meal avoid drinking fluid x1 hour start 1x/day and increase to 4 if needed

Pain control using a Celiac Plexus Block may cause _______

diarrhea

If bile acid-related diarrhea is present, _______ medication may be beneficial

Cholestyramine (bile acid sequestrant)

Postoperative pancreatic fistula is the leakage of _______ into the ________

Pancreatic fluid into the abdomen **oral intake is usually fine, doesn't increase stimulation of the pancreas EN > PN

Define chyle leak

Output of milky colored fluid from wound or drain and into the pleural (lung) space It's high in trigycerides and requires a diet low fat/fat free, possibly with MCT

Do parenterally administered fats contribute to chyle leak?

What are 3 long term side effects of pancreatic cancer survivors?

-Micronutrient deficiencies (pert needs to be optimize to best utilizie micronutrients) -Decreased bone density -hepatic steatosis (NAFLD) - unknown etiology. PERT may help treat

Where in the body is calcium absorbed?

Duodenum