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Additional CSO Cards > Chapter 20: Pancreatic > Flashcards

Chapter 20: Pancreatic Flashcards

1
Q

The pancreas is located in the abdomen, behind the _________

A

Stomach

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2
Q

Endocrine pancreatic cells produce these 2 hormons

A

Insulin & glucagon

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3
Q

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

A

Bicarbonate
Digestive (lipase, amylase, protease)

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4
Q

What does Trypsin & Chymotrypsin do?

A

Break down proteins into amino acids

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5
Q

What is the ampulla of vater?

A

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

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6
Q

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

A

Exocrine cells
Adenocarcinoma

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7
Q

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

A

Endocrine
Pancreatic neuroendocrine

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8
Q

Pancreatic adenocarcinoma is AKA

A

Ductal cell carcinoma or ductal adenocarcinoma

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9
Q

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

A

“Cyst” or “Pseudo” neoplasms

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10
Q

7 risk factors for pancreatic adenocarcinoma

A

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

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11
Q

This marker is elevated in most patients with pancreatic cancer

A

CA 19-9

(Carbohydrate antigen 19-9)

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12
Q

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

A
  1. Resectable (potentially curable)
  2. Bordeline resectable (potentially curable) - requires neoadjuvant chemo
  3. Unresectable (locally advanced or metastatic)
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13
Q

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

A

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

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14
Q

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

A

True

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

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15
Q

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

A

Poor performance status

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16
Q

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

A

FOLFIRINOX

fluoroacil, leucovorin, irnotecan, oxaliplatin

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17
Q

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

A

6

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18
Q

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

A

8-12 weeks

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19
Q

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

A

Body
Tail

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20
Q

Concurrent chemoRT typically includes 1 of the following 3 chemo agents

A

Fluorouracil
Capectiabine
Gemecitabine

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21
Q

3 surgeries for resectable pancreatic cancer

A

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

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22
Q

PPDD doesn’t modify any of the _______

A

stomach

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23
Q

5 organs removed w/ whipple

A

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

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24
Q

5 side effects of Whipple

A
  1. PEI
  2. DM
  3. Lactose intolerence
  4. Dumping syndrome
  5. Delayed gastric emptying
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25
Q

What is NOT a side effect or PPPD

A

Dumping syndrome

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26
Q

These are the 2 main side effects of distal pancreatectomy

A

PEI, DM

(no GI issues)

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27
Q

Why may you see jaundice w/ pancreatic cancer?

A

If the head of the pancreas obstructs the bile duct

28
Q

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

A

Narcotics ghat slow gut motility

29
Q

Are tests or judgment better indicators of PEI?

A

Judgement/clinical signs

the tests often underdiagnose and are expensive

30
Q

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

A

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

31
Q

Signs of PEI

A

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

32
Q

What are pancreatic enzyme main ingredient

A

Pancrealipase

33
Q

The most common dosing of PERT is ________- based

A

Meal

34
Q

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

A

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

35
Q

Starting dose for PERT

A

1-3 capsules with meals and snacks

10,000-15,000 lipase units per capsule

36
Q

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

A
  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)
37
Q

Fat-based dosing for pancreatic enzymes

A

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

38
Q

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

A

Basic, nothing with ph> 4 (like milk)

39
Q

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

A

Semi-elemental
MCT

*severe PEI may still require PERT

40
Q

PERT with EN frequency

A

q3 hours for continuous
with each feeding for gravity/bolus

41
Q

How to deliver PERT through feeding tube

A

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

42
Q

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

A

Cystic fibrosis

43
Q

Fat restriction recommendation for severe steatorrhea

A

</= 75 g/day

44
Q

Possible use/benefit of MCT oil?

A

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

45
Q

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

A

</= 8%

CHO control and A1c </= 7% is more appropriate for those post-treatment

46
Q

What is the ligament of trietz?

A

separation between the duodenum & jejunum

47
Q

Gastric outlet obstruction is AKA

A

Duodenal obstruction

48
Q

What is gastric outlet obstruction? How is it treated?

A

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

49
Q

Difference between gastric outlet obstruction and small bowel obstruction?

A

Small bowl = beyond ligament of trietz

Gastric outlet = duodenum

50
Q

MNT for duodenal stent & vented g tube

A

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

51
Q

What is serum ascites albumin gradient? (SAAG)

A

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

52
Q

Kcal recommendations for pancreatic cancer pre & post op

A

25 kcal/kg
30 kcal/kg

53
Q

EN vs PO post-pancreatic surgery

A

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

54
Q

Immunonutrition w/ pancreatic cancer surgery?

A

Likely benefit found on outcomes with these products

55
Q

Diet progression post-whipple

A

Low fat/fiber ~1-2 weeks post op

Regular ~4-8 weeks, low fat if needed

56
Q

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

A

With

do the opposite w/ dumpong

57
Q

MNT for delayed gastric emptying

A

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)

58
Q

Recommendations for absorptive fiber

A

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

59
Q

Pain control using a Celiac Plexus Block may cause _______

A

diarrhea

60
Q

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

A

Cholestyramine (bile acid sequestrant)

61
Q

Postoperative pancreatic fistula is the leakage of _______ into the ________

A

Pancreatic fluid into the abdomen

**oral intake is usually fine, doesn’t increase stimulation of the pancreas

EN > PN

62
Q

Define chyle leak

A

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

63
Q

Do parenterally administered fats contribute to chyle leak?

A

No

64
Q

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

A

-Micronutrient deficiencies (pert needs to be optimize to best utilizie micronutrients)

-Decreased bone density

-hepatic steatosis (NAFLD) - unknown etiology. PERT may help treat

65
Q

Where in the body is calcium absorbed?

A

Duodenum

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