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7: Digestive System > Chapter 97 Pancreas > Flashcards

Chapter 97 Pancreas Flashcards

1
Q

What % of pancreatic mass is made up of exocrine pancreas?

A

98%

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2
Q

What is the name of the islands of polygonal cells that make up the endocrin epancreas?

A

Islets of Langerhans

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3
Q

What are the fours disctinct cell types within pancreatic islets? What do they each synthesise?

A

Alpha cells –> Glucagon

Beta cells –> Insulin

Delta cells –> Somatostatin

F or PP cells –> Pancreatic polypeptide

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4
Q

Label the diagram

A
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5
Q

What is the innervatioon to the pancreas?

A

Enteric to blood vessels, vagal to acinar and islet cells

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6
Q

What are the anatomic and ‘other’ names for the two canine pancreatic ducts?

Where do they open?

A

Pancreatic ducts aka Duct of Wirsung. Opens at major duodenal papilla

Accessory pancreatic duct aka Duct of Santorini. Opens at minor duodenal papilla

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7
Q

List 2 possible anatomic pancreatic duct variations in dogs.

A

Presence of accessory duct only

Presence of three openings

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8
Q

How does feline pancreatic duct anatomy differ from canine?

A

80% of cats have only pancreatic duct (i.e. only 20% have accessory pancreatic duct)

Conjoined opening of pancreatic duct + CBD at major duodenal papilla.

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9
Q

Briefly decribe effect of insulin on:

Glucose

Fatty acids

Amino acids

A

Promotes intracellular conversion as follows:

Glucose –> glycogen

Fatty acids –> Triglycerides

Amino acids –> Protein

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10
Q

In 1 sentence describe function of glucagon

A

Mobilizes energy stores by increasing glycogenolysis, gluconeogenesis and lipolysis

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11
Q

List 4 ‘digestive’ (i.e. not related to glucose metabolism) functions of pancreas

A
  • Digestive enzymes (as inactive zymogens)
  • Production of co-factors that facilitate absorbtion of cabalamin, zinc and colipase C
  • Secretion of bicarb for neutralization of gastric acid
  • Inhibit bacterial proliferation within duodenum
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12
Q

What does intrinsic factor do?

A

Facilitates absorbtion of cobalamin (B12) in ileum

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13
Q

Describe cycle of trypsinogen in duodenum.

A

Activation of trypsinogen to trypsin by enterokinase (produced by the enterocytes).

Trypsin then converts the other proenzymes to active forms through proteolytic cleavage.

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14
Q

What are the three primary mechanisms for prevention of pancreatic autodigestion?

A
  1. Proteolytic and phospholipolytic enzymes sythesized, stored and secreted as inactive zymogens/pro-enzymes.
  2. Segregated storage of zymogens as membrane bound granules
  3. Acinar cells synthesise pancreatic secretory trypsin inhibitor –> prevents premature activation of pancreatic zymogens
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15
Q

What are the roles of secretin and cholecystekinin?

Where are they secreted from?

A

Secretin –> bicarb-rich fluid secretion

Cholecystekinin –> digestive enzyme secretion (+ gall bladder contraction)

Secreted from duodenal mucosal cells

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16
Q

What is necrotizing pancreatitis characterised by?

A
  • Extensive acinar necrosis
  • Peripancreatic fat necrosis
  • Interstitial microabcess formation
  • Microvascular thrombosis and local haemorrhage
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17
Q

How do alpha 2 agonists affect BG/insulin?

A

Alpha 2 agonists –> hypoinsulinaemia and hyperglycaemia

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18
Q

List 4 methods used for partial pancreatectomy

A
  • Suture fracture
  • Blunt dissection + ligation
  • Vessel sealing devices
  • Stapling
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19
Q

How much of pancreas can be removed without impairment of exocrine or endocrine function (provided remaining duct intact)

A

75-90%!!

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20
Q

List 3 potential complications of pancreaticoduodenectomy

A

EPI

DM

Ulceration

+ usuals

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21
Q

What is most common disease process of exocrine pancreas?

A

Pancreatitis and associated complications (e.g. abcess, pseudocyst)

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22
Q

Define acute panreatitis, acute recurrent pancreatitis and chronic pancreatitis

A
  • Acute pancreatitis:* Inflammation of pancreas that is sudden in onset and reversible
  • Acute recurrent pancreatitis:* Repeated episodes of pancreatic inflammation with no permanent histopathological change.
  • Chronic pancreatits:* Continuous, often sub clinical inflammation of pancreas accompanied by irreversible histological changes that typically include fibrosis and atrophy.
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23
Q

Vomiting is hallmark c/s of pancreatitis in dogs - what % of cats with pancreatitis vomit?

A

40%

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24
Q

What blood work change can be seen wiht necrotizing pancreatitis?

A

Hyperglycaemia

Reportedly due to stress related release of cathecholamines and cortisol –> hyperglucagonaemia

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25
Q

HO ware amylase and lipase excreted?

A

Renal

i.e. any reduction in GFR –> increased values

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26
Q

TLi used for dx of EPI. Why not for panc?

A

Also renally excreted (like amylase and lipase therefore any cause for reduced GFR –> increased value)

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27
Q

What si most sens/spec text for dx of canine pancreatitis?

A

Pancreatic lipase immunoreactivity (cPLI)

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28
Q

What are possible radiographic lesions seen with pancreatitis?

A

Loss of serosal detail R cranial quadrant

Mass effect i.e.

  • widening of angle between pyloric antrum and proximal duodenum
  • L displacement of stomach
  • R displacement of descending duodenum
  • mass effect medial to descending duodenum
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29
Q

What US findings with pancreatitis?

A
  • Hypoechoic pancreas (hyper with fibrosis)
  • Mass lesion in pancreas
  • Hyperechoic surrounding mesentery
    *
30
Q

List 4 indications for surgical intervention in pancreatitis cases

A
  1. Infection
  2. Local complications e.g. biliary obstruction, pancreatic abcess
  3. Confirmation of diagnosis with biopsy
  4. Lack of response to aggressive medical management
31
Q

How should pancreatic abcess be managed (n.b. most veterinary ones are sterile (cf humans)

A

Surgery; partial pancreatectomy, biopsy, provision of drainage, cholecystoenterostomy, duodenal R+A

32
Q

Comment re culture results from oancreatic abcess cases

A

Abcess culture often sterile but abdominal cavity culture positive i.e. submit specimans from multiple sites

33
Q

What radiography sign may be seen with pancreatic abcess?

A

Gas in pancreas

34
Q

What is reported survival following sx for pancreatic abcess?

A

15-50%

35
Q

Define pancreastic pseudocyst

A

Collection of pancreatic secretions and debris within no-epithelialised fibrous sac

36
Q

How is pancreatic pseudocyst diagnosed?

A

US + pancreatic enzyme concentration of cyst fluid > serum

37
Q

where are the majority of pancreatic pseudocyst located?

A

L limb

38
Q

List 3 tx options for pancreatic pseudocyst

What was overall survival (caes treated by any of the 3 methods)

A

Monitor for a few weeks - may resolve spontaneously

US guided aspiration

Sx if above fail or patient worsens

75% survival

39
Q

In what part of pancreas has torsion been reported?

A

L limb in puppy

40
Q

What is most common tumour of exocine pancreas?

A

Carcinoma

41
Q

What paraneoplastic sign has been reported in cats with pancreatic carcinoma?

A

Alopecia

42
Q

On contrast enhanced ultrasonography, how does pancreatitis differ from pancreatic carcinoma from insulinoma?

A

Pancreatitis: Delayed peak perfusion and prolonged enhancement

Pancreatic carcinoma: Hypoechoic and hypovascular lesions

Insulinoma: Uniformly hypervascular

43
Q

Where do pancreatic carcinomas commonly metastasize to?

A

Liver and LNs

44
Q

What % of insulinaomas are carcinoma vs adenoma?

A

60% carcinoma, 40% adenoma

45
Q

What % of insulinoma dogs ahve metastasis at timem of diagnosis?

Where to usually?

A

50%

Liver + LNs

46
Q

Bwloe what BG level is insulin secretion usually inhibited?

A

< 80 mg/dL (= 4.4 mmol/L)

47
Q

In insulinoma cases, name a common association (in terms of history) with hypoglycaemic episodes

A

Often precipitated by excitement, exercise or fasting

48
Q

Name a PE finding that may be related to chronic hypoglycaemia /9i.e. in insulinoma)

A

Peripheral neuropathy

49
Q

How is insulinoma diagnosed?

A

Serum insulin measurmement during period of hypoglycaemia. If insulin high or normal = highly siggestive of insulinoma

Can also get idea from fructosamine

50
Q

HOw does insulinoma cytology differ from normal exocrine pancreatic cytology?

A

Insulinoma cells lack the pink zymogen granules seen in cytoplasm of pancreatic exocrine cells

51
Q

What type of CT should be used for dx insulinoma

A

Dual phase angiography

52
Q

What radioisotpe is used for scintigraphy in insulinoma?

A

Radio-labelled somatostatin

53
Q

List 2 pre-op management treatements for insulinoma

A

Glucocorticoid –> increased hepatic glucose production and decreases cellular glucose uptake

Regular small meals

Small pre-GA meal 2-3 hour before

(CRI glucagon if intractable hypoglycaemia)

54
Q

What % of insulinoma odgs have a solitary nodule?

A

80%

55
Q

What factor was associated with shorter sx and hospitalisation time for sx treatment of insulinoma

A

Use of vessel sealing device (rather than suture fracture technique).

N.B. vessel sealing device did not –> clinical signs of pancreatitis

56
Q

What additional procedure shoudl be carried out with insulinoma excision?

A

LN and liver biopsy.

57
Q

If primary insulinoma lesioon cannot be identified, what can be doen to aid localisation?

When is maximal staining achieved?

A

IV methylene blue

(3 mg/kg of 1% methylene blue diluted in 250 ml in sterile saline, administered over 30 mins)

Maximal staining 30 mins after administration

58
Q

What is a potential complication of methylene blue administration

A

Heinz body anaemia

59
Q

How can persistent hypoglycaemia (following insulinoma sx) be managed?

What were 2 most common side effects?

A

Streptozocin (a nitrosourea abx) selectively destroys beta cells in the pancreas and at metastatic sites.

  • Give with saline as risk nephrotoxicity
  • S/e: GI toxicity 60% and DM 40%
60
Q

What was median duration of normoglycaemia and survival time in insulinoma dogs treated with streptozocin (for hyperglycaemia after insulinoma sx)?

A

median normoglycaemia 160 d

MST 300 d

61
Q

Name 4 potential drugs for use in persistent/recurrent hyperglycaemia due to insulinoma

A
  • Streptozocin: selectively destroys beta cells in the pancreas and at metastatic sites
  • Glucocorticoids: –> increased hepatic glucose production and decreases cellular glucose uptake
  • Diazoxide (benzothiadiazine derivative –> inhibits insulin secretion, stimulated hepatic gluconeogenesis and glycogenolysis and inhibits ude of glucose)
  • Octreotide (Long acting somatostatin analogue –> inhibits insulin synthesis and secretion)
62
Q

What was median euglycaemia period for dog with vs without mets at time of sx?

And MST mets vs no mets

A

Euglycaemia:

  • Mets 2.5 months
  • No mets: 14 months

MST:

  • Mets 7-9 months
  • No mets 2-4 years
63
Q

What 3 factors were associated with poor prognosis in insulinoma cases?

A
  • Tumours >2cm
  • LN and liver mets
  • Ki76 index >2.5%
64
Q

Aside from insulinoma, name 2 other tumours of endocrine pancreas

A

Gastrinoma

Glucagonoma

65
Q

What is the dyndome name for

Non-beta cell neuroendocrine tumour in pancreas

+

Hypergastrinaemia

+

GI ulceration

A

Zollinger-Ellison syndrome

66
Q

Aside from pancreas - where else can gastrinomas arise from?

A

Duodenum, mesentery, peripancreatic LNs

67
Q

What is met rate for gastrinoma?

A

70%

68
Q

What % of gastrinoma patients have GI ulceration?

A

80%

69
Q

What biochemical value is highly suggestive of gastrinoma?

A

Increased fasting serum gastrin concentration

(especially with gastric hyperacidity pH <3)

Lesion usualy v small so may not be visible on imaging. Histo for definitive dx.

70
Q

What paraneoplastic syndrome is associated with glucagonoma?

What are c/s of this?

What is typical histo finding?

A

Superficial necrolytic dermatitis (also associated with advanced liver disease = hepatocutaneous syndrome)

C/s: Erythema, ulcerations, excoriations, foot pad hyperkeratosis, foot pad fissures, skin thickening/crusting

Histo: red, white, blue.

Upper layer—the stratum compactum—appearing red

Middle layer of ballooning degeneration in the stratum spinosum appearing white

Lower layer of hyperplastic basal cells of the epidermis appearing blue.

71
Q

How is glucagonoma diagnosed?

A

increased serum glucagon concentration or histo (IHC positive for glucagon)

Tx = surgery but prognosis poor

7: Digestive System (12 decks)

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