Disorders of the Pancreas Flashcards
Where is the pancreas?
Retroperitoneal behind the stomach
How and where does the pancreas enter the duodenum?
Forms the hepatopancreatic ampulla/ampulla of vater with the bile duct, which is separated from the duodenum by the sphincter of Oddi.
What are the exocrine enzymes released by the pancreas and the endocrine hormones?
- Exocrine: protease, lipase, amylase
- Endocrine: Glucagon and insulin
3 components of the Islets of Langerhans
- Alpha: glucagon
- Beta cells: insulin (MC cell type)
- Delta cells: somatostatin (inhibits insulin, increases glucagon secretion)
What do acinar cells secrete?
- Proteases = protein
- Lipases = triglycerides
- Amylase = carbs
- Epithelial cells: Bicarb = neutralize acid
MCC of GI-related hospitalization
Acute pancreatitis
MCC of acute pancreatitis
- Gallstone
- Heavy alcohol intake (more than just a binge)
Drinking what can reduce the risk of non-biliary pancreatitis?
Caffeine
3 components of the pathophysiology of acute pancreatitis
- Edema/obstruction at ampulla, causing bile reflux
- Premature/overactivation of enzymes
- Autodigestion (early activation of enzymes)
3 phases of acute pancreatitis
- Initial phase: activation of enzymes
- Second phase: activation of leukocytes and macrophages
- Third phase: Activated proteolytic enzymes and cytokines
What characterizes the beginning of gallstone induced acute pancreatitis?
Gallstone blocks the ampulla but you are still making enzymes
What happens as pancreatic enzymes buildup during gallstone blockage in acute pancreatitis?
Microvascular injury leading to inflammatory mediator release and damage.
Classic presentation of acute pancreatitis
- Epigastric abdominal pain radiating to the back that improves when leaning forward.
- N/V
- Weakness, sweating, anxiety
What would cause jaundice in acute pancreatitis?
If it is at the ampulla of Vater
What are the PE signs for acute pancreatitis?
- Cullen’s sign: bruising of the periumbilical region
- Grey Turner sign: bruising of the flanks
Grey Turner = 2 words = 2 flanks
Both suggest presence of retroperitoneal bleed
What are the two classifications of acute pancreatitis?
- Acute interstitial edematous pancreatitis
- Necrotizing acute pancreatitis
What is the most sensitive test for acute pancreatitis?
Serum Lipase (3x ULN)
Which serum lab rises sooner in acute pancreatitis?
Serum lipase
Elevation of what labs might suggest biliary pancreatitis?
ALT/AST/ALP
Is imaging needed for diagnosis of acute pancreatitis?
Nope if labs are abnormal
What XRAY signs might be seen in acute pancreatitis?
- Sentinel Loop: Dilated air filled SI near pancreas
- Colon cut-off sign: gas filled segment of transverse colon abruptly ends at pancreas.
What imaging modality is generally not that helpful in acute pancreatitis?
US unless looking for a gallstone specifically.
What are the essentials of diagnosing acute pancreatitis?
- Abrupt onset of deep, epigastric pain that radiates to the back
- Hx of previous episodes, often related to alcohol intake
- N/V, sweating, and weakness
- ABd tenderness, fever, and distention
- Serum amylase/lipase and leukocytosis
If imaging is used to help diagnose acute pancreatitis, which scan will be diagnostic?
Abd CT w/o con
What is the primary criteria we use for acute pancreatitis?
Ranson’s criteria
What are the 5 prognostic signs for Ransons on admission?
- Age > 55
- BG > 200
- LDH > 350
- AST > 250
- WBC > 16k
3+ = severe course
What are the 6 ranson’s signs we obtain within 48 hours of admission?
- HCT decrease by 10%
- BUN increases by 5+
- Serum calcium < 8
- PaO2 < 60
- Base deficit > 4
- Estimated fluid sequestration > 6L
What is the BISAP scale?
- BUN > 25
- Impaired mental status
- Systemic inflammatory response syndrome (SIRS)
- Age > 60
- Pleural effusion
3+ = high chance of mortality
Tx of mild acute pancreatitis
- Admit
- Rest pancreas
- NPO + NG tube + fluids
- IV analgesia with meperidine (TOC)
- IV antiemetics
- Bed rest
- Cholecystectomy if gallstone induced
3 days to resolve generally
Tx of severe acute pancreatitis
- ICU
- Massive fluid resus (6-8L)
- Enteral feeding if pt cant eat for 5 days or more
- ABX (imipenem) only if abscess present
What is the role of CT in severe acute pancreatitis?
Looking for associated complications
Complications of acute pancreatitis
- Pancreatic abscess
- Acute peripancreatic fluid secretion
- Pancreatic pseudocyst
Presence of what two things on CT suggest increased mortality in acute pancreatitis?
- Peripancreatic fluid = +10%
- Necrotizing pancreatitis = +30%
What is the MCC of chronic pancreatitis?
Alcohol
In children, what is the MCC of chronic pancreatitis?
Cystic fibrosis
What happens to the pancreas in chronic pancreatitis?
Persistent inflammation leading to permanent damage.
MC clinical presentation of chronic pancreatitis?
- LLQ pain after eating
- malabsorption
- Intermittent acute attacks
- 65% of patients have osteopenia or osteoporosis
MC reason to hospitalize chronic pancreatitis
Increase in pain
MC scan used to diagnose chronic pancreatitis
CT
What is the most sensitive imaging modality for imaging the pancreatic duct?
ERCP
Non-pharm tx of chronic pancreatitis
- Low fat
- Avoid alcohol
- Avoid opioids or aspirin
- Enzymes
- Insulin
- Treatment of any primary malabsorptive condition
What are the invasive therapies for chronic pancreatitis?
- Puestow procedure: Fileted open pancreas
- Whipple procedure
- Stimulators
Where are most carcinomas of the pancreas found and what are the main types?
In the head, made of adenocarcinomas
An older patient develops new onset DM. What must always be in the DDx?
Pancreatic cancer
What is the greatest risk factor for pancreatic cancer?
Smoking
What is the clinical presentation of pancreatic cancer?
- Vague epigastric pain with radiation to the back
- Acute pancreatitis without an identifiable cause
What is courvoisier’s sign?
Painless jaundice and enlarged palpable gallbladder from tumor blocking common bile duct.
What is the hard periumbilical nodule called when it is palpable?
Sister Mary Joseph nodule
What is the first-line study to look for pancreatic cancer?
CT
What is the second-line imaging if CT is inconclusive for pancreatic cancer?
ERCP showing simultaneous dilation of pancreatic and common bile duct
When is open surgical exploration indicated in pancreatic cancer?
Unable to get CT guided or ERCP guided biopsies.
How is pancreatic cancer staged?
TNM
How does surgery happen in pancreatic cancer treatment?
- Exploratory/staging laparoscopy
- Whipple procedure (radical pancreaticoduodenal resection)
What does the whipple procedure remove?
- Pancreatic head
- Duodenum
- 15cm of jejunum
- Common bile duct
- Gall bladder
- Partial gastrectomy
When can we do a distal pancreatomy?
If the tumor is only in the body and tail, but you gotta take out the spleen too.
Why is a total pancreatomy bad?
We still need pancreatic enzymes to function properly.
When is resection not indicated in pancreatic cancer?
- Mets to liver, peritoneum, and omentum.
- Encasement of superior mesenteric artery/vein
- Extension into IVC
How do we treat non-resectable pancreatic cancer?
- Biliary stents
- Chemo
- Palliative
Who should get screened for pancreatic cancer?
1st degree relative = get screened at 40-45 or 10 yrs before that person got cancer.
No normal screening for healthy adults.
What are the 3 common S/S of pancreatic cancer patients should monitor for?
- Jaundice
- Unexplained weight loss
- Pain (radiating to the back)
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
