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GI Exam 2 > Disorders of the pancreas > Flashcards

Disorders of the pancreas Flashcards

1
Q

What is the pancreas?

A
  • Insulin production (endocrine)
  • Manufacture and secretion of digestive enzymes for carbohydrate,
    fat, and protein metabolism (exocrine)
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2
Q

What is pancreatitis?

A
  • Inflammatory process
  • Premature activation of pancreatic enzymes within the pancreas
    leads to organ injury
  • Pancreatic enzymes autodigest the gland
  • It is unclear exactly what pathophysiologic event triggers the onset
    of acute pancreatitis
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3
Q

Recurrent acute pancreatitis and chronic
pancreatitis causes: TIGAR-O

A
  • Toxic-Metabolic
  • Idiopathic
  • Genetic
  • Autoimmune
  • Recurrent and Severe Acute Pancreatitis
  • Obstructive
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4
Q

Acute pancreatitis etiology

A
  • Gallstones (40%)
  • Alcohol (35%)
    Less Common Causes:
  • Iatrogenic
  • Trauma
  • Infection
  • Drug reaction
  • Scorpion venom
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5
Q

I GET SMASHED acronym for the etiology of acute pancreatitis

A
  • Irradiation (x-rays)
  • Gallstones
  • Ethanol
  • Trauma/Triglycerides
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion stings
  • Hyperlipidemia/Hypercalcemia
  • ERCP
  • Drugs
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6
Q

PRESENTATION of acute pancreatitis

A

Abdominal pain: Pain radiates directly through the abdomen to the back in 50% of cases
Other symptoms include:
* Nausea, Vomiting, Anorexia, or Diarrhea
* Discomfort worsens with the patient in
the supine position or walking
– Improves when leaning forward
* Duration of pain varies but typically lasts
more than a day
* Patients often have a history of previous
biliary colic or binge alcohol consumption

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7
Q

Exam findings for acute pancreatitis

A
  • Fever (76%)
  • Abdominal tenderness, muscular guarding
    (68%)
  • Tachycardia (65%)
  • Abdominal distention (65%)
  • Jaundice (28%)
  • Hemodynamic instability (10%)
  • Ischemic injury to the retina (uncommon)
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8
Q

CULLEN SIGN

A
  • Bluish discoloration around the
    umbilicus
  • Pancreatic necrosis
  • 3% of cases
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9
Q

GREY-TURNER SIGN

A
  • Reddish-brown discoloration
    along the flanks
  • Results from retroperitoneal
    blood dissecting along tissue
    planes
  • 3% of cases
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10
Q

LABS for acute pancreatitis

A
  • Serum amylase and lipase
  • Amylase or lipase levels at least 3 times above the reference range are
    generally considered diagnostic of acute pancreatitis
  • Elevated lipase level is more specific to the pancreas than elevated amylase levels
    Also may want to check:
  • AST and ALT , Serum electrolytes, BUN, creatinine, glucose, cholesterol,
    triglycerides, CBC with diff, CRP , LDH, HCG
  • Arterial blood gases
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11
Q

Initial Screening test for acute pancreatitis

A

ULTRASOUND: determining the
etiology of acute pancreatitis
* Technique of choice for detecting
gallstones

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12
Q

When is abdominal CT indicated in acute pancreatitis

A
  • Always indicated in patients with severe acute pancreatitis or diagnostic
    uncertainty
  • Imaging study of choice for patient’s over 40 years of age
  • Generally not indicated for patients less than 40 years of age with a single
    episode of mild pancreatitis unless a pancreatic tumor is suspected
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13
Q

ADDITIONAL TESTS for Acute pancreatitis

A
  • Magnetic resonance cholangiopancreatography (MRCP)
  • Endoscopic Retrograde Cholangiopancreatography (ERCP)
    – Should never be used as a first-line diagnostic tool in this disease
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14
Q

When is it justified to do an ERCP for acute pancreatitis?

A

– Should never be used as a first-line diagnostic tool in this disease
– Use with extreme caution in patients with acute pancreatitis and only in the following
situations:
* Patients who have severe acute biliary pancreatitis with organ failure or cholangitis
* Patients with persistent or incipient biliary obstruction, those deemed to be poor candidates for
cholecystectomy, and those in whom there is strong suspicion of bile duct stones after cholecystectomy
* Pancreatic ductal disruptions that occur as part of the inflammatory process and result in persistent
peripancreatic fluid collections

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15
Q

Predicting Severity of acute pancreatitis

A
  • Mild acute pancreatitis which is characterized by the absence of organ failure
    and local or systemic complication
  • Moderately severe acute pancreatitis which is characterized by transient
    organ failure (resolves within 48 hours) and/or local or systemic complications
    without persistent organ failure (>48 hours)
  • Severe acute pancreatitis which is characterized by persistent organ failure that
    may involve one or multiple organs
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16
Q

TREATMENT of acute pancreatitis

A
  • Prompt IV hydration with isotonic crystalloid
    within the first 24 hours*
  • NPO*
  • Pain control
  • Monitor urine output (>0.5 to 1 cc/kg/hour)
  • Monitor electrolytes, Serum glucose
  • Hematocrit and BUN should improve within 24 hours
  • Severe = ICU with mechanical ventilation,
    hemodialysis, and support of blood pressure
  • Nutritional support
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17
Q

Patient education in acute pancreatitis

A
  • Advise against alcohol in binge amounts
  • Discontinue risk factors such as fatty meals
    – Balanced diet with fruit, vegetable, whole grains
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18
Q

Chronic Pancreatitis

A
  • A continuing, chronic, inflammatory
    process of the pancreas
  • Characterized by irreversible
    morphologic changes
  • Can lead to impairment of endocrine and exocrine function of the pancreas Chronic Pancreatitis
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19
Q

PATHOPHYSIOLOGY of chronic pancreatitis

A
  • Pancreatic fibrogenesis appears to be a
    typical response to injury
  • Initiated early by an attack of acute
    pancreatitis; the subsequent recurrent
    injury and remodeling lead to
    pancreatic fibrosis
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20
Q

Alcohol-induced illness is more prevalent in ____

A

males

21
Q

Idiopathic and hyperlipidemic-induced pancreatitis is more prevalent in _____

A

females

22
Q

PRESENTATION of chronic pancreatitis

A
  • Abdominal pain: Intermittent, discreet attacks of severe pain
  • Pancreatic insufficiency
  • Diabetes mellitus
  • Average time from the onset of symptoms until a diagnosis is 62 months
23
Q

EXAM findings of chronic pancreatitis

A
  • During an attack, many patients assume a
    characteristic position
  • A tender fullness or mass may be palpated
    in the epigastrium
  • Patients with advanced disease may exhibit
    physical signs of malnutrition
24
Q

LABS for chronic pancreatitis

A
  • Blood tests: Amylase and lipase, trypsin
  • Fecal tests: Fecal pancreatic elastase-1 (FPE-1), Fecal fat analysis
25
Q

Imaging for chronic pancreatitis

A
  • Plain films: Pancreatic calcifications observed in approximately 30% of cases
  • CT
    – Enhanced visualization of the pancreas
    – Mainstay of noninvasive testing
  • ERCP
  • MRCP with EUS – Becoming test of choice if available
  • Secretin stimulation test
26
Q

TREATMENT for chronic pancreatitis

A
  • Analgesia, reducing inflammation, and
    overcoming intrapancreatic pressure
  • Lifestyle modifications
  • Pain management
  • Restoration of digestion/absorption
27
Q

Diet modifications for chronic pancreatitis

A
  • Low in fat
    – 20 g/day or less
    – Malabsorption of fat-soluble vitamins (A, D, E, and K), vitamin B-12, and calcium may occur. Provide oral supplementation
  • High in protein
  • High in carbohydrates
  • Small meals
  • MCT (medium chain triglycerides): Source of fat that doesn’t bother the pancreas as much, can improve nutrient absorption
28
Q

ENDOSCOPIC THERAPY in chronic pancreatitis

A
  • Decompress any obstructed pancreatic duct
    – Papillary stenosis
    – Pancreatic duct strictures
    – Pancreatic duct stones
    – Pancreatic pseudocysts
29
Q

Surgical options for chronic pancreatitis

A
  • Pancreatic duct drainage/decompression
  • Pancreatic resection
  • Denervation
  • Total pancreatectomy and islet autotransplantation
    – 34% insulin dependent 2-10 years from surgery
30
Q

HEREDITARY PANCREATITIS

A
  • Autosomal dominant
  • Premature conversion of trypsinogen to trypsin
  • Associated mutations: SPINK1, CFTR
  • 1% of pancreatitis cases
  • Onset before age 20 years
31
Q

PRESENTATION of hereditary pancreatitis

A
  • Symptoms may start shortly after birth, though some patients do not exhibit symptoms until adulthood
  • Attacks of epigastric pain
    – Nausea, vomiting
  • Usually progresses to chronic pancreatitis
32
Q

CANCER RISK in hereditary pancreatitis

A
  • 40% lifetime pancreatic cancer risk
    by the age of 75
  • AVOID TOBACCO AND ALCOHOL
  • Pancreatic cancer screening
  • Yearly MRCP/EUS starting at age 40
  • Some patients choose elective
    prophylactic total pancreatectomy
33
Q

Pancreatic cancer mortality

A

High: just 2-10% of those diagnosed survive five years

34
Q

PANCREATIC CANCER morphology

A
  • 80-90% are adenocarcinomas of the
    ductal epithelium
  • 70% of all pancreatic carcinomas occur within
    the head or neck of the pancreas
  • 10% occur in the body of the pancreas
  • At the time of diagnosis, 52% of all patients have distant disease and 26% have regional spread
35
Q

Pancreatic cancer etiology

A
  • 95% develop from the exocrine
    portion
  • 40% of cases are sporadic in nature
  • More common in Blacks, Polynesians, and New Zealanders
  • 30% are related to smoking
  • 20% are associated with dietary factors
  • 5-10% are hereditary
  • Patients with chronic diabetes mellitus have a 2-fold increased risk
36
Q

Pathophysiology of pancreatic cancer

A
  • Can directly invade surrounding visceral organs such as the duodenum, stomach, and colon
  • Can metastasize to any surface in the abdominal cavity via peritoneal spread, regional lymph nodes, then to liver
37
Q

GENETIC FACTORS that impact pancreatic cancer

A
  • BRCA2
  • PALB2
  • Peutz-Jeghers syndrome
  • Familial Atypical Multiple Mole
    Melanoma (FAMMM) syndrome
  • Mutations of the K-ras oncogene are seen in more than 90% of tumors and are the hallmark of pancreatic adenocarcinoma
38
Q

PRESENTATION of pancreatic cancer

A
  • Early diagnosis is difficult
  • Pain, Jaundice, Weight loss
  • Gradual, subtle, non-specific symptoms
    – Anorexia
    – Malaise
    – Nausea
    – Fatigue
    – Epigastric pain
39
Q

EXAM findings in pancreatic cancer

A
  • Exam will likely be normal early in the
    disease process
  • Ascites
  • Lymphadenopathy: Virchow’s node
  • Jaundice
  • Courvoisier sign: Jaundice & Palpable
    gallbladder (not painful)
  • Sister Mary Joseph nodules: Subcutaneous
    metastases in the paraumbilical area
  • Blumer’s shelf: Metastatic mass in the
    rectal pouch
40
Q

LAB FINDINGS in pancreatic cancer

A
  • Usually nonspecific
  • Serum amylase and lipase
  • Patients presenting with jaundice: Significant elevations in bilirubin (conjugated
    and total), alkaline phosphatase,
    aminotransferases, gamma-glutamyl
    transpeptidase, AST, ALT
41
Q

TUMOR MARKERS in pancreatic cancer

A
  • CA 19-9: Of patients with pancreatic carcinoma, 75-85% have elevated CA 19-9 levels
  • Carcinoembryonic antigen (CEA): Only 40-45% of patients with pancreatic carcinoma have elevated levels
42
Q

A CA 19-9 value of greater than 100 U/mL is
highly specific for ____

A

malignancy, usually pancreatic

43
Q

Imaging of choice for pancreatic cancer

A

CT - The best initial imaging study is CT scan of the abdomen and pelvis

44
Q

ENDOSCOPIC US (EUS) use in pancreatic cancer

A
  • High-frequency ultrasonography (7.5-12
    MHz) can be used to produce very high-
    resolution (submillimeter) images
  • Better for small tumors
  • Negative EUS is nearly 100% specific at
    ruling out pancreatic neoplasm
  • Simultaneous EUS-guided fine-needle
    aspiration
  • Patient requires conscious sedation
45
Q

TREATMENT for pancreatic cancer

A
  • GI/oncology referral for surgery
  • Surgical resection is the only curative treatment for pancreatic cancer Invasion of the superior mesenteric or portal vein is no longer an absolute contraindication
  • Invasion of the superior mesenteric, celiac, and hepatic arteries still presents a barrier to resection
  • Chemotherapy , Radiation, Palliative care
46
Q

Screening guidelines for pancreatic cancer

A
  • The USPSTF found no evidence that screening for pancreatic cancer is
    effective in reducing mortality
  • International Cancer of the Pancreas Screening (CAPS) Consortium
    released consensus guidelines for pancreatic cancer screening with EUS
    and/or MRCP for the following high-risk groups:
    – Carriers of p16, PALB2, or BRCA2 mutations with a first-degree relative with
    pancreatic cancer
    – Peutz-Jeghers syndrome
    – Individuals with Lynch syndrome and a first-degree relative with pancreatic
    cancer
47
Q

PATIENT EDUCATION in pancreatic cancer

A
  • Risk
  • Genetic testing
  • Genetic counseling
  • Lifestyle
    – Smoking
48
Q

Possible Preventative Measures in pancreatic cancer

A
  • Aspirin: Taking a daily low-dose aspirin for just three years lowered the chances of
    pancreatic cancer by 46%
  • Metformin: Among 255 diabetic patients, the risk of developing pancreatic cancer was
    62% lower in those who received metformin than in those who did not

GI Exam 2 (6 decks)

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