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GI/GU II Exam 2 > DSA 1: Approach to Pancreatic Pt > Flashcards

DSA 1: Approach to Pancreatic Pt Flashcards

1
Q

What part of the abd will pancreas problems present

A

RUQ

Epigastric

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2
Q

what is the pathophysiology of acute pancreatitis

A

Cellular injury from - activation of digestive enzymes in pancreas - trypsinogen to trypsin results in autodigestion of pancreas and peri-pancreatic tissue

Saponification- interaxn of cations w/ FFA released by action of activated lipase on triglyceride in fat cells –> hypocalcemia

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3
Q

What is the etiology of acute pancreatitis

A

biliary tract - gallstones (=<5 mm)

heavy alc use

hypertriglyceride, trauma, meds, ERCP, AI, infxns, CFTR, idiopathic

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4
Q

What is the Hx/PE of acute pancreatitis

A

Hx: epigastric abd pain - constant boring pain straight through the back

RUQ pain/dyspepsia, GB dz etiology

never smoke/active lifestyle - decrease risk ; h/o GB dz- increase risk

PE: cullen or grey turner sign; ARDS (difficulty breathing, crackles); chvostek and trousseau signs for hypocalcemia

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5
Q

What are diagnostic criteria and lab criteria for acute pancreatitis

A

atleast 2 of 3: epigastric pain, lipase (& amylase) 3 x the ULN, CT changes consistents w/ pancreatitis

CBC (increase WBC, Hct)

CMP/BMP (hyperglycemia; hyperbilirubinemia; increase BUN, alkaline phosphatases, creatinine, ALT; hypoCa2+ saponification)

UA: proteniuria, granular casts in urine, glycosuria

increase CRP

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6
Q

What are diagnositic radiography criteria of acute pancreatitis

A

x-ray: sentineal loop (LUQ-air filled SI); colon cutoff sign (gas filled segment of transverse colon abrupting ending at the area of pancreatitic inflam)

US: not helpful

CT w/ rapid-bolus IV contrast - after aggressive vol resuscitation after 3 days of severe pancreatitis - find area of necrosis, avoid when Cr > 1.5 mg/dL; IV contrast may increase compllications of pancreatitis & AKI

PCT: specifically focus on an organ and it’s perfusion (pancreas in this case)

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7
Q

how do you determine the severity of acute pancreatitis

A

prognostic indicators for SAP (severe acute pancreatitis):

Ranson criteria

Bedside index for severity in acute pancreatitis - BUN >25 mg/dL, impaired mental status, SIRS, age > 60 & pleural effusion

APACHE II- > 8 = higher mortality

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8
Q

how do you treat/manage acute pancreatitis

A

treat the cause

Mild: fluid resuscitation (lots) - 1st thing (IV); pancreas rest - NPO, bed rest, NG suction for ileus

severe: early surgical consult, hemodynamic monitoring in ICU, Ca2+-gluconate IV for hypoCa2+ w/ tetany, fresh frozen plasma (FFP) for coagulopathy, albumin infusion for hypoalbuminemia

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9
Q

What are the compllications for acute pancreatitis

A

Leak of fluid in pancreatic bed (3rd spacing)

pre-renal azotemia

fluid collections (pleural effusion)

necrosis - w/ or w/o infxn (emphysematous pancreatitis)

pseudocysts

ARDS

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10
Q

what is a (+) cullen’s sign

A

ecchymosis of umbilicus from retroperitoneium fluid & bleeding

in acute pancreatitis

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11
Q

what is a (+) grey turner sign

A

ecchymosis of flank from fluid and blood in retriperitoneium

seen in acute pancreatitis

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12
Q

What are ranson criteria

A

assess severity of acute pancreatitis

GA-LAW = glucose > 200, age >55, LDH > 350, AST >250, WBC > 16,000

C & HOBBS (after 48 hrs admission) = Ca2+ < 8, HCT >10%, PaO2 <60 mmHg, base deficit >4, BUN increase > 5, sequestration of fluid > 6L

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13
Q

What is BISAP Score

A

Bun > 25

Impaired mental status

SIRS > 2-4 present

Age > 60

Pleural effusion

=acute pancreatitis

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14
Q

What is APACHE

A

acute pancreatitis > 8 means severe pancreatitis & 18% mortality

helps to determine diagnostics and Tx

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15
Q

What is a sentineal loop or localized ileus a sign for

A

acute pancreatitis

=single dilated loop of small bowel in LUQ

signals presence of adjacent irritative or inflam process

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16
Q

what is it called when there is infected pancreatic necrosis w/ secondary gas formation

how do you treat this

A

emphysematous pancreatitis

can form from C. perfringens, E. aerogenes, E. faecalis

Tx = surgical debridement & ABx (imepenem/meropenem)

17
Q

what is chvostek and trousseau signs for hypoCa2+

A

Chvostek: twitching of Ms innervated by facial N; refers to an abnormal rxn to the stimulation of facial N

Trousseau: (+) when ionized Ca2+ is 1.75-2.25 mmol/L; hand adopts a characterisitic posturewhen the sphygmomanometer. cuff is inflated above the sBP w/i 3 mins

(can be seen in acute pancreatitis)

18
Q

what is ARDS

and what can be seen on imaging

A

=bilateral fluffly inflitrate

normal cardiac size

tracheostomy tube

L subclavian central line going inside the R atrium

ECG wires

19
Q

why is lipase preferred over amylase when testing for acute pancreatitis

A

amylase can be elevated for many other reasons - high intestinal obstruction, gastroenteritis, mumps, ectopic preg, opioids, after abd surgery

lipase could be elevated in some of these but is still considered more accurate of a measurement for pancreatic source

20
Q

what is the etiology of chronic pancreatitis

A

alcoholism = MCC of clinically apparent chronic pancreatitis

irreversible damage to pancreas

self perpetuating- characterized by chronic pain/recurrent episodes of acute pancreatitis & pancreatic exocrine/endocrine insufficiency (malabs/DM, respectively)

21
Q

what is the Hx/PE of chronic pancreatitis

A

epigastric pain, steatorrhea [chronic fatty diarrhea], unintentional wt loss, abnormal pancreatic imaging

Anorexia, N/V, constipation, flatulence, and malabs, fatigue

Pain is cardinal symptom

Attacks =only a few hrs or as long as 2 weeks;

Steatorrhea (bulky, foul, fatty stools) may occur late in the course; Malabs- aka EPI (Exocrine Pancreas Insufficiency)

22
Q

what are diagnostic findings of chronic pancreatitis

A

decreased fecal elastase (<100 mcg/gram)

glucose/HbA1c (80% develop DM after 25 yr of chronic pancreatitis)

AI pancreatitis - elevated IgG4

x-ray - calcifications

CT: calcifications; tumefactive chronic pancreatitis = concern for pancreatic CA

EUS: Bx tissue

23
Q

What is the mneumonic used for chronic pancreatitis causes

A

TIGAR-O

Toxic metabolic: alcoholic (45-80%)

Idiopathic (early onset - 23 yo OR late - 62 yo)- smoking = RF

Genetic (<30) - CFTR- CF

AI- celiac dz, hypergammaglobuminemia (IgG4)

Recurrent: develops in 36% of pt w/ recurrent acute pancreatitis

Obstructive: stricture, stone or tumore

24
Q

What is the Tx for chronic pancreatitis

A

supportive, pain control

pancreatic enzyme supplementation: alcohol is forbidden, avoid opoids if possible, supplements w/ high lipase activity for statorrhea)

Tx associated DM

25
Q

what are complications of chronic pancreatitis

and what is the prognosis

A

brittle DM (develop DM w/i 25 yr)

pancreatic insufficiency - steatorrhea, malnutrition

pancreatic CA- main cuase of death

26
Q

what is pancreatic insufficiency

A

seen in chronic pancreatitis, CF or pancreatic CA

significant steatorrhea - due to malabs of triglycerides

–> wt. loss, gaseous distention & flatulence, large, greasy, foul-smelling diarrhea

exocrine- detection of decreased fecal chymotrypsin, pancreatic fecal elastase, secretin stimulation test, 40% B12 malabs

endocrine- 80% develop DM after 25 yrs

27
Q

what are pancreatic function tests

A

fecal elastase (<100 mcg/gram stool)

trypsinogen, pancreatic malabs, CCK/secretin

28
Q

what are Hx/PE of pancreatic CA

how do you treat this

A

=adenoCA

painless jaundice, pain is mid-epigastric pain - hurts the most at night (lying flat on back and relieved w/ bending forward

trousseau sign of malignancy = repeated attacks of multiple venous thrombosis at different and changing sites due to procoagulant factors (aka migratory thrombophlebitis)

courvoisier sign, CA 19-9 >100 U/mL = highly specific for malignancy

jaundice commonly complicates tumors of the head, due to biliary obstruction

  • surgical resection; chemotherapy
29
Q

What are RFs for pancreatic CA

A

smoking, obesity, male, african american

>65 yo, DM, chronic pancreatitis, liver cirrhosis (alc), FHx

associated w/ MEN 1

30
Q

What are the associations of MEN Type 1

A

>= 2:

Parathyroid: hyperCa2+, increase PTH

Pancreas: gastrinoma (ZE syndrome) & insulinoma

Pituitary: acromegaly/cushing dz

GI/GU II Exam 2 (19 decks)

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