GI: Pancreas Flashcards
What are the two most common causes of acute pancreatitis?
Gallstones and alcohol use are the most common causes of acute pancreatitis, accounting for 80% of cases in the United States.
How is acute pancreatitis diagnosed?
Diagnosis of acute pancreatitis requires two of three criteria: (1) acute onset of upper abdominal pain, (2) serum amylase or lipase level increased by at least three times the upper limit of normal, and (3) characteristic findings on cross-sectional imaging (contrast CT, MRI, or ultrasound).
What imaging should be used for the evaluation of acute pancreatitis?
- Because gallstones are the most common cause of pancreatitis, all patients should be evaluated with a transabdominal ultrasound unless another obvious cause of pancreatitis is present.
- Contrast-enhanced CT is not usually required to diagnose acute pancreatitis; it is less sensitive than ultrasound for gallstones, exposes patients to the risk of contrast-medium–induced nephropathy (particularly in underresuscitated patients), and is expensive.
What are poor prognostic indicators for acute pancreatitis?
Poor prognostic indicators for acute pancreatitis are elevated serum blood urea nitrogen level greater than 20 mg/dL (7.1 mmol/L), a hematocrit greater than 44%, or an elevated serum creatinine level.
How do you manage uncomplicated pancreatitis?
In patients with uncomplicated gallstone pancreatitis, a cholecystectomy should be performed prior to discharge.
What are the signs and symptoms of chronic pancreatitis?
The hallmark symptom of chronic pancreatitis is abdominal pain that often radiates to the back; however, pain can be absent. Pain is typically intermittent, with attacks interrupted by varying pain-free intervals. Constant pain may occur from local anatomic causes (compressing pseudocyst, biliary or pancreatic duct stricture) or from visceral hyperalgesia (increased sensation in response to stimuli) from chronic narcotic use and centralization of pain. Other hallmark clinical features, particularly in severe disease, are (1) exocrine pancreatic insufficiency with bulky and greasy stools, fat-soluble vitamin deficiencies, and weight loss; (2) diabetes; and (3) pancreatic calcifications.
What imaging offers diagnostic clues for chronic pancreatitis?
- An abdominal radiograph should be performed to detect pancreatic calcifications.
- pancreas-protocol CT or magnetic resonance cholangiopancreatography should be done to detect abnormalities of the main and side-branch pancreatic ducts.
- endoscopic ultrasound (EUS), which can allow application of EUS-based criteria to aid in making the diagnosis in cases where cross-sectional imaging is unremarkable
- Endoscopic retrograde cholangiopancreatography should be reserved for patients requiring therapeutic interventions.
Treating chronic pancreatitis?
Step 1: Patients with chronic pancreatitis should be counseled to stop smoking and drinking alcohol.
2) Acute intermittent attacks of pain are treated with supportive care, acetaminophen, and ibuprofen
3) Persistent pain is treated in a stepwise approach beginning with simple analgesics, tramadol, low-dose tricyclic antidepressants, and gabapentinoids (gabapentin and pregabalin)
4) Pancreatic enzymes help relieve symptoms of steatorrhea,
5) Percutaneous or EUS-guided celiac plexus blockade using glucocorticoids provides only short-term pain relief in 50% of patients
6) In persistent or refractory pain, several treatment options are available based on anatomic location.
7) In patients with a dilated pancreatic duct and intraductal calcifications, options include endoscopic stenting, lithotripsy, and surgical drainage (pancreaticojejunostomy).
8) Pancreaticojejunostomy provides superior short- and long-term pain relief.
What is the 5-year survival rate for pancreatic adenocarcinoma?
The 5-year survival rate for pancreatic adenocarcinoma remains low at 5%.
What are the most common presenting symptoms of pancreatic cancer?
The most common presenting symptoms of pancreatic cancer are weight loss, abdominal pain, and jaundice.
How is pancreatic adenocarcinoma diagnosed?
Contrast-enhanced multidetector CT has 90% sensitivity for detecting pancreatic malignancy. it is also good for staging.
How is autoimmune pancreatitis diagnosed on imaging?
Patients with AIP typically have painless obstructive jaundice and cross-sectional imaging evidence of focal or diffuse “sausage-shaped” pancreatic enlargement with a featureless border. Pancreatic adenocarcinoma must be excluded. AIP presents rarely with acute pancreatitis.
How is autoimmune pancreatitis treated?
Almost all patients (>90%) enter clinical remission in response to glucocorticoids. Those with jaundice typically require biliary stenting. Rituximab, a monoclonal antibody, has also been found to be successful in those with recurrent disease or glucocorticoid dependency.
Describe how functional most neuroendocrine tumors are
Of all pancreatic neuroendocrine tumors, 75% to 90% are nonfunctional; 10% to 25% are functional and hypersecrete hormones, most commonly gastrin and insulin.
What does testing of neuroendocrine tumors focus on?
Testing focuses on determining the functional status of the tumor and localizing it by cross-sectional CT or MRI imaging. Occult lesions require EUS (90% sensitivity) and pentetreotide scintigraphy (octreotide scanning). Insulinomas and gastrinomas are typically small.
