Lecture 13: Pancreas Flashcards
Pancreas is ______peritoneal
Retro
Arterial supply to pancreas
Gastroduodenal, SMA, splenic
Venous drainage of pancreas
Portal vein, splenic vein
Nerves to pancreas (stimulatory, inhibitory)
Vagal = stimulatory; sympathetic = inhibitory
Three stages of pancreas embryology and time scale
Formation, rotation, fusion; 5-8 weeks
2 ducts in pancreas, and they drain into…
Accessory and main, they drain into the Ampula of Vater (major papilla, note: minor duct also drains into minor papilla)
What else drains into the Ampulla of Vater? Sphincter?
Bile duct; sphincter of Oddi
Pancreas is 90%…
Exocrine
What does secretin cause in the pancreas?
Bicarbonate secretion (secretin stimulated by detection of H+)
What does CCK cause in the pancreas?
Pancreatic enzymes (CCK stimulated by detection of aa and fatty acids)
Majority of pancreatic enzymes are…
Proteases (but also lipases, glycosidases, and nucleases)
Describe the process of trypsinogen secretion
Trypsinogen –> trypsin via enterokinase; trypsin –> other zymogens into active enzymes
Four protective mechanisms in the pancreas (4)
Zymogens, trypsin inhibitor in zymogen granules, enzymes bound in membranes enterokinase restricted to small intestine
Acute pancreatitis: pathological activation casade
Failed regulation of trypsin (autoactivation)
Types of pancreatitis (mild –> worse)
Interstitial with inflammation/edema (acute edematous pancreatitis) –> hemorrhagic –> necrotizing pancreatitis
Causes of acute pancreatitis: 2 most common and gender associations
Gallstones (F) and alcohol (M)
Causes of acute pancreatitis: some other classes (7)
Drugs, trauma, metabolic (hypertriglyceridemia), obstruction (stones/sludge/tumors), toxin (scorpion), infection, pregnancy
How do stones cause pancreatitis?
Stone arising from gallbladder obstructs either the common channel or pancreatic duct
Vast majority of gallstones pass…
On their own
How does alcohol cause acute pancreatitis (4)
Intracellular accumulation of pancreatic enzymes, Sphincter Oddi spasm (obstruction), toxic metabolite accumulation, abnormal blood flow
What is Divisum? What can it cause?
Embryologically, lack of fusion of ductal system –> main pancreatic duct draining through minor papilla –> pancreatitis
ERCP
Endoscopic procedure that allows one to visualize the common bile duct and pancreatic duct and remove stone = therapeutic procedure
Pancreatitis: clinical featurs
PAIN (can radiate to back), N/V, fever, hypocalcemia, ileus (bowel paralysis due to abdomen inflammation) and other other “-itis” of the abdomen
Pancreatitis: signs, lab values
Ab tenderness, fever, tachycardia; leukocytosis, hyperamylasemia/hyperlipasemia
Pancreatitis: diff dx
Choledocholithiasis, perforated ulcer, mesenteric ischemia, intestinal obstruction, salpingitis/ectopic pregnancy
% organ failure in necrotizing pancreatitis
~50%
Pancreatitis: dx
Clinical picture + lab values (increased amylase and lipase, especially with injury) +imaging
Are increased pancreatic enzymes specific to pancreatitis?
Nope: can be related to renal failure, medications, and female GU problems
Who do we worry about with pancreatitis?
Older, high WBC, high glucose, hematocrit fall
Pancreatitis: imaging tools
CT scan with contrast, ultrasound for stones, MRCP (MRI of pancreas), ERCP
What might we see around the pancreas during pancreatitis?
Surrounding fluid/edema
Describe stones: what other test will be elevated and how can we test bile? How do we view and treat stones?
Elevation in liver chemistries, bile aspiration analysis, ultrasound or MRCP (imaging) and ERCP (therapeutic)
Interstitial pancreatitis: tx
Give fluid, NPO (rest pancreas), pain control, maintain nutrition if they are very sick (tube), address underlying cause (stones –> surgery/alcohol)
If a pancreatitis patient doesn’t improve, what do you suspect? What should you do (2)?
Necrotizing pancreatitis: CT scan to evaluate perfusion (w/ contrast AND perfusion the pancreas will be “enhancing”) and if you suspect infection, do a fine needle asiration
Late complications of pancreatitis: 3
Pseudocyst (not true due to lack of epithelium, assymptomatic unless large), abscess, hemorrhage (hemosuccus pancreaticus = rare form of GI bleed)
T/F: Pancreatitis can cause systemic complications
True! ARDS, DIC, renal failure
Chronic pancreatitis: define
Chronic inflammation with irreversible morphologic changes and loss of exocrine AND endocrine function
Most common cause of chronic pancreatitis. What are some other causes?
ALCOHOL; tropical, pancreas divisum, autoimmune, neoplastic
Two mechanisms of alcohol pancreatitis
Abnormal secretion theory leading: protein plugs –> obstruction; necrosis-fibrosis: repeated episodes of acute pancreatitis –> fibrosis –> necrosis and obstruction
Chronic pancreatitis: presentation
Daily pain with exacerbations, steatorrhea, weight loss
What is the best test to look for chronic pancreatitis?
Flat plate (abdominal X-ray) with CALCIFICATIONS
Chronic pancreatitis: tx
Quit drinking, give analgesics, give pancreatic enzymes, invasive procedures (celiac plexus block, endoscopic decompression, surgical drainage)
Chronic pancreatitis: complications
Pseudocyst, diabetes, steatorrhea, obstruction (bile duct), pancreatic ascities
Pancreatic neoplasms: type, who, risk factors
Mostly adenocarcinoma, men in 60s, risk: smoking, alcohol, hereditary factors
Where do pancreatic neoplasms typically land?
2/3 in head; 1/2 in body or tail
Pancreatic neoplasm: clinical features
Painless jaundice, nonspecific (N/V, depression, new onset diabetes)
Pancreatic neoplasm: exam
Jaundice, Courvosier’s sign (palpable gallbladder)
What is one way to palliate jaundice-related pruritus?
ERCP to drain bile
What are two other kinds of pancreatic tumors?
Neuroendocrine tumors (gastrinoma with peptic ulcer disease, inulinoma, glucagonoma, VIPoma with secretory diarrhea); lymphoma
Neuroendocrine tumors: better or worse prognosis?
Better
