Lecture 18: Pancreatic Disorders Flashcards
pancreas is both ____ and ___ organ
endocrine; exocrine
what does it do as exocrine organ?
produce enzymes and bicarbonate necessary for digestion
what are some exocrine hormones?
trypsin, chymotrypsin, carboxypeptidase, ribonyclease, elastase, lipase, cholesterol esterase, alpha amylase
what does it do as endocrine organ?
produce hormones central for substrate metabolism
what are some endocrine hormones?
insulin, glucagon, somatostatin, pancreatic polypeptide
valve that controls pancreatic juices is called:
sphincter of Oddi
before activation, pancreatic enzymes called :
zymogens
zymogens only activate when enter _____
small intestine
first zymogen to activate is:
trypsinogen –> trypsin (activates other things)
what are things that stim pancreatic secretion?
CCK, secretin, gastrin, VIP, cephalic phase of eating
what are things that inhibit pancreatic secretion?
GLP1, PP, PYY, OXM
pancreatitis is characterized by:
hemorrhage of pancreatic tissue,
edema,
autodigestion,
fat necrosis
types of acute pancreatitis:
interstitial and hemorrhagic
acute interstitial (80-85%) characterized by:
gland architecture preserved but edematous, inflamm cells prominent
acute hemorrhagic (15-20%) characterized by:
marked necrosis, hemorrhage of tissue, fat necrosis, vascular inflamm and thrombosis
signs and symptoms of acute pancreatitis?
ab pain, nausea/vomiting, low-moderate fever
diagnostic markers for AP
^ pancreatic enzymes 3x greater than high end of normal (^ amylase and lipase)
__% AP caused by gallstones, ___% by alcohol, and ___ % by hypertriglyceridemiea
40; 30;2-5
what is MNT for mild AP?
pain limited analgesics, IVF, start progressive low fat oral diet, small meals (6x/d), eventually normal diet
what is MNT for severe AP?
NPO for pancreatic rest, EN is preferred route (traditionally)
for EN in severe AP, feed into where?
gastric (NG), if not tolerated then jejunal (NJ)
feed NJ below the ligament of ___
Treitz
when to start feeding for severe AP?
early EN indicated, anticipate NPO >5-7days
rate (modality) of feed for severe AP?
continuous
severe AP need ___ kcal/kg, protein ____ g/kg
25-35; 1.2-1.5
EN preferred for SAP cuz:
v mortality, v septic complications, v surgical procedures, v hospital LOS, ^ trophic action on intestinal wall, prevent/reduce bacteria translocation
when is PN warranted for SAP?
EN not tolerated or contraindicated for other reasons
examples of irreversible morphological changes of CP?
fibrosis, calcifications/stones, loss of islet/acinar cells
exocrine/endocrine insufficiency associated with:
steatorrhea, wt loss, malnutrition
clinical manifestations of CP:
ab pain with/without exocrine/endocrine insufficiency, pain which is increased by fatty food and alcohol intake (result in anorexia)
etiopathogenic risk factors for CP:
toxic metabolic (alcoholism, smoking, hypertriglyceridemia), genetic mutations, autoimmune pancreatitis, obstructive, idiopathic
exocrine insufficiency is attributed to:
loss of acinar cell mass or pancreatic duct obstruction–>v digestive enzymes, v ductal bicarbonate secreted
endocrine insufficiency is attributable to destruction of pancreatic _____ which results in loss of islet cells, or _____ diabetes
parenchyma; pancreatogenic (type 3c)
nutr implications of exocrine insufficiency in CP?
fat maldigestion (steatorrhea), CHO and protein maldigestion (v amylase, v trypsin)
steatorrhea occurs when pancreatic lipase secretion < ___% of normal, and is the primary cause of ____ in CP
10; weight loss
steatorrhea = fecal fat excretion > __g/d
7
v amylase secretion causes:
impaired CHO digestion, abdo distension, gas, loose stools
vit ____ deficiencies most common
A and E
clinical manifestations of deficiencies in fat sol vits?
vision, bone density
average resting expenditure in CP is ___kcal/day > than average
200
3 pronged approach to nutr management of CP:
1) pancreatic enzyme replacement therapy
2) assessment/correction of nutr deficiencies
3) maintain adequate diet intake and avoid alcohol
enzymes in PERT usually combo of ____
lipase, protease, amylase
example of PERT:
cotazyme (also used in EN feed tube clogged)
if uncoated, use with ____ (eg. PPI)
gastric acid suppressant
timing of PERT?
with/just before eating
if on PERT, need to know these things:
adherence, dose, timing of doses
nutr recommendations for CP?
high energy (35kcal/kg), high protein (1-1.5g/kg), fat restriction if steatorrhea persists (MCT oil?)
v trypsin secretion means less ____ digestion
protein
