Lecture 23 - Medical Aspects of Pancreas and Billiary Tract

Question 1

The two most common causes of Acute pancreatitis are _____ disease, usually from stones, and _____ use.

Answer 1

Billiary disease, usually from stones

Alcohol use

Question 2

The three categories for Pancreatitis are Mild, Moderate, and Severe, with the prognosis progressively worsening with each category.

Mild is categorized as no _____ failure and no Local or _____ complication. It usually resolves within ___ week.

Moderate is defined by local or _____ complications such as necrosis or transient organ failure < ____ hrs.

Severe is defined by _____ and persistent organ failure lasting > ____ hrs. The mortality rate at this point is about ____ %.

Answer 2

Organ failure

Systemic

1 week

Systemic

< 48hrs

SIRS (Systemic Immune Response Syndrome –> tachy, leukocytosis, fever, all that good stuff)

> 48hrs

50%

Question 3

Diagnostic criteria for Acute pancreatitis requires at least 2 of the following:

1. Acute onset ____ pain, often radiating to the back.
2. Serum ____ and/or _____ levels elevated to 3-5x the upper limit of normal.
3. Abnormal findings on imaging suggestive of pancreatitis.

Answer 3

1. Acute onset abdominal pain
2. Serum Lipase or Amylase
3. Abnormal findings on imaging

Question 4

The first line treatment for patients presenting with acute pancreatitis is _______ resuscitation (usually Lactated Ringer’s) within the first 12-24hrs.

Routine use of ______ is not warranted.

Oral ____ should begin as soon as possible. If not tolerated, begin Enteral within 72 hours.

ERCP is indicated in patients suspected for _____ obstruction or Cholangitis. If gall stones are determined to be the issue, the patient should undergo ______ before discharge.

Answer 4

Fluid

Antibiotics

Feeding

Billiary obstruction or Cholangitis

Cholecystectomy

Question 5

Complications of Acute pancreatitis typically include ____ failure in the 1st week or Pancreatic Fluid Collections (PFC) beyond the 1st week.

PFC does not require treatment unless is progresses to Pseudocyst (typically from PFC that persists beyond 4 weeks) and/or Walled Off Pancreatic Necrosis (WOPN). How do these two types of PFC differ?

Answer 5

Both are well-defined walled off PFC, but Pseudocyst is typically clear and without debris. It is generally treated if the patient experiences symptoms. WOPN is turgid and has debris. WOPN may become infected, at which point Abs are indicated (Remember they are NOT indicated otherwise). Delay debridement of this type of wound for at least 4 weeks.

Question 6

Chronic Pancreatitis is defined by ongoing inflammation and resultant activation of _____ cells –> fibro-inflammatory response

Answer 6

Stellate cells

Question 7

Most common causes of Chronic Pancreatitis include ____ and _____ use, hyper_____, hyper______, and CKD.

Answer 7

Alcohol and Tobacco use

Hypercalcemia

Hypertriglyceridemia

Question 8

Chronic pancreatitis is more common in ____ (gender) and in _____ (race). It is most common between the ages of 45-54.

Answer 8

Males

Blacks

Question 9

Pancreatic ______ on Xray are highly specific for Chronic pancreatitis, but they are only seen in about 30% of cases.

The most common tests used to diagnose chronic Pancreatitis are ___/_____ or EUS (endoscopic ultrasound).

Answer 9

Calcifications

MRI/MRCP

Question 10

The most common complication of Chronic Pancreatitis is formation of _______. Keep in mind Chronic Pancreatitis is a risk factor for _____ _____.

Answer 10

Pseudocysts (25% of cases)

Pancreatic Cancer

Question 11

The most important treatment for Chronic Pancreatitis is cessation of ____ and ____ use.

Answer 11

EtOH and Tobacco use

Question 12

Two of the Genetic risk factors for Pancreatic Adenocarcinoma are ____-_____ syndrome and ______ germline mutations. The overall 5-year survival rate is < ___%.

Answer 12

Peutz-Jeghers syndrome

BRCA2

<6%

Question 13

Compared with other malignancies, Pancreatic Adenocarcinoma patients present with high rates of ______. Also be on the lookout for adult patients presenting with newly onset ______.

Answer 13

Depression

Diabetes

Question 14

The most common method of diagnosis for Pancreatic Adenocarcinoma is ____ or _____ imaging. EUS guided Fine Needle Aspiration (FNA) or ERCP w/brushing and biopsy can be used as well.

Answer 14

CT or MRI

Question 15

_____ _____ is the only curative treatment for patients with Pancreatic Adenocarcinoma that has NOT metastasized. Otherwise, Preoperative _____ and/or Radiation therapy are used for patients with locally advanced disease.

Answer 15

Surgical Resection

Chemo

Question 16

The vast majority of Gallstones are comprised mainly of ____.

< 10% of gallstones are Pigmented. What are black and brown stones comprised of?

Answer 16

Cholesterol

Black –> polymerized calciumbilirubinate

Brown –> monomeric calciumbilirubinate

If bilirubin is a component, this likely suggests the stones are found in the LIVER!

Question 17

Which gender is at higher risk for gallstones?

Answer 17

Females

Question 18

_____ infection is one of the key component for pigmented gallstone formation.

Answer 18

Bacterial

Question 19

The vast majority of gallstone patients are ________ and require no treatment. Treatment is ONLY indicated in symptomatic patients or patients presenting with _______ gallbladder.

Treatment is ______ within 2 weeks of biliary colic.

Answer 19

Asymptomatic

Porcelain

Cholecystectomy

Question 20

____ scan is the most sensitive and specific test for Acute Cholecystitis.

Answer 20

HIDA (it’s a type of scintigraphy)

Question 21

How does the formation and composition of Bile Duct stones differ in Western vs Easter/Asian populations?

Answer 21

Western –> Mostly formed in gallbladder and composed of Cholesterol

Eastern/Asian –> form in the duct de novo and composed of pigment (usually from infection and/or stasis).

Question 22

The vast majority of Bile Duct stone patients are ______ (symptomatic or asymptomatic?). How does this compare to gallbladder stone patients?

Answer 22

Symptomatic

So this is the OPPOSITE of gallbladder stone patients.

Question 23

Diagnosis of bile duct stones is confirmed with elevation in ____/____. Normal LFTs within ___hrs after the onset of pain rules OUT bile duct stones with an NPV of 95-98%.

EUS and MRI are used to diagnose, but which one can detect stones < 5cm?

What is the gold standard for diagnosis and treatment combo?

Answer 23

AST/ALT

24hrs

EUS can detect stones < 5cm

ERCP

Question 24

Patients who receive papillotomy for bile duct stones should alse receive _____ within 72hrs of treatment.

Answer 24

Cholecystectomy

Question 25

Biliary _____ is the treatment for Acute Cholangitis, as antibiotics have no definitive effect. This treatment should be delivered within ____hr for unstable patients and within ____hrs for stable patients.

Answer 25

Decompression

6hrs

24hrs

Question 26

Intrahepatic Cholangiocarcinoma is the ____ (least or most?) common type of Cholangiocarcinoma.

Answer 26

Least

Question 27

_____ _____ _____ is the MOST important risk factor for Cholangiocarcinoma (specifically for perihilarcholangiocarcinoma pCC)

Answer 27

Primary Sclerosing Cholangitis

Question 28

Though surgery is curative, why is it only successful in < 30% of Cholangiocarcinoma patients?

Answer 28

The disease is typically too advanced at the time of presentation.