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GI II Exam 2 > Lecture 3 - Pancreas Disorders > Flashcards

Lecture 3 - Pancreas Disorders Flashcards

1
Q

What are 3 of the most common neoplasias associated with MEN-2A?

A
  1. Parathyroid hyperplasia –> hypercalcemia
  2. Medullary thyroid carcinoma –> elevated calcitonin = low Ca2+
  3. Pheochromocytoma –> elevated catecholamines
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2
Q

Autoimmune pancreatitis is associated with high levels of?

A

Hypergammaglobulinemia (IgG4)

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3
Q

When should Rapid-bolus IV contrast-enhanced CT be avoided in Acute Pancreatitis?

A

When serum Cr > 1.5 mg/dL

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4
Q

Which drug can improve pain in chronic pancreatitis and low pain medicaton requirement?

A

Pregabalin

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5
Q

What are some of the complications associated with Severe Acute Pancreatitis?

A
  • Necrotizing pancreatitis
  • Acute respiratory distress syndrome (ARDS)
  • Multisystem organ failure
  • Intravascular volume depletion
  • Ileus
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6
Q

Which imaging modality for Chronic Pancreatitis may show calcification not seen on plain film?

A

CT

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7
Q

Treatment for Chronic Pancreatitis requires abstaining from what?

Aimed at controlling?

A
  • Abstain from alcohol use
  • Aimed at controlling pain and malabsorption
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8
Q

How does Acute Pancreatitis lead to Hypocalcemia?

A
  • Saponification
  • Cations (Ca2+) interact w/ FFA’s released by actions of activated lipases on TAG’s in fat cells —> Hypocalcemia
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9
Q

In patients with Chronic Pancreatitis w/ suspected pancreatic steatorrhea (malabsorption/insufficiency), which tests are useful for evaluation?

A
  • Fecal elastase-1
  • Small-bowel biopsy
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10
Q

Which % of pancreatic necrosis is associated with 2, 4, or 6 additional points added to the CT grade points for the severity index of acute pancreatitis?

A
  • <30% = 2 points
  • 30-50% = 4 points
  • >50% = 6 points
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11
Q

What will levels of Fecal-Elastase be like in pancreatic exocrine insufficiency?

A

Low (<100 mcg/gram stool)

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12
Q

Upon PE of someone with Acute Pancreatits what are some of the common findings you can expect to see?

A
  1. Low-grade fever, tachycardia, hypotension (even shock)
  2. Erythematous skin nodules due to subcutaneous fat necrosis
  3. Basilar rales and pleural effusion (often on the left - fluid shifts) –> (edema-3rd spacing)
  4. Cullen’s sign (periumbilical) or (Grey) Turner’s sign (flanks)
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13
Q

Which imaging modalities should be considered in pts with recurrent pancreatitis, especially after repeated attacks of idiopathic acute pancreatitis?

A
  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Magnetic resonance cholangiopancreatography (MRCP)
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14
Q

What are 5 of the risk factors for high levels of fluid sequestration (3rd spacing/edema) seen in Acute Pancreatitis?

A
  • Younger age
  • Alcohol etiology
  • Higher hematocrit value
  • Higher serum glucose
  • Systemic Inflammatory Response Syndrome in the first 48 hours of admission
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15
Q

What are 5 risk factors for Acute Pancreatitis?

A
  1. Smoking
  2. High dietary glycemic load
  3. Abdominal adiposity
  4. Increasing age
  5. Obesity
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16
Q

What is the mnemonic and values for the Ranson Criteria used 48 hours after admission for Acute Pancreatitis?

A

C-HOBBS

Calcium <8

Hematocrit drop >10%

Oxygen (PaO2) <60mmHg

Base deficit >4

BUN increase >5

Sequestration of fluid >6

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17
Q

What is Trousseau’s sign of hypocalcemia vs. Trousseau’s sign of malignancy?

A
  • Of Malignancy = repeated attacks of multiple venous thrombosis (migratory thrombophlebitis) –> pancreatic cancer
  • Hypocalcemia = spasm of muscles of hand + forearm w/ flexion at wrist after putting BP cuff on patient
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18
Q

What are some examples of trauma which can cause Acute Pancreatitis?

A
  • Blunt abdominal trauma
  • Surgery
  • Peritoneal dialysis
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19
Q

Elevated amylase is not the preferred marker for Acute Pancreatitis because it can also be elevated in which 6 conditions?

A
  • High intestinal obstruction
  • Gastroenteritis
  • Mumps (not involving pancreas - salivary amylase)
  • Ectopic pregnancy
  • Administration of opioids
  • Post-abdominal surgery
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20
Q

What are the 2 most common causes of Acute Pancreatitis in the US?

A
  1. Cholelithiasis (gallstones)
  2. Alcohol
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21
Q

What are some of the common complications associated with Chronic Pancreatitis?

Which specific type of diabetes?

A
  • Chronic abdominal pain
  • Gastroparesis
  • Malabsorption/Maldigestion/Malnutrition/Steatorrhea
  • Impaired glucose tolerance (Brittle diabetes mellitus)
  • Nondiabetic retinopathy
  • Bile duct stricture, osteoporosis, and peptic ulcer
  • Pancreatic cancer
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22
Q

When is Rapid-bolus IV Contrast-Enhanced CT used for Acute Pancreatitis?

Which steps need to be taken to perform the test?

Identifies?

A
  • Following aggressive volume resuscitation
  • Particularly useful after 3 days of severe acute pancreatits
  • Identifies areas and degree of pancreatic necrosis
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23
Q

What “sign” is this and what pathology is it associated with?

A
  • “Sentinel Loop”
  • Acute pancreatitis
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24
Q

Large elevations (>3x normal) of amylase virtually assure the diagnosis of Acute Pancreatitis as long as which other pathologies have been excluded?

A
  • Salivary gland disease
  • Intestinal perforation/infarction
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25
Q

Which CT findings correlate with a score of 1-4 for CT grade of Acute Pancreatitis?

A

1 = Pancreatic Enlargement

2 = Pancreatic inflammation and/or peripancreatic fat

3 = Single acute peripancreatic fluid collection

4 = 2+ acute peripancreatic fluid collections or retroperitoneal air

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26
Q

Draining a pseudocyst associated with acute pancreatitis is done with the help of what imaging modality?

A

Endoscopic Ultrasound (EUS)

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27
Q

Hypertriglyceridemia (usually >1000) with acute pancreatitis requires what work-up?

A

Check a lipid panel for severe acute pancreatitis etiology

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28
Q

What are the common symptoms associated with Acute Pancreatitis?

A

Boring pain in the epigastric and periumbilical regions may radiate to the back, chest, flanks, and lower abdomen

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29
Q

What is the mnemonic for the pre-disposing factors for Chronic Pancreatitis?

A
  • TIGAR-O
  • Toxic-metabolic (i.e., alcohol, smoking, meds, hyper-calcemia/lipidemia
  • Idiopathic
  • Genetic –> CF, PRSS1, CASR, SPINK1
  • Autoimmune
  • Recurrent and severe acute pancreatitis
  • Obstructive
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30
Q

It is important to distinguish chronic pancreatitis from what?

A

Pancreatic carcinoma

31
Q

What are some of the signs/symptoms associated with pancreatic adenocarcinoma?

A
  • Painless jaundice, N/V, fatigue, weight loss, steatorrhea
  • Trousseau sign of malignancy
  • Courvoisier sign (palpable enlarged GB that is non-tender)
32
Q

What constitutes mild, moderate, and severe disease classifications using the Revised ATLANTA critera for Acute Pancreatitis?

A
  • Mild = no organ failure and no local (peri-pancreatic necrosis or fluid collection) or systemic complications
  • Moderate = transient (< 48 hrs) organ failure or local or systemic complications, or both
  • Severe = persistent (48 hours or more) organ failure
33
Q

Which serious respiratory complication may result from Acute Pancreatitis?

A

Acute Respiratory Distress Syndrome (ARDS)

34
Q

What is the cardinal symptom of Chronic Pancreatitis?

Other common signs/ symptoms?

A
  • Cardinal sx = PAIN
  • Chronic or intermittent epigastric pain, steatorrhea, weight loss
  • Anorexia, N/V, constipation, flatulence
35
Q

What are 7 of the more common causes of Acute Pancreatitis?

A
  • Alcohol
  • Gallstones
  • Hypertriglyceridemia
  • Endoscopic Retrograde Cholangiopancreatography (ERCP)
  • Drugs
  • Trauma
  • Post-operative (abdominal and non-abdominal)
36
Q

What is a common sign/symptoms occurring late in the course of Chronic Pancreatitis and is associated with Exocrine Pancrease Insufficiency?

A

Steatorrhea –> bulky, foul, fatty stools = Malabsorption

37
Q

An elevated Hct = >44% (hemoconcentration) is associated with what finding in Acute Pancreatitis?

A

Pancreatic necrosis

38
Q

What are 2 protective factors for Acute Pancreatitis?

A
  1. Eating your veggies
  2. Perhaps using “statins” –> But may also be a cause!
39
Q

Autoimmune pancreatitis often responds to and can be treated with what drugs?

A

Corticosteroids

40
Q

Which type of imaging for acute pancreatitis can identify occult biliary disease (i.e., small stones, sludge, microlithiasis)?

A

Endoscopic Ultrasound (EUS)

41
Q

How do severity index scores of 1, 4, 7, and 10 correlate with mortality rate in acute pancreatitis?

A

1 = 0% –> (i.e., pancreatic enlargement w/ 0% necrosis)

4 = <3% –> (i.e., inflammation/peripancreatic fat + <30% necrosis)

7 = 6% –> (i.e., single acute peripancreatic fluid colleciton + 30-50% necrosis)

10 = >17% (i.e., 2+ acute peripancreatic fluid collection/retroperitoneal air + >50% necrosis)

42
Q

Are there specific lab tests for Chronic Pancreatitis?

Which levels are often normal and which are elevated?

A
  • NO
  • Lipase and amylase are often normal
  • Serum bilirubin and AlkPhos may be elevated w/ compression of bile duct
43
Q

Which complication can arise due to pain management of Chronic Pancreatitis?

A

Opioid/Narcotic addiction = commn

44
Q

Plain films (XR) of the abdomen with someone that has chronic pancreatitis may reveal what?

A

Pancreatic calcifications

45
Q

The Acute Physiology and Chronic Health Evaluation (APACHE II) score is used for what?

Meeting how many criteria is associated with higher mortality?

A
  • Not just for pancreatitis (ICU scoring system predicting hospital mortality)
  • >8 = higher mortality
46
Q

Hypoalbuminemia and marked elevations of serum LDH in Acute Pancreatitis are associated with what?

A

Increased mortality rate

47
Q

Over 80% of adults with Chronic Pancreatitis will develop what within 25 years?

A

Diabetes Mellitus

48
Q

The scale of BISAP scores for pancreaitits is from 0-5; what are the mortality rates associated with a score of 0-1 or up to 5?

A
  • 0-1 = <1%
  • Up to 5 = 27%
49
Q

A pH <7.0 with normal albumin is associated with what in Acute Pancreatitis?

A

Tetany and poor prognosis

50
Q

How is malabsorption in chronic pancreatitis managed clinically?

A
  • Low-fat diet
  • Pancreatic enzyme replacement
51
Q

Although plan radiographs (X-ray) are not specific for pancreatitis, what are 2 findings that are characteristically seen?

A
  1. “Sentinel loop” –> segment of air-filled small intestine most commonly in LUQ
  2. “Colon cutoff sign” –> gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation
52
Q

The diagnosis of Acute Pancreatitis is established by the presence of at least 2 findings out of which 3 criteria?

A
  1. Typical abdominal pain that’s epigastric and may radiate to the back
  2. 3-fold or greater elevation in serum lipase and/or amylase
  3. Confirmatory findinds on cross-sectional abdominal imaging
53
Q

What is the “Rosemont” criteria for Chronic Pancreatitis when visualizing with EUS?

Describe pancreatic duct and parenchyma lesion and findings associated with autoimmune pancreatitis.

A
  • Hyperechoic foci w/ shadowing indicative of calculi in main pancreatic duct (PD)
  • Lobularity w/ honey-combing of pancreatic parenchyma
  • Autoimmune = diffuse enlargement of pancreas, a peripheral rim of hypoattenuation, and irregular narrowing of main PD
54
Q

What are 2 types of Pancreatic Neuroendocrine (Islet Cell) Tumors associated with MEN-1?

A

1) Insulinoma –> hypoglycemia
2) Gastrinoma –> ZE syndrome

55
Q

MEN-1 will have 2+ neoplasias is which 3 common areas?

A
  1. Pituitary adenoma
  2. Parathyroid hyperplasia
  3. Pancreatic tumors
56
Q

What are the criteria for the Harmless Acute Pancreatitis Score (HAPS)?

How accurate?

A
  • Predicts a non-severe course w/ 98% accuracy
    1) No abdominal tenderness, rebound or guarding
    2) Normal hematocrit
    3) Normal serum creatinine
57
Q

What is the imaging modality of choice for Chronic Pancreatitis?

Followed by which modalities?

A
  • CT scan = modality of choice
  • Followed by MRI, endoscopic US, and pancreas function testing
58
Q

What is the mnemonic and values for the Ranson Criteria used at admission for Acute Pancreatitis?

A

GA-LAW

Glucose >200

Age >55

LDH >350

AST >250

WBC >16,000

59
Q

CT of a patient with chronic pancreatitis may show what finding that is a concern for pancreatic cancer?

A

Tumefactive chronic pancreatitis

60
Q

What type of CT can be performed on day 3 of acute pancreatitis and can specifically look at the fluid collection inside the pancreas?

A

Perfusion CT (PCT)

61
Q

What is the most frequent cause of clinically apparent Chronic Pancreatitis?

A

Alcoholism

62
Q

What is the prognosis of Chronic Pancreatitis?

Main cause of death?

A
  • Often leads to disability and reduced life expectancy
  • Main cause of death = pancreatic cancer
63
Q

Which type of imaging can confirm the clinical impression of Acute Pancreatitis and can also be helpful in evaluating the complications?

A

Unehanced CT (no contrast)

64
Q

Which genetic disorder is commonly associated with Chronic Pancreatitis?

A

Cystic Fibrosis –> mutations of CFTR

65
Q

What is the significance of fluid collection in the pancreas during acute pancreatitis when visualized with PCT?

A

Correlates with increased mortality rate

66
Q

Using the Ranson Criteria, how many criteria met is associated with a 1%, 16%, 40% and 100% mortality rate in someone with Acute Pancreatitis?

A
  • 0-2 = 1%
  • 3-4 = 16%
  • 5-6 = 40%
  • 7-8 = 100%
67
Q

If shock persists after adequate volume replacement (including packed red cells) in a pt with Acute Pancreatitis, which type of drug may be required?

A

Vasopressors

68
Q

Which labratory finding for Acute Pancreatits is the most accurate and preferred test?

A

Lipase –> 3x the upper limit of normal

69
Q

What are the criteria for using the Bedside Index for Severity in Acute Pancreatitis (BISAP) during the first 24 hrs (before onset of organ failure)?

A
  • BUN >25 mg/dL
  • Impaired mental status
  • SIRS
  • Age >60
  • Pleural effusion during first 24 hrs
70
Q

What is the most important treatment for acute pancreatitis?

A
  • Safe, aggressive IV fluid resuscitation
  • Resulting in: adequate urine ouput, stabilizing BP, and heart rate, with restoration of central venous pressure
71
Q

How is the severity index for acute pancreatitis using CT grade calculated?

A

Severity index = CT grade points + Pancreatic necrosis (additional points)

72
Q

Which type of imaging technique is indicated in patients > 40 yo with acute pancreatitis, to exclude malignancy?

A

Endoscopic Ultrasound (EUS)

73
Q

What “sign” is this and what pathology is it associated with?

A
  • “Colon Cutoff Sign”
  • Acute pancreatitis
74
Q

ERCP is one of the possible causes of acute pancreatitis, so when would we use it for acute pancreatitis?

A
  • Not indicated after a 1st attack: unless there is associated cholangitis, jaundice, or bile duct stone known to be present
  • Selected pts –> aspiration of bile for crystal analysis may confirm suspicion

GI II Exam 2 (15 decks)

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