Lecture 3 - Pancreas Disorders Flashcards by Maren Osterholt

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

Parathyroid hyperplasia –> hypercalcemia
Medullary thyroid carcinoma –> elevated calcitonin = low Ca²⁺
Pheochromocytoma –> elevated catecholamines

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Autoimmune pancreatitis is associated with high levels of?

Hypergammaglobulinemia (IgG₄)

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

When serum Cr > 1.5 mg/dL

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

Pregabalin

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

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

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

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Treatment for Chronic Pancreatitis requires abstaining from what?

Aimed at controlling?

Abstain from alcohol use
Aimed at controlling pain and malabsorption

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How does Acute Pancreatitis lead to Hypocalcemia?

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

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

Fecal elastase-1
Small-bowel biopsy

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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?

<30% = 2 points
30-50% = 4 points
>50% = 6 points

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

Low (<100 mcg/gram stool)

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

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

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

Endoscopic retrograde cholangiopancreatography (ERCP)
Magnetic resonance cholangiopancreatography (MRCP)

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

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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What are 5 risk factors for Acute Pancreatitis?

Smoking
High dietary glycemic load
Abdominal adiposity
Increasing age
Obesity

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

C-HOBBS

Calcium <8

Hematocrit drop >10%

Oxygen (PaO₂) <60mmHg

Base deficit >4

BUN increase >5

Sequestration of fluid >6

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

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

Blunt abdominal trauma
Surgery
Peritoneal dialysis

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

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

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

Cholelithiasis (gallstones)
Alcohol

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

Which specific type of diabetes?

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

Which steps need to be taken to perform the test?

Identifies?

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

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

“Sentinel Loop”
Acute pancreatitis

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

Salivary gland disease
Intestinal perforation/infarction

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

**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

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

Endoscopic Ultrasound (EUS)

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

Check a **lipid panel** for **severe acute pancreatitis** etiology

What are the common symptoms associated with Acute Pancreatitis?

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

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

- **TIGAR-O** - **T**oxic-metabolic (i.e., alcohol, smoking, meds, hyper-calcemia/lipidemia - **I**diopathic - **G**enetic --\> CF, *PRSS1, CASR, SPINK1* - **A**utoimmune - **R**ecurrent and severe acute pancreatitis - **O**bstructive

It is important to distinguish chronic pancreatitis from what?

Pancreatic carcinoma

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

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

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

- **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

Which serious respiratory complication may result from Acute Pancreatitis?

Acute Respiratory Distress Syndrome (ARDS)

What is the cardinal symptom of Chronic Pancreatitis? Other common signs/ symptoms?

- **Cardinal sx** = PAIN - Chronic or intermittent epigastric pain, steatorrhea, weight loss - Anorexia, N/V, constipation, flatulence

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

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

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

Steatorrhea --\> bulky, foul, fatty stools = Malabsorption

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

Pancreatic necrosis

What are 2 protective factors for Acute Pancreatitis?

1. Eating your veggies 2. Perhaps using "statins" --\> But may also be a cause!

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

Corticosteroids

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

Endoscopic Ultrasound (EUS)

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

**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)

Are there specific lab tests for Chronic Pancreatitis? Which levels are often normal and which are elevated?

- **NO** - Lipase and amylase are **often normal** - Serum bilirubin and AlkPhos may be elevated w/ compression of bile duct

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

Opioid/Narcotic addiction = commn

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

Pancreatic calcifications

The Acute Physiology and Chronic Health Evaluation (APACHE II) score is used for what? Meeting how many criteria is associated with higher mortality?

- Not just for pancreatitis (**ICU scoring** system predicting hospital mortality) - **\>8 = higher mortality**

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

Increased mortality rate

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

Diabetes Mellitus

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?

- **0-1** = \<1% - **Up to 5** = 27%

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

**Tetany** and **poor prognosis**

How is malabsorption in chronic pancreatitis managed clinically?

- Low-fat diet - Pancreatic enzyme replacement

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

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

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

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**

What is the "Rosemont" criteria for Chronic Pancreatitis when visualizing with EUS? Describe pancreatic duct and parenchyma lesion and findings associated with autoimmune pancreatitis.

- **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

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

1) **Insulinoma --\> hypoglycemia** 2) **Gastrinoma --\> ZE syndrome**

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

1. Pituitary adenoma 2. Parathyroid hyperplasia 3. Pancreatic tumors

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

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

What is the imaging modality of choice for Chronic Pancreatitis? Followed by which modalities?

- **CT** scan = modality of choice - Followed by MRI, endoscopic US, and pancreas function testing

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

**_GA-LAW_** **G**lucose **\>200** **A**ge **\>55** **L**DH **\>350** **A**ST **\>250** **W**BC **\>16,000**

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

Tumefactive chronic pancreatitis

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

Perfusion CT (PCT)

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

Alcoholism

What is the prognosis of Chronic Pancreatitis? Main cause of death?

- Often leads to **disability** and **reduced life expectancy** - Main cause of death = **pancreatic cancer**

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

Unehanced CT (**no contrast**)

Which genetic disorder is commonly associated with Chronic Pancreatitis?

Cystic Fibrosis --\> mutations of CFTR

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

Correlates with **increased mortality rate**

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

- **0-2** = 1% - **3-4** = 16% - **5-6** = 40% - **7-8** = 100%

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

Vasopressors

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

**Lipase** --\> **3x** the upper limit of normal

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)?

- **B**UN **\>25 mg/dL** - **I**mpaired mental status - **S**IRS - **A**ge **\>60** - **P**leural effusion during first 24 hrs

What is the most important treatment for acute pancreatitis?

- **Safe, aggressive IV fluid resuscitation** - **Resulting in:** adequate urine ouput, stabilizing BP, and heart rate, with restoration of central venous pressure

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

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

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

Endoscopic Ultrasound (EUS)

What "sign" is this and what pathology is it associated with?

- **"Colon Cutoff Sign"** - Acute pancreatitis

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

- **Not** indicated after a 1st attack: **u****nless** there is associated cholangitis, jaundice, or bile duct stone known to be present - **Selected pts** --\> aspiration of bile for crystal analysis may confirm suspicion