Lecture 8 Pancreas Flashcards
An acute inflammatory process of the pancreas characterized by acute abd pain and elevated pancreatic enzymes
Most commonly caused by what?
Acute pancreatitis… most commonly caused by gallstones or alcohol abuse
RIsk factors for pancreatitis?
Gallstone (-> ampullary obstruction) Alcohol abuse Hypertriglyceridemia Smoking Cystic fibrosis
Characterized by acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but w/o RECOGNIZABLE TISSUE NECROSIS
Interstitial edematous acute pancreatitis
Atlanta classification
Characterized by inflammation associated WITH pancreatic parenchymal necrosis and/or peripancretic necrosis
Necrotizing acute pancreatitis
Atlanta classification
Characterized by the absence of organ failure and local or systemic complications
Mild acute pancreatitis
Characterized by transient organ failure (resolves w/in 48 hours) and/or local or systemic complications w/o persistent organ failure
moderate acute pancreatitis
Characterized by persistent organ failure that may involve one of multiple organs
severe acute pancreatitis
Bilateral upper quadrant/epigastric abd pain
(severe, steady, boring AND radiation to the back is common)
Nausea vomiting
Acute pancreatitis ssx
ACUTE onset of bilateral upper quadrant pain…
Steady, boring, severe w/ radiation to the back
What ya thinking?
Acute onset in gallstone pancreatitis
more gradual if due to other causes
PE findings for acute pancreatitis?
Pain INCREASED w/ lying supine (better leaning forward)
Epigastric/abd TTP
Fever, tachy, HOTN
(may have hypoactive bowel sounds)
(may have obstructive jaundice)
Cullen’s or Grey-Turner sign (associated w/ more severe disease)
With acute pancreatitis, what position makes it better? What makes it worse?
Pain is increased when lying supine.
Pain is better with leaning forward
Lab findings for acute pancreatitis?
What’s most sensitive?
Serum amylase and lipase
(lipase is better! It increases earlier, remains elevated longer, and has higher sensitivity)
CBC = leukocytosis CMP = elevated BUN LFT = elevated ALK PHOS and bilirubin
(elevated CRP, of course)
Radiograph of choice for acute pancreatitis?
CT scan!
Reveals diffuse pancreatic enlargement
Some ddx for acute pancreatitis?
cholecystitis, choledocholithiasis, cholangitis
PUD
perforated viscus
intestinal obstruction
mesenteric ischemia
Ranson criteria? What are the 5 you “see upon initial presentation?”
Blood glucose (>200) Age (>55) Leukocytosis (>16,000) LDH (>350) AST (>250)
Ranson criteria… what are the 6 that you assess at 48 hours?
HCT (fall by more than 10%) BUN (increase by more than 5 mg/dL despite fluids) SrCr (<8 mg/dL) pO2 (<60 mm Hg) Base deficit (>4 mEg/L) Fluid sequestration (>6000)
Acute peripancreatic fluid collection
Pancreatic pseudocyst
acute necrotic colleciton
Walled off necrosis
Complications of pancreatitis
you might see the initially, or on a subsequent CT scan…
General tx measures for acute pancreatitis?
ERCP for gallstone pancreatitis
(w/ 24 hours of admission)
(not for alcoholic pancreatitis)
Admission
Pancreatic rest (NPO)
Bed rest
IV fluid/electrolyte replacement
Pain control (MORPHINE, maybe meperidine, but probably MORPHINE)
Tx for acute MILD acute pancreatitis
What’s the tx for SEVERE acute pancreatitis?
- Admission to ICU
- Early surgical consultation
IV fluid/electrolyte replacement (monitor hemodynamics)
Abx
A progressive fibro-inflammatory process of the pancreas that results in permanent structural damage and impairment of exocrine/endocrine function
What is it and who’s it common in?
Chronic pancreatitis, most common in chronic alcoholics
How does chronic pancreatitis present clinically?
Recurrent episodes of LUQ/epigastric pain (attacks may last **hours, days)
Anorexia/wt loss
nausea/vomiting
constipation
Flatulence
**Steatorrhea
Diagnostic testing for chronic pancreatitis is different from acute pancreatitis…
What does diagnostic testing for chronic pancreatitis look like?
Plain film/CT film showing pancreatic calcification is diagnostic (must r/o pancreatic cancer)
Amylase, lipase may be normal in chronic (so not very useful)
Can quantitatively evaluate fecal fat
What is a test typically performed by specialists that can help detect chronic pancreatitis that is w/o characteristic radiographic findings?
Secretin pancreatic function test
Main role is diagnosis of early chronic pancreatitis in patients w/ compatible clinical features but no radiographic features
stimulation of the pancreas followed by evaluation of the duodenal fluid.
Tx for chronic pancreatitis?
referral to GI/pancreatology
low fat diet
NO ETOH
*Non-opioid pain control
pancreatic enzyme supplementation
Due to deficiency of exocrine pancreatic
enzymes (-> inability to digest food)
Clinical diagnosis is difficult becuase of vague ssx that are common in other GI conditions
Patients complain of dyspepsia, abd cramping/bloating w/ flatulence, watery diarrhea
PATIENTS MAY ALSO COMPLAIN OF STEATORRHEA (lack of pancreatic lipase)
exocrine pancreatic insufficiency
ddx =
- Celiac/malabsorption syndromes
- IBS
- IBD
Most common etiologies for exocrine pancreatic insufficiency?
CHronic pancreatitis
Cystic fibrosis
Watery, bulky, foul-smelling diarrhea w/ steatorrhea
Wt loss
Abd pain
Bloating
Flatulence
exocrine pancreatic insufficiency
clinical presentation
Diagnostic approach…
Suspect in all patients w/ abd pain, chronic diarrhea/steatorrha
Routine labs to observe for anemia, nutrient deficiences
Labs to evaluate pancreatic function (fecal elastase)
- R/o other malabsorption causes
- refer to GI
What’s the mainstay of tx?
exocrine pancreatic insufficiency
Mainstay = pancreatic enzyme replacement therapy
Highly lethal due to late presentation
Risk factors include…
tobacco use ETOH abuse obesity chronic pancreatitis Fam Hx
Pancreatic CA
Abd pain, jaundice, WT LOSS
(vague, diffuse epigastric/LUQ pain)
Pos Courvoisier sign
Pancreatic CA
What’s the Courvoisier sign?
NON-TENDER, palpable gallbladder
seen in Pancreatic CA, biliary carcinoma
Lab findings for pancreatic cancer?
**CA 19-9 = serum tumor marker
Non specific (w/w/o amylase/lipase)
Pancreatic cancer might not be directly “image-able” but what imaging modalities might you use to r/o other etiologies?
US (to evaluate jaundice)
Abd CT (to eval pain/wt loss)
ERCP (evaluate ducts)
Tx for pancreatic CA?
msotly surgical resection… prognosis is poor
