Pancreas Flashcards
pt px w/ epigastric pain radiating to back
elevated lipase/amylase
what imaging do you get first?
U/S
In Pancreatitis an Elevated __ is the worst prognosis
BUN
Common causes of acute pancreatitis: (3) Hypercalcemia Post-\_\_\_\_ Scorpion stings Infections (CMV) Drugs (valproate, thiazides)
Alcohol use
Gallstones
Hyper Triglyceridemia
Post- ERCP
Diagnosis of Acute Pancreatitis requires 2 of the following 1. \_\_ 2. \_\_ 3. On u/s enlarged pancreas On abdominal x-ray: Sentinel loop sign Colon cut off sign
- Acute epigastric pain radiating to the back
2. Amylase or Lipase 3x> normal
ALT > ___ suggests gallstone pancreatitis
150
__ is characterized by intermittent epigastric pain that radiates to the back and worsens after meals.
+/- steatorrhea
+/- h/o Diabetes
Chronic pancreatitis
Chronic pancreatitis
Imaging demonstrates pancreatic atrophy and __, in some cases.
calcifications
Management of chronic pancreatitis
Pancreatic enzyme supplementation
(lipase, protease, amylase)
is used to treat both exocrine insufficiency and pain
(smoking/etoh cessation)
3 causes of chronic pancreatitis
- ___
- ___
- Autoimmune
- Alcohol/Tobacco use
2. Cystic Fibrosis
___ is a rare complication of chronic pancreatitis that results from damage to the pancreatic duct, leading to leakage of pancreatic juice into the peritoneal space.
Pancreatic ascites
Like ascites from other causes, sxs include abdominal distension, dyspnea, and early satiety
Pt presents with epigastric TTP & early satiety
Physical exam significant for shifting dullness & fluid wave.
Serum albumin is low at 3.4 mg/dL.
Paracentesis reveals serosanguinous fluid showing high
levels of total protein & amylase.
Diagnosis
Pancreatic ascites
___ is the most common complication after ERCP
Acute pancreatitis
Order Amylase & Lipase levels first
Pancreatic ___ is an encapsulated area (composed of enzyme-rich fluid, tissue, and debris) that causes an inflammatory response.
pseudocyst
Diagnosis is confirmed by abdominal imaging
For pts w/ pancreatic pseudocyst & minimal or no symptoms and without complications __ management is preferred.
expectant
This procedure is typically reserved for patients w/ pancreatic pseudocyst & significant symptoms:
(abdominal pain, vomiting),
infected pseudocyst,
or evidence of pseudoaneurysm.
Endoscopic drainage
Initial management in pts with acute pancreatitis presenting with epigastric pain and vomiting includes
(4)
NPO
IVF
NGT
Analgesia (NSAIDS; Opioids)
- Early oral feeding (w/in 24 hrs) as tolerated or Enteral tube (nasogastric or nasojejunal)
- If s/t gallstones → ERCP (within < 24 hours indicated if concurrent cholangitis) → cholecystectomy
Pancreatic ___ can be 2/2 Acute Pancreatitis or abdominal trauma
It can eventually progress to ___ or ___
abscess
pancreatic pseudocyst
chronic pancreatitis
Edematous pancreatitis commonly occurs 2/2 alcohol use or post ___
Laryngeal interventions
Type of pancreatitis that presents with:
- ↑ HCT
- ↓ HCT
- Edematous
2. Hemorrhagic
Pancreatic abscess or necrosis seen on CT
What is the first and second step in management?
First: ABxs
Second: Drain (percutaneous/open)
Pancreatic ___ can be 2/2 Acute Pancreatitis or abdominal trauma.
It presents weeks after acute pancreatitis, deep mass, early satiety, and abdominal pain.
Pseudocyst
In Pancreatic Pseudocysts
Get U/S or CT
If ≤6cm & ≤6 weeks old → ____
If >6cm & >6 weeks old → ____
Observe
Percutaneous drainage
Chronic Pancreatitis commonly 2/2 multiple pancreatic episodes.
Management includes:
Insulin
Pancreatic Enzyme replacement
+/- MRCP (drain pancreatic duct)
In hemorrhagic pancreatitis obtain daily ___ and start the patient on ___
CT scans
Abxs
Gallstone Pancreatitis presents with sxs of cholangitis and elevated amylase/lipase.
Obtain U/S
Initial management includes (3) followed by ___
NPO, NGT, IVFs
Cholecystectomy
(+/-) ERCP or sphincterotomy
Skin changes (rare)
Cullen sign: periumbilical ecchymosis and discoloration
Grey Turner sign: flank ecchymosis with discoloration
Fox sign: ecchymosis over the inguinal ligament
suggest what diagnosis
Acute Pancreatitis
_____ in the first 12–24 hours has the greatest impact on the clinical outcome of patients with acute pancreatitis.
IVF resuscitation
___ are not recommended in acute pancreatitis, and should only be used in pts with evidence of infected necrosis.
Prophylactic antibiotics
Bowel rest is no longer routinely recommended for acute pancreatitis.
___ nutrition should be initiated as early as tolerated.
Ideally within 24 hrs.
Enteral (via oral or enteral tube/NGT)
Urgent __ is not indicated in acute gallstone pancreatitis unless acute cholangitis is present.
ERCP
*Cholecystectomy in all pts to prevent recurrence
What lung manifestation can occur in acute pancreatitis?
Pleural effusion and/or ARDS
In Chronic Pancreatitis ↓ ___ confirms steatorrhea is due to pancreatic lipase insufficiency
Fecal elastase-1
Analgesics used for pancreatitis include
NSAIDs &
Opioids (fentanyl or ___)
for severe pain
hydromorphone
Necrotizing pancreatitis
necrosis of pancreatic tissue
Clinical features:
Fever, persistent tachycardia, or insufficient symptomatic ___ over several days
Treatment
Can usually be managed conservatively
Encourage enteral nutrition if feasible.
improvement
Necrostomy is severe
Infected necrotizing pancreatitis
Bacterial superinfection of necrotic pancreatic parenchyma
Clinical features:
persistent or worsening leukocytosis, bacteremia, & inflammatory markers
CT abdomen: gas or fluid around/in the pancreas
Treatment:
Antibiotics
Drain is clinical deterioration or no improvements w/Abxs
A STEP-wise approach to diagnosing chronic pancreatitis may include: Survey, Tomography/imaging, Endoscopic imaging, and Pancreatic function testing.
Abdominal CT (with and without contrast) or MRCP/MRI
Pancreatic enzyme levels are often normal in ____ and cannot be used to confirm or rule out the diagnosis.
chronic pancreatitis
*Acute pancreatitis always causes significant enzyme elevation.
Complication of chronic pancreatitis
Encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis
+/- Features:
Painless abdominal mass
Gastric outlet obstruction (early satiety, NB emesis, abd pain)
Pancreatic pseudocysts
*Splenic vein thrombosis is another cx
Courvoisier sign: enlarged, nontender gallbladder and painless jaundice
&
Trousseau syndrome: superficial thrombophlebitis
suggests what pancreatic cause?
pancreatic cancer
- MCC: ductal adenocarcinoma (95%)
- Lymphatic & Hematogenous spread
Double-duct sign
Increasing size of ___ tumor may block bile drainage in the CBD & pancreatic duct leading to dilatation of both.
pancreatic head
Pancreatic head carcinoma treatment:
Pancreaticoduodenectomy (Whipple procedure)
*Resection of the pancreatic head, distal stomach (antrum/pylorus), duodenum, proximal jejunum, gallbladder, CBD, lymphadenectomy, and reconstruction via Roux-en-Y.
Pancreatic body and tail carcinoma treatment:
Resection of the pancreatic body & tail with splenectomy
*In some cases, Duodenum is resected also
Palliative approach to pancreatic cancer:
- Pain management: opioids
- _____: for symptomatic metastasis, especially to the brain and bones
- _____: when pain management fails
- Radiotherapy
3. Celiac ganglion/plexus block
2 indications for Whipple’s Procedure
Pancreaticoduodenectomy
- Periampullary tumors
2. Chronic pancreatitis
[Procedure] is recommended in patients with gallstone pancreatitis who have cholangitis, visible common bile duct dilation/obstruction, or increasing liver enzyme levels.
Endoscopic retrograde cholangiopancreatography (ERCP)
*Allows for cannulation and sphincterotomy to relieve the obstruction.
A pancreaticopleural fistula (between the pancreatic duct and the pleural space) resulting in an amylase-rich exudative pleural effusionoccurs most commonly as a result of _____.
acute or chronic pancreatitis
Management includes bowel rest to promote fistula closure +/- ERCP
Imaging study performed in all patients with suspected gallstone-induced pancreatitis.
Abd U/S
