Pancreas Flashcards
What is the BEST treatment of a PANCREATIC DUCT LEAK (post-op, etc.) even if the ASCITES it created is SIGNIFICANT?
ERCP with PD STENT placement
What are the RISK factors for POST-ERCP pancreatitis?
CONTRAST injection, YOUNG age, SOD indication
What should be done for ALL pancreatic cysts whether or not they are thought to be pseudocysts or not?
EUS/FNA (CEA, lipase, cytology)
What is the recommended TREATMENT for LARGE BILOMAS?
PERCUTANEOUS DRAIN and BILIARY STENT
In a patient with CHRONIC PANCREATITIS and a BILIARY STRICTURE, what is the CRITERIA for ERCP treatment?
CBD >12 mm and ALP >3 X normal
What is the BEST association for SOD?
BILIARY PAIN post-CHOLECYSTECTOMY
In which SOD TYPE is the use of Sphincter of Oddi Manometry (SOM) predictive of good outcome with ERCP/Sphincterotomy?
SOD Type-II
When is EUS/FNA needed for a MALIGNANT BILIARY OBSTRUCTION?
If planning on PRE-OP NEOADJUVANT therapy or there is a DELAY in SURGERY
If a patient presents with a MALIGNANT BILIARY OBSTRUCTION and has SURGERY planned soon, do they require biliary DRAINAGE (T.Bili <14)?
NO
Wht MUST be done PRIOR to an ERCP when a HILAR MALIGNANCY is suspected?
MRCP
Besides biliary obstruction, what can AMPULLARY TUMORS and pancreatic ADENOCARCINOMA cause?
Idiopathic PANCREATITIS
Prior POST-ERCP pancreatitis, FEMALE, previous ACUTE RECURRENT pancreatitis, suspected SOD, young age <40, ABSENCE of CHRONIC PANCREATITIS, NORMAL BILIRUBIN are all risk factors for?
Post-ERCP PANCREATITIS
At what AGE should a patient with a LYNCH genetic mutation be SCREENED for COLON cancer?
At the age of 20-25 and every 1-2 years thereafter
During the FIRST WEEK of treatment of ACUTE PANCREATITIS, what determines SEVERITY and PROGNOSIS?
The presence of ORGAN FAILURE (renal, pulmonary, cardiovascular)
How elevated do the AMYLASE/LIPASE values need to be to diagnose ACUTE PANCREATITIS?
3 X upper limit of normal
If concerned for NECROSIS in a patient with ACUTE PANCREATITIS, when should a CT scan WITH CONTRAST be performed?
At least 3 DAYS AFTER the diagnosis of pancreatitis
What should be performed in ALL patients in whom GALLSTONE PANCREATITIS is suspected?
US
Acute pancreatitis grade WITHOUT ORGAN FAILURE (renal, pulmonary, cardiovascular) WITHOUT LOCAL COMPLICATIONS (fluid collection, necrosis) WITHOUT SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?
MILD
Acute pancreatitis grade WITH TRANSIENT ORGAN FAILURE <48 HOURS (renal, pulmonary, cardiovascular) WITH LOCAL COMPLICATIONS (fluid collection, necrosis) WITH SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?
MODERATE
Based on an ADMISSION CT, can MILD ACUTE PANCREATITIS be radiologically diagnosed within the first 48 HOURS?
NO
Acute pancreatitis grade WITH PERSISTENT ORGAN FAILURE >48 HOURS (renal, pulmonary, cardiovascular)?
SEVERE
A patient who is >60 yo, BMI >30, first ACUTE PANCREATITIS attack, multiple COMORBIDITIES, PLEURAL EFFUSIONS, and SIRS have what type of prognosis?
MUCH HIGHER RISK for SEVERE PANCREATITIS
TWO or more of: Pluse >90 bpm; TEMP <36 C or >38 C; WBC <4,000 or >12,000; RESPIRATIONS >20 bpm; PCO2 <32 mm Hg is indicative of what?
Systemic Inflammatory Response Syndrome (SIRS)
Do the levels of AMYASE/LIPASE correlate with SEVERITY of ACUTE PANCREATITIS?
NO
What LABORATORY findings are SUGGESTIVE of SEVERE PANCREATITIS and likely the develoment of NECROSIS?
Hct >44, RISE in BUN after the FIRST 24 HOURS, ELEVATED Cr (>1.8)
In the setting of PERSISTENT MULTIORGAN FAILURE, what is the mortaity RISK for ACUTE PANCREATITIS?
50%
How does the presence of NECROSIS affect PROGNOSIS of ACUTE PANCREATITIS?
It does NOT, only if INFECTED NECROSIS
WHEN is HYDRATION the most important when treating ACUTE PANCREATITIS?
In the FIRST 6-12 HOURS (250 - 500 mL/hr)
How long CAN you wait in SEVERE PANCREATITIS before starting PO or TUBE FEEDS (preferred over parenteral)?
5 DAYS (only if PO not tolerated)
In MILD (no organ failure, no localized complications, no systemic complications) acute pancreatitis, WHEN should you FEED the patient and how?
EARLY ORAL (LOW FAT) when SYMPTOMS IMPROVE, without having to advance (for SEVERE, can wait 5 days but optional and via NGT if not tolerating PO)
A >3 X ELEVATION of ALT/AST in the presence of ACUTE PANCREATITIS is suggestive of what ETIOLOGY?
Gallstones
In a patient with ACUTE PANCREATITIS and COEXISTENT CHOLANGITIS, WHEN should the ERCP be performed?
WITHIN 24-72 HOURS
What DIFFERENTIATES a pancreatic PSEUDOCYST from WALLED-OFF PANCREATIC NECROSIS?
The LOCATION of the fluid collection (outside of the pancreas - pseudocyt, inside - necrosis)
What MUST be done when a pancreatic PSEUDOCYST becomes infected (abscess)?
DRAINAGE
What is it called when on a CONTRAST-ENHANCED CT in a patient with ACUTE PANCREATITIS, there is >30% of non-enhancement of the pancreas?
PANCREATIC NECROSIS (needs ICU monitoring) - avoid lines, parenteral nutrition to avoid infection
ACUTE PANCREATITIS, 7-14 DAYS after presentation, develops FEVER and LEUKOCYTOSIS?
INFECTED NECROSIS (biopsy to direct antibiotic choice)
WHEN is SURGICAL NECROSECTOMY (debridement) indicated for infected pancreatic necrosis?
4 WEEKS after initial hospital admission
WHEN is CHOLECYSTECTOMY indicated for a patient with ACUTE BILIARY PANCREATITIS?
SAME ADMISSION
Can PANCREATIC CANCER present as the FIRST ATTACK of PANCREATITIS?
YES (rarely)
What is the TIME frame for PREDICTING and for DEFINING severity in ACUTE PANCREATITIS?
48 HOURS (can predict before, can only define after)
Which CRYSTALLOID suspension is preferred but NOT MANDATORY for resusscitation of ACUTE PANCREATITIS?
Lactated Ringers (or NS)
Drinking ALCOHOL 4-5 drinks/day for 5-10 years with or without SMOKING (synergistic) can result in what CHRONIC condition of the PANCREAS?
CHRONIC PANCREATITIS
Mutations in which GENES are implicated in HEREDITARY chronic pancreatitis?
PRSS1, SPINK1, CFTR, CTRC, and claudin-2
PANCREATITIS presenting in a patient with BILIARY STRICTURES, HILAR LYMPHADENOPATHY, SCLEROSING SIALADENITIS, RETROPERITONEAL FIBROSIS, PSEUDOTUMORS and TUBULOINTERSTITIAL NEPHRITIS is what type?
AUTOIMMUNE PANCREATITIS TYPE-I (AIP type I) - IgG4 (>2 X ULN)
>10 IgG4 PLASMA cells per HPF in PANCREATIC BIOPSY means what?
TYPE-I AIP
How does AIP TYPE-II differ from AIP TYPE-I?
AIP TYPE-II occurs ONLY in the PANCREAS and is ASSOCIATED with IBD
Which AIP TYPE is associated with IBD?
AIP TYPE-II (pancreas involvement only)
PAINLESS JAUNDICE or ACUTE PANCREATITIS due to obstruction of the intra-pancreatic bile duct in a patient with NO OBSERVABLE pancreatic mass?
AIP
SAUSAGE-SHAPED pancreas with LOW-DENSITY RIM around the pancreas seen on CT?
AIP
Suggestive IMMAGING of the PANCREAS and pancreatic DUCT, SEROLOGY, OTHER ORGAN INVOLVEMENT, HISTOLOGY and response to STEROID THERAPY (the treatment) are the diagnostic criteria for what?
AUTOIMMUNE CHRONIC PANCRATITIS
Which TYPE of AIP REQUIRES a PANCREATIC BIOPSY?
AIP TYPE-II
What MUST be RULED OUT FIRST before initiating STEROIDS for presumed AIP?
PANCREATIC MALIGNANCY
What is the TREATMENT and its DURATION for AIP?
PREDNISONE 40 mg PO daily, tapering off by 5-10 mg/week for a total of 10-12 WEEKS
Which TYPE of AIP REPLAPSES (biliary strictures, jaundice) in 30-50% of patients and how is it treated?
AIP TYPE-I (repeat steroid taper) as azathioprine does not work and RITUXIMAB is used in REFRACTORY disease
A patient from SOUTHWEST INDIA presents with mutations in SPINK1 and CTRC, youth to early adulthood, abdominal pain, severe MALNUTRITION, EXOCRINE and ENDOCRINE pancreatic dysfunction, LARGE PD and PD STONES?
TROPICAL PANCREATITIS
What are the most SENSITIVE tests for diagnosing CHRONIC PANCREATITIS (can detect disease prior to developing exocrine/endocrine insufficiency)?
DIRECT HORMONAL STIMULATION TESTS (secretin stimulation test), a BICARBONATE concentration <80 meq/L after 60 min is ABNORMAL
What do SERUM TRYPSIONGEN (<20 ng/mL) and FECAL ELASTASE (<200 µg/g) signify?
Pancreatic INSUFFICIENCY due to CHRONIC PANCREATITIS
What are the RECOMMENDED initial IMAGING tests for dignosing CHRONIC PANCREATITIS?
MULTIDETECTOR-CT or MRI with MRCP
What are the AGENTS to use with CHRONIC PANCREATITIS PAIN?
TRAMADOL, PREGABALIN, TCA or SSRI or combined SSRI/NRI (duloxetine)
What is the DIFFERENCE between CELIAC PLEXUS BLOCK and CELIAC PLEXUS NEUROLYSIS?
BLOCK - BUPIVICANE only
NEUROLYSIS - addition of ABSOLUTE ALCOHOL
What can be done for chronic pancretitis PAIN if pt does not respond to medical or endoscopic therapy?
SURGERY (lateral pancreaticojejunostomy - modified PUSTEOW procedure) - with Roux-en-Y and immediate pain relief in 80% of patients
What are the TWO most significant causes of CHRONIC PANCREATITIS?
ALCOHOL and SMOKING
What should be considered in ALL patients after SUBTOTAL PANCREATECTOMY performed for chronic pancreatitis or otherwise?
Pancreatic ENZYME supplementation for likely sublte exocrine pancreatic defficiency
How many UNITS of LIPASE are delivered by the pancreas with a meal?
~900,000 USP (90,000 are required to eliminate steatorrhea)
What is IMPORTANT to keep in mind when prescribing pancreatic ENZYME supplementation?
Pancreatic ENZYMES MUST BE ENTERICALLY COATED or patient must be PRESCRIBED H2-blockers or PPIs
What ELSE must be done in patients with pancreatic exocrine insufficiency with STEATORRHEA besides ENZYME supplementation?
Supplementation of the FAT-SOLUBLE vitamins (D, E, K, A) as well as BONE DENSITY to prevent osteopenia and osteoporosis
What is DM Type 3C?
It is DIABETES MELLITUS associated DIRECTLY with ISLET CELL LOSS due to CHRONIC PANCREATITIS or other pancreatic diseases
What is the PREFERRED medication to use in patients with DM due to chronic pancreatitis?
METFORMIN (prevents adenocarcinoma)
The development on an ACUTE GIB in the presence of a PANCREATIC PSEUDOCYST is idicative of what?
PSEUDOANEURYSM (erosion of the pseudocyst into a vessel) 40% MORTALITY - emergent CT with IV contrast (high-density material) after negative EGD - small sentinel bleed followed days to weeks later by massive bleed
Which PANCREATIC CYSTS require SURGICAL removal?
MUCINOUS CYSTIC NEOPLASMS and IPMNs (>3 cm , growth of >3 mm/year, or if PD is >10 mm) or SOLID COMPONENT
SPLENIC VEIN thrombosis, SIBO, GASTROPARESIS are all complications of this condition?
Chronic Pancreatitis
Which AIP type is associated with IgG4?
TYPE-I (systemic and not just involving the pancreas)
In a patient with CHRONIC PANCREATITIS PAIN, if no stricture, no stone, s/p surgery but still with pain, why?
CNS sensitization, a nerve problem
Which pancreatic CYSTS have an OVARIAN-LIKE stroma?
MUCINOUS CYSTIC NEOPLASMS (MCN, not ipmn)
A CEA value of WHAT is considered elevated for a pancreatic CYST?
CEA >192
What is the recommendation for SURVEILLANCE (CT, MRI, EUS) of pancreatric CYSTS?
<10 mm, every 12 MONTHS
10 - 20 mm, 6-12 MONTHS
>20 mm, 3-6 MONTHS
IF NO CHANGE after 2 YEARS, lengthen the interval
What follow-up is required for a PANCREATIC REST?
NONE, its a benign lesion
In a patient with IDIOPATHIC PANCREATITIS, if EVERYTHING including EUS has been done without explanation, what would be the recommended next step?
EMPIRIC CHOLECYSTECTOMY
What should be done as far as FEEDING for a patient with NECROTIZING PANCREATITIS even if hypoactive bowel sounds?
TRIAL of PO FEEDING
In a patient with ACUTE NECROTIZING PANCREATITIS, with a FEVER and LEUKOCYTOSIS, when should you think of INFECTED NERCOSIS?
With ORGAN FAILURE and ~1 WEEK out, NOT EARLY in the process
Which GENE is MOSTLY associated with HEREDITARY (family members) CHRONIC PANCREATITIS?
PRSS1 (autosomal dominant)
In a patient with IDIOPATHIC PANCREATITIS but NO FAMILY HISTORY of heredity, which GENE is most likely mutated?
CFTR
HOW are GASTRIC VARICES (fundic) caused by SPLENIC VEIN THROMBOSIS treated?
These RARELY BLEED if caused by splenic vein thrombosis, and unless they do, NO INTERVENTION is required. If they do bleed, treat with SPLENECTOMY
4 cm CYST in TOP, with SEPTATIONS and scattered CALCIFICATIONS?
MUCINOUS CYSTIC NEOPLASM (MCN)
3 cm SIMPLE (no INTERNAL NODULES or SEPTATIONS) pancreatic CYST with ELEVATED CEA and MILD PD DILATION, what should be done NEXT?
IMAGING in 1 YEAR (SIMPLE cyst, even if mucinous)
Which IVF is the BEST for preventing ORGAN FAILURE and MORTALITY in a patient with ACUTE PANCREATITIS?
NONE, all the same (NS or LR)
Which FINDINGS on IMAGING of the pancreas correlate best with PANCREATIC PAIN?
NONE
What is the RECOMMENDED TREATMENT for a HEMORRHAGIC pancreatic PSEUDOCYST?
ANGIOGRAPHY with embolization
In ACUTE PANCREATITIS, which ENZYME (amylase or lipase) decreases to the reference range MUCH FASTER because that enzyme comes from MULTIPLE SOURCES and which of the TWO is SPECIFIC for PANCREATITIS?
AMYLASE normalizes MUCH FASTER (multiple sources)
LIPASE is SPECIFIC to the PANCREAS
At which LEVEL of HYPERTRIGLYCERIDEMIA is PANCREATITIS POSSIBLE?
>1,000 (with suppression of the rise amylase)
ACUTE LFT (ALT) elevations in a patient with PAIN, are STRONGLY INDICATIVE of what etiology of ACUTE PANCREATITIS?
BILIARY (stones, sludge)
What are the RISK FACTORS for SEVERE PANCREATITIS?
A pt’s AGE (>55), WEIGHT (BMI >30), HEMOCONCENTRATION and RESIRATORY COMPROMISE (organ failure at admission i.e. renal or pulm)
What is the RECOMMENDED INITIAL management of ACUTE PANCREATITIS?
AGGRESSIVE FLUID HYDRATION and CLOSE MONITORING
The DEGREE of HEMOCONCENTRATION is predictive of what in ACUTE PANCREATITIS?
HIGHER RISK for SEVERE COURSE
The HARMLESS ACUTE PANCREATITIS SCORE (HAPS) consists of WHAT values that can predict with 98% certainty that the pancreatitis course will be MILD to MODERATE?
ABSENCE of REBOUND, NORMAL Hct and NORMAL Cr
CT CHARACTERIZATION of ACUTE PANCREATITIS IF ACTUALLY NEEDED, should be done WHEN after presentation?
48-72 HOURS
WHEN should NUTRITION be instituted in ACUTE PANCREATITIS?
EARLY, within the FIRST 24-48 HOURS to maintain GUT INTEGRITY
HOW should ANALGESIA be administered for a patient with ACUTE PANCREATITIS?
(PATIENT-CONTROLLED ANALGESIA) PCA PUMP
In a patient with ACUTE PANCREATITIS who develops FEVER, LEUKOCYTOSIS, RESPIRATORY COMPROMISE, RENAL FAILURE (elevated Cr), HYPOTENSION, TACHYCARDIA, with CT demonstrating NECROSIS and FLUID CONSOLIDATION, what should be done?
ICU CARE and CT-GUIDED ASPIRTATION of PANCREAS (rule out infection) and ANTIBIOTIC therapy
YOUNG pt with ABDOMINAL PAIN, OBSTRUCTIVE JAUNDICE, and a DIFFUSELY ENLARGED PANCREAS on IMAGING, with NORMAL IgG4, no other organ involvement, NO STONES, NO ALCOHOL?
TYPE-2 AIP (GRANULOCYTE EPITHELIAL LESION with NEUTROPHILIC INFILTRATE in the PANCREATIC DUCT epithelium, OBLITERATING the LUMEN)
MUTATION in WHICH of the HEREDITARY CHRONIC PANCREATITIS GENES is most SPECIFIC for this CONDITION?
PRSS1 (R117H and N21I)
MUTATIONS in SPINK1 and CFTR are associated with what TYPE of PANCREATITIS?
IDIOPATHIC PANCREATITIS
PERSISTENT, MILD increase in serum AMYLASE levels may indicate WHAT if the LIPASE is normal?
MACROAMYLASEMIA (BENIGN)
WHAT ONE IMAGING FINDING of the PANCREAS (CT, EUS, ETC) is HIGHLY-SUGGESTIVE for CHRONIC PANCRETITIS?
INTRA-DUCTAL STONES
HOW MUCH of the PANCREATIC EXOCRINE FUNCTION must be LOST in order to have STEATORRHEA?
>90%
WHEN SHOULD PANCREATIC ENZYMES be taken when eating?
THROUGHOUT the MEAL, NOT BEFORE or AFTER (30,000 to 45,000 units of LIPASE per meal)
CORRECTION of STEATORRHEA with ORAL ENZYME SUPPLEMENTS is associated with CORRECTION of WHAT else?
CORRECTION of CARBOHYDRATE and PROTEIN MALABSORPTION
For patients who have PAIN due to CHRONIC CALCIFIC (pancreatic duct STONES) PANCREATITIS with a DILATED DUCT, what is the RECOMMENDED INTERVENTION?
LATERAL PANCREATICO-JEJUNOSTOMY
What is the RECOMMENDED management for a GALLBLADDER ADENOMA >18 mm (fixed, hyperechoic lesion, protruding into the GB lumen without shadowing)?
OPEN CHOLECYSTECTOMY (HIGH-LIKELIHOOD of ADVANCED CANCER)
In a patient who presents with ALCOHOLIC ACUTE PANCREATITIS and GB microlithiasis is found, what is done for the MICROLITHIASIS?
NOTHING, unless SECOND episode of acute pancreatitis occurs WITHOUT ALCOHOL involvement or another etiologic factor
What is the RECOMMENDATION for management of a PREGNANT woman with SYMTOMATIC GB disease?
CHOLECYSTECTOMY (laparoscopic, when possible)
Which PARASITES cause RECURRENT PYOGENIC CHOLANGITIS?
ASCARIS and OPISTHORCHIS
What COLORED BILIARY STONES are seen in patients with CYSTIC FIBROSIS, CHRONIC HEMOLYSIS, MECHANICAL HEART VALVES, CIRRHOSIS and GILBERT’s SYNDROME or who are on TPN?
BLACK - colored stones
What COLORED BILIARY STONES are seen in patients with BACTERIAL or PARASITIC infestation of the BILIARY SYSTEM?
BROWN - colored stones
What is a MICRO GALLBLADDER (2-3 cm in size) ASSOCIATED with?
CYSTIC FIBROSIS and NEONATAL HEPATITIS
What CONGENITAL GALLBLADDER TYPE is associated with risk of TORSION?
WANDERING GALLBLADDER (long mesentery, no firm attachment to the liver)
PHARYGIAN CAP, HOURGLASS GALLBLADDER, WANDERING GALLBLADDER and GALBLADDER AGENESIS are all which TYPE of variants?
CONGENITAL ANOMALIES (macro-galbladder is NOT congenital)
