Pancreas Flashcards
What is the most effective dose of pancreatic enzyme replacement for pancreatic insufficiency?
A starting dose of 40,000 to 50,000 USP units of lipase is recommended with dose increase up to 90,000 USP units of lipase based on response to treatment.
What is the differential for obstructive jaundice?
pancreatic cancer
-elevated IgG4
-atrophic pancreas
-dilated ducts
autoimmune pancreatitis
-elevated IgG4
-sausage-like pancreatic tissue with rim like hypoenhanement
-narrow bile ducts without marked upstream dilation
What are the features of autoimmune pancreatitis?
histology
imaging
serology
histology- lymphoproliferative infiltrate
imaging- pancreatic lesion with rim hypoenhancement, diffusely enlarged pancreas, can have biliary stricture
serology- elevated IgG4 >2x ULN, can also have elevated CA 19-9
What are the differences between AIP type 1 and type 2. Which is more likely to relapse?
Type 1- typically presents with painless jaundics, IgG4 related, associated with systemic disease (salivary gland, secondary sclerosing cholangitis, RP, lungs), high risk of relapse so may need maintenance, can use 1. pred or 2. rituximab
Tyle 2- typically presents with pancreatitis, low IgG4 levels, no systemic involvement, associated with iBD, low risk of relapse once treated
Autoimmune pancreatitis
diffusely enlarged pancreas, can also have areas of rim enhancement
can’t distinguish between type 1 or type 2 based on radiologic imaging alone
What are the features of chronic pancreatitis on EUS?
(Minimal standard terminology- MST)
lobularity
cysts
hyperechoic foci and strands
calcification of the duct
main PD dilation or irregularity
visible side-branches
What are the most common meds associated with acute pancreatitis?
AZA, 6-MP, ACE-I, valproate, lasix, cimetidine, estrogens, tetracycline, HCTZ, salicylates, metronidazole
Atlanta criteria
<4 weeks
acute peri-pancreatic fluid collection
acute necrotic collection
> 4 weeks
pseudocyst
WON
What are the genetic causes of pancreatitis?
PRSS1- AD inheritance
The following mutations predispose to pancreatitis
CFTR mutation > SPINK-1 (AR inheritance)
What are the diagnostic tests for pancreatic insufficiency?
fecal elastase <100, 72hr fecal fat >7g (while eating fat diet) - start with 40 to 50,000 U lipse/meal
fat soluble vitamin deficiencies
What are the complications of CPI?
osteoporosis
pancreatic ascites (amylase >1000) Rx with TPN and octreotide
splenic thrombosis and IGV - if h/o bleeding then get splenectomy
What is this and how is it managed?
Mucionus cystic neoplasm
CEA >200
low amylase
glucose <50
found in body and tail of pancreas
+malignant potential, surgical resection needed
IPMN
CEA >200
high amylase because connected to ducts
What are the worrisome features of an IPMN
-Main duct IPMN
-size >3cm
-enhancing mural nodule <5 = EUS, >5= surgery
-PD dilation >5 = EUS, >10 = -surgery
-growth >5mm/ 2 years
Serous cyst adenoma
multiple microcysts with a central scar (honeycomb appearance)
low CEA, low amylase
low malignant potential, only remove if symptomatic
Serous cyst adenoma
multiple microcysts with a central scar (honeycomb appearance)
low CEA, low amylase
low malignant potential, only remove if symptomatic
Solid pseudopapillary neoplasm
young women
low cea and amylase
solid and cystic components
+malignancy, remove and annual surveillance
How are cholesterol gallstones made?
supersaturation and nucleation grown
cholesterol crystal
How are pigmented stones made?
precipitation
made from calcium bilirubinate
Black- unconjucated bili (i.e. hemolytic anemia, SC)
Brown= stasis or infection, often seen >2 years after cholecystectomy
What are the indications for cholecystectomy?
-porcelain GB (GB wall calcifications)
-APBJ
-Polyp >8cm in PSC or >10cm in avg risk (follow with US q6-12 mo)
-use of somatostatin analog in pt with gallstones
-chronic salmonella
What are the causes of bile leak after cholcystectomy?
cystic duct stump
ducts of luschka (from R IH ducts that connect directly with gb)
What are the high risk and int risk criteria for choledocho?
HIGH RISK
-stone visualized
-cholangitis
-TB >4 and CBD >6 w/ GB or >8 w/o GB
INT RISK
-age >55
-abnormal LFTs
-CBD dilated
how do you remove a CBD stone >1cm?
sphincterotomy and large balloon transpapillary dilation
What is the rome criteria for sphincter of oddi dysfunction?
Need all 3
-biliary pain
-AST/ALT >3x ULN
-CBD>10
Perform sphincterotomy
suspected SOD
-biliary pain
-either increased LFTs or CBD dilation
controversial- ERCP +/- manometry
What are the RF for shpincter of oddi dysfunction?
- after cholecystecomy with ongoing biliary colic
- recurrent idopathic pancreatitis
- biliary pain in pt with GB intact and no gallstone (controversial)
What is the typical presentation for choledochal cysts and what are they associated with?
jaundice, fever, pancreatitis, pain
associated with APBJ, cholangio, GB cancer, pancreatic cancer
Describe the 5 types of choledochal cysts and how they are treated.
Type 3 can be treated with sphincterotomy, the rest need surgery
What are the common causes of bile duct leak and how are they managed?
Large biloma needs PTC
post CCY- cystic duct stpump >ducts of lushka; Rx with plastic stent x 4 weeks, CHD injury = surgery
post OLT- plastic stent
trauma/liver injury
How to manage hilar strictures?
Get MRI then EUS/FNA
don’t routinely stent with ERCP, just sent to surgery
Type 3 choledochal cyst
What is the most common GI manifestation in cystic fibrosis?
exocrine insufficiency
What is a functional test for chronic pancreatitis?
Pancreatic function testing with secretin can assess pancreatic ductal function by measuring duodenal concentrations of bicarbonate after intravenous administration of secretin.
pancreatic lesions in Von Hippel-Lindau disease
pancreatic abnormalities, with pancreatic cysts being the most common. These are most commonly serous cystadenomas and thus not at risk of malignant transformation.
