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GI Boards November 20th 2024 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

TWO of which THREE criteria are REQUIRED for the diagnosis of ACUTE PANCREATITIS?

A
  1. Upper abdominal PAIN
  2. Elevated LIPASE or amylase 3xULN
  3. Evidence on IMAGING
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2
Q

What are the ONLY two indication for using CT imging in a patient with ACUTE PANCREATITIS?

A
  1. UNCLEAR diagnosis
  2. FAILURE to IMPROVE 48-72 hours post admission
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3
Q

Which LABS are significant in the DIAGNOSIS of ACUTE PANCREATITIS?

A

LIPASE, Hct, CRP, Cr, Trig, Ca

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4
Q

What IMAGING modality is almost ALWAYS indicated in patients with ACUTE PANCREATITIS?

A

Abdominal US

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5
Q

Acute pancreatitis SYMPTOMS in the presence of this LAB result is 95% specific for etiology of BILIARY pancreatitis?

A

ALT >150 U/L

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6
Q

What is the LIMITATION od abdominal US for diagnosing BILIARY pancreatitis in most and especially in OBESE patients?

A

Distal CBD stones

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7
Q

What are the RECOMMENDATIONS if acute PANCREATITIS is found on US to be caused by BILIARY STONES? SLUDGE?

A

STONES - cholecystectomy
SLUDGE - CONSIDER cholecystectomy

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8
Q

Besides ALCOHOL causing PANCREATITIS, what else does alcohol do to the pancreas?

A

SENSITIZES the pancreas to ANY OTHER ETIOLOGY

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9
Q

If SUSPECTING ALCOHOL as the etiology of acute pancreatitis but patient denies and no other causes are found, what TEST can you use to knoiw for sure?

A

PHOSPHATIDYLETHANOL

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10
Q

What is the TRIGLYCERIDE level that is considered a possibility as the etiologic factor for ACUTE PANCREATITIS?

A

>1000 mg/dL (usually UNCONTROLLED DM, normal amylase, treat with NPO and Insulin drip)

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11
Q

Which DIABETIC medications carry a RISK of ACUTE PANCREATITIS?

A

GLP-1 (-tide)
DPP-4 (-gliptin)

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12
Q

What CHEMOTHERAPY durg class carries a RISK of ACUTE PANCREATITIS?

A

CHECKPOINT INHIBITORS (PD-1, PD-L1, CTLA-4) - can cause lipase elevation without clinical pancreatitis

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13
Q

DEATH from LATE ACUTE PANCREATITIS (2-6 weeks) is caused by?

A

PERSISTENT ORGAN FAILURE, INFECTIONS

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14
Q

What are the FOUR predictors of ACUTE PANCREATITIS SEVERITY?

A
  1. OBESITY
  2. OLDER AGE
  3. SIRS
  4. ORGAN FAILURE
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15
Q

What is CRITICAL in the management of ACUTE PANCREATITIS?

A

EARLY (6-12 hours from presentation) AGGRESSIVE FLUID MANAGEMENT

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16
Q

Which is the PREFERRED IVF to use in treatment of ACUTE PANCREATITIS?

A

LR

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17
Q

HOW is PRESERVATION of gut MUCOSAL integrity and prevention of mitochondrial DYSFUNCTION achieved in the TREATMENT of MILD ACUTE PANCREATITIS?

A

EARLY (< 24 HRS) PO diet

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18
Q

Are PERSISTENT FLUCTUATING levels of LIPASE or amylase contraindications to ADVANCING DIET in a patient with ACUTE PANCREATITIS?

A

NO

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19
Q

In cases of SEVERE ACUTE PANCREATITIS where the patient CANNOT tolerate PO nutrition (nausea/vomiting), what is recommended?

A

NGT vs NJT nutrition NOT TPN

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20
Q

Besides HYDRATION to reduce inflammation in ACUTE PANCREATITIS, what other factor has been demonstrates to REDUCE MORTALITY, INFECTIONS and ORGAN FAILURE?

A

ENTERAL NUTRITION

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21
Q

In a patient with ACUTE PANCREATITIS who presents with CHOLANGITIS, when should an ERCP be done?

A

EMERGENT (under < 24 HRS)

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22
Q

In a patient with ACUTE PANCREATITIS who presents with RETAINED CBD STONE PRE/POST CHOLY, when should an ERCP be done?

A

URGENT (< 24 HRS)

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23
Q

In a patient with ACUTE PANCREATITIS who is NOT a surgical candidate for CHOLECYSTECTOMY, when should an ERCP be done?

A

NON-URGENT

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24
Q

Are PROPHYLACTIC ANTIBIOTICS recommended for NECROTIC pancreatic fluid collections?

A

NO

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25
Q

What is a MATURE pancreatic fluid collection known as?

A

WALLED-OFF NECROSIS vs acute necrotic collection (early)

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26
Q

What are the CONCERNS for an INFECTED WALLED-OFF pancreatic necotic collection?

A
  1. AIR loculations inside the collection on IMGAING
  2. Clinical DETERIORATION
  3. Gm STAIN positive of fluid sampling (FNA)
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27
Q

What is the FIRST step in TREATMENT of an INFECTED pancreatic NECROTIC FLUID COLLECTION?

A

DELAY >4 WEEKS + ANTIBIOTICS (if not improving, DRAIN or DEBRIDE)

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28
Q

After DISCHARGING a patient who recovered from IDIOPATHIC ACUTE PANCREATITIS, WHICH patients MUST be followed-up with IMAGING?

A

ALL those >40 YO (21% cancer risk)

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29
Q

In 20% of patients whom suffered an ACUTE episode of PANCREATITIS, what COMPLICATIONS can occur WITHIN 60 DAYS?

A

RE-ADMISSION for recurrence (can cause chronic pancreatitis)

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30
Q

In 25% of patients whom suffered an ACUTE episode of PANCREATITIS, what COMPLICATIONS can occur WITHIN 3 YEARS?

A

Development of DM

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31
Q

Which patients whom suffered from ACUTE PANCREATITIS tend to eventually develop CHRONIC PANCREATITIS?

A

Those with RECURRENT episodes and SMOKERS (independent risk factor)

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32
Q

What is the BEST way to PREVENT ACUTE BILIARY PANCREATITIS or its RECURRENCE?

A

SAME ADMISSION CHOLECYSTECTOMY

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33
Q

What is the BEST way to PREVENT IDIOPATHIC ACUTE PANCREATITIS or its RECURRENCE?

A

CHOLECYSTECTOMY after >2 unexplained episodes

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34
Q

A pathologic FIBRO-INFLAMMATORY syndeome diagnosed by IMAGING?

A

CHRONIC PANCREATITIS

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35
Q

ALCOHOL >4-5 drinks/day (40%) and SMOKING (25%) are independent RISK factors for?

A

CHRONIC PANCREATITIS

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36
Q

Most important GENE mutation in HEREDITARY PANCREATITIS (strong family histroy) is what?

A

PRSS1 - AUTOSOMAL DOMINANT (gain of function - excessive TRYPSIN activity)

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37
Q

Abnormalities in SALIVARY glands, KIDNEYS with elevated IgG4, CT shows SAUSAGE PANCREAS (diffusely enlarged with smooth borders) or CAPSULE SIGN?

A

AUTOIMMUNE PANCREATITIS (type-1)

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38
Q

This disease of the pancreas is HIGHLY respopnsive to STEROID therapy but there is a 50% risk of RELAPSE?

A

AUTOIMMUNE PANCREATITIS (type-1)

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39
Q

Pancreatitis that occurs in younger patients (50 yo), is SPECIFIC to ONLY the pancreas (no other organ involvement), LOW IgG4 presence, also respondes to STEROIDS with LOW risk of relapse and on histology the finding is a GRANULOCYTIC EPITHELIAL LESION?

A

AUTOIMMUNE PANCREATITIS (type-2)

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40
Q

What is an INDEPENDENT and DOSE-DEPENDENT strong risk factor for RECURRENT acute pancreatitis and CHRONIC pancreatitis?

A

SMOKING

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41
Q

Pancreatic CALCIFICATIONS noted on CT?

A

CHRONIC PANCREATIITS (also duct diltion and parenchymal atrophy)

42
Q

Which IMAGING modality is more SENSITIVE for DUCTAL changes (dilated MPD, dilated side branches) decreased T1 signal indicative of FIBROSIS and ATROPHY?

A

MRI

43
Q

Is EUS a SPECIFIC study for the diagnosis of CHRONIC pancreatitis?

A

NO (too sensitive - notes changes with smoking, age, etc)

44
Q

What is the WHO ANALGESIC LADDER to treat CHRONIC PANCREATITIS pain?

A
  1. OTC (acetaminophen, ibuprophen)
  2. Alternatives (TCAs, SSRIs, SNRIs)
  3. OPIOIDS (TRAMADOL, then more potent)
45
Q

Which NEUROLOGIC anlagesic has shown EFFICACY in treatment of CHRONIC PANCREATITIS pain?

A

PREGABALIN (gabapentinoid)

46
Q

Besides PREGABALIN, what else has been shown to be somewhat helpful when treating PAIN in CHRONIC PANCREATITIS patients?

A

ANTIOXIDANTS (vitamins A, C, E, selenium, methionine)

47
Q

What is the role of SURGERY in treating PAIN in CHRONIC PANCREATITIS?

A

To RELIEVE an OBSTRUCTION (PD, CBD, GOO) as well as remove occult MALIGNANCY

48
Q

Which has been shown to be more EFFICACIOUS in relieving PAIN of CHRONIC PANCREATITIS, endoscopic approach or surgical?

A

SURGICAL (80%) - relieve obstruction in PD, CBD, GOO

49
Q

What is DM-IIIC?

A

DM caused by CHRONIC PANCREATITIS (loss of ISLET cells, insulin deficiency)

50
Q

Is there medical treatment available to reverse the effects of CHRONIC PANCREATITIS or its sequela (DM, etc.)?

A

NO

51
Q

What should be SCREENED for ANNUALY in patients with CHRONIC PANCREATITIS?

A

DM (treat with metformin and insulin - watch for HYPOglycemia)
OSTEOPOROSIS (DXA)

52
Q

What SYMPTOMS occur decades after diagnosis of CHRONIC PANCREATITIS and SYMPTOMS should be screened for?

A

FAT MALDIGESTION (steatorrhea with greasy, oily stools, weight loss, bloating and flatulence)

53
Q

How much stool FAT is diagnostic for STEATORRHEA?

A

>7-15 g in 24 HRS

54
Q

Pancreatic enzyme supplementation should be started at what dose?

A

25,000 - 50,000 LIPASE UNITS/MEAL and 50% with SNACKS

55
Q

At what DEFICIENCY of LIPASE OUTPUT do you see STEATORRHEA?

A

< 10% of normal lipase output (90,000 UNITS)

56
Q

Why MUST pancreatic enzyme supplements be given with PPIs?

A

So as to AVOID gastric acid DEACTIVATION

57
Q

Metabolic BONE DISEASE such as OSTEOPENIA (40%) and OSTEOPOROSIS (25%) occur with this PANCREATIC disorder?

A

CHRONIC PANCREATITIS - chronic inflammatory state (low-trauma fractures)

58
Q

Is it RECOMMENDED to ROUTINELY SCREEN a patient with CHRONIC PANCREATITIS for PANCREATIC CANCER?

A

NO (incidence is there but < 5%)

59
Q

If a patiet has HEREDITARY PANCREATITIS (PRSS1) or TROPICAL PANCREATITIS (SPINK1) or developed DM due to CHRONIC PANCREATITIS, what should you DO?

A

SCREEN for PANCREATIC CANCER

60
Q

What VASCULAR complication can CHRONIC PANCREATITIS cause?

A

ISOLATED GASTRIC VARICES (splenic vein thrombosis)
Perform SPLENECTOMY if bleeding - curative

61
Q

Which VITAMIN defficiencies do you see with CHRONIC PANCREATITIS?

A

Fat soluble vitamins (A, D, E, K)

62
Q

Which MINERAL defficiencies do you see with CHRONIC PANCREATITIS?

A

MAGNESIUM & ZINK

63
Q

What happens nutritionally in CHRONIC PANCREATITIS besides vitamin and mineral deficiencies?

A

LOW BMI, SARCOPENIA (muscle wasting)

64
Q

What is HEMOSUCCUS PANCREATICUS?

A

In CHRONIC PANCREATITIS, bleeding that communicates with the pancreatic duct and presents as HEMOBILIA

65
Q

Which are the BENIGN pancreatic cysts?

A

Pseudocyst
Walled-Off Necrosis
Serous Cystadenoma

66
Q

Which are the PRE-CANCEROUS pancreatic cysts?

A

IPMN
Mucinous Cystadenoma
Solid Pseudopapillary Neoplasm
Pancreatic Neuroendocrine Tumor
Pancreatic Duct Adenocarcinoma

67
Q

What TESTS should aspirated pancreatic cysts be sent for (4)?

A

CEA (>192) - mucinous
Amylase
Glucose < 50 - mucinous
Cytology

68
Q

What feature of the major papilla is PATHOGOMONIC for a main-duct IPMN?

A

FISH MOUTH (mucin)

69
Q

What is done with MAJORITY of IPMNs?

A

RADIOGRAPHIC surveillance

70
Q

Which PANCREATIC CYST has OVARIAN STROMA?

A

MUCINOUS CYSTADENOMA (MCN)

71
Q

UNILOCULAR pancreatic cysts, usually located in BOP or TOP, 90% found in WOMEN and can have scattered CALCIFICATIONS?

A

MUCINOUS CYSTADENOMA (MCN)

72
Q

A MUCINOUS CYSTADENOMA is found in the pancreas which has an ENHANCING SOLID COMPONENT or MPD >10 mm or has CONCERNING CYTOLOGY or causes OBSTRUCTIVE JAUNDICE, what’s the RECOMMENDATION?

A

SURGERY

73
Q

A MIXED solid/cystic mass in the pancreas with CALCIFICATIONS, seen in YOUNG WOMEN, where the cancer risk is 15%?

A

Solid Pseudopapillary Neoplasm (SPN) - SURGERY

74
Q

A pancreatic lesion demonstrating ENHANCEMENT of the WALLS of the pancreatic cyst and associated with MEN-1?

A

Cystic Pancreatic NEUROENDOCRINE TUMOR (>2 cm SURGERY if NON-FUNCTIONAL, ie no symptoms associated with hormone production)

75
Q

Microcystic HONEYCOMB lesion of the panceas with multiple cysts (grapes), 25% have a CENTRAL CALCIFICATION, NO malignant potential, ONLY RESECT if large and SYMPTOMATIC?

A

SEROUS CYSTADENOMA

76
Q

These CYSTIC fluid collections occur as a result of TRANSIENT MPD leak with amylase >1,000 and occurr typically in patients with CHRONIC PANCREATITIS or can occur after severe acute pancreatitis?

A

PSEUDOCYSTS (no surveillance, ONLY treat if symptomatic)

77
Q

Pancreatic CYST, noted with DILATED MPD, possible Branch Duct - IPMN, next step?

A

EUS (further RISK stratification)

78
Q

Chronic pancreatitis (calcifications on CT) with WEIGHT LOSS but no mass on imaging, whats the NEXT step?

A

FECAL ELASTASE (check for pancreatic insufficiency)

79
Q

Worsening ASCENDING CHOLANGITIS with development of FEVER, LEUKOCYTOSIS, ICU care requiring INTUBATION due to worsening SpO2, SEPSIS and worsening LFTs, what’s the most INDICATED intervention?

A

ERCP

80
Q

RUQ pain, s/p cholecystectomy with unchanged pain, incosistent and very mild LFT elevation, normal CBD. NEXT step?

A

TCA (amitriptyline) for SOD likely Type 2

81
Q

In a patient with ACUTE NECROTIZING pancreatitis who was discharged home and presents < 4 WEEKS with abdominal pain and early satiety, imaging shows poorly demarcated necrosis, whats the NEXT step?

A

CONSERVATIVE management (not ready for drainage, or surgery)

82
Q

Patient with ACUTE RECURRENT pancreatitis, elevated LIPASE but normal LFTs and normal TRIGLYCERIDES, no family history, doesn’t drik or smoke. What’s the NEXT step?

A

EUS (neoplasm, sludge)

83
Q

In a patient with weight loss, CHRONIC IDIOPATHIC pancreatitis with evidence of EXOCRINE defficiency (low fecal elastase) with recent CT demonstrating atropy and dilated MPD, who has been started on pancreatic enzymes but still losing weight, what’s the NEXT step?

A

INCREASE enzyme supplementation to 90,000 units with each meal (if still not successful, add PPI or H2 blocker as the enzymes may be deactivated by gastric acid or hydrogen breath test for SIBO, but only after maximizing ezymes!!)

84
Q

ALL ERCP patients should receive WHAT periprocedurally to prevent ERCP-related PANCREATITIS?

A

RECTAL indomethacin

85
Q

Patient with MODERATE/SEVERE acute pancreatitis, with mildly distended abdomen and decreased bowel sounds not NO NAUSEA or VOMITING, NO REBOUND. What is the NUTRITIONAL recommendation?

A

TRIAL of PO DIET (no reason for NGT yet)

86
Q

In a patient with ACUTE NECROTIZING pancreatitis with LEUKOCYTOSIS and LOW-grade fever, no chnages in presentation otherwise, do you start antibiotics?

A

NO (only if localizing signs of infection, sepsis, etc.)
CONTINUE CONSERVATIVE therapy

87
Q

A genetic mutation in which GENE is likely to be present in a patient with CHRONIC PANCREATITIS with family history of chronic pancreatitis?

A

PRSS1 (autosomal DOMINANT)

88
Q

A COMMON mutation in this GENE is seen in the MAJORITY of CHRONIC IDIOPATHIC PANCREATITIS and has NO FAMILY HISTORY (autosomal recessive)?

A

CFTR

89
Q

In a patient presenting with a FOCAL abnormality of their pancreas, regardless of IgG4, obstructive JAUNDICE, DOUBLE duct sign, NARROWING of the distal CBD, whats the NEXT step?

A

EUS

90
Q

Patient with CHRONIC PANCREATITIS is found to have splenic vein thrombosis as well as large gastric fundic VARICES. They are on enzume supplementation and their weight is stable, what do you do?

A

CONTINUE PRESENT THERAPY (varices in pancreatitis are LESS LIKELY to BLEED and therefore NO PROPHYLAXIS is needed) - if these varices bleed, splenectomy is curative

91
Q

CYST found in the pancreas, has internal SEPTATIONS and scattrered CALCIFICATIONS, what type of cyst is this?

A

MUCINOUS CYSTIC NEOPLASM (mucinous cystadenoma) - usually in the TAIL and WOMEN

92
Q

Do ENTERIC COATED pancreatic enzymes need PPI or H2 blockers added to prevent gastric acid breakdown?

A

NO

93
Q

Patients with CHRONIC PANCREATITIS who have pancreatic INSUFFICIENCY with WIGHT loss whoudl also be tested for?

A

OSTEOPOROSIS (DXA scan)

94
Q

A patient with gallstone PANCREATITIS with imaging showing gallbladder stones, once pancreatitis cools off in 24-48 hours, what is recommended as the NEXT step is LFTs are normalizing?

A

CHOLECYSTECTOMY NOW (to prevent recurrence of pancreatitis) - ERCP with sphincterotomy only if NOT an operative candidate

95
Q

A pancreatic CYST is found on EUS to have MURAL NODULES, what is the NEXT step?

A

SURGICAL RESECTION (strong predictor of malignancy)

96
Q

If on EUS, you note a 3 cm LOW-RISK cyst such as BRANCH DUCT IPMN (main duct is NOT DILATED) and with CEA >192, what is the RECOMMENDATION?

A

MRI in 1 YEAR (imaging surveillance) - no high-risk features (dilated main duct, mural nodules) - size alone does NOT MATTER

97
Q

In a patient with HEMOSUCCUS PANCREATICUS (pancreatic pseudocyst with blood inside) what is the RECOMMNEDED treatment?

A

ANGIOGRAPHY for embolization

98
Q

What is the recommended TREATMENT for a PLEURAL EFFUSION caused by CHRONIC PANCREATITIS by pancreatico-pleural FISTULA?

A

ERCP with stenting of the pancreatic duct (treat the active pancreatic duct leak)

99
Q

Pancreatic CYST with MULTIPLE small microcystic components and a CENTRAL SCAR is what type of cyst?

A

SEROUS CYSTADENOMA

100
Q

Recurrent PANCREATITIS episodes from a YOUNG AGE with no family history and normal imaging and LFTs, what should be done NEXT?

A

GENETIC TESTING

101
Q

A patient with ACUTE NECROTIZING pancreatitis who deteriorates after 2 WEEKS of being hospitalized and develops INFECTION in the necrotic collection requiring PRESSORS, what do you do NEXT?

A

STEP-UP approach with first, a PERCUTANEOUS DRAIN placement (too early for surgery, usualy 4 weeks or if drain fails to improve symptoms)

GI Boards November 20th 2024 (11 decks)

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