Pancreas Flashcards
1
Q
TWO of which THREE criteria are REQUIRED for the diagnosis of ACUTE PANCREATITIS?
A
- Upper abdominal PAIN
- Elevated LIPASE or amylase 3xULN
- Evidence on IMAGING
2
Q
What are the ONLY two indication for using CT imging in a patient with ACUTE PANCREATITIS?
A
- UNCLEAR diagnosis
- FAILURE to IMPROVE 48-72 hours post admission
3
Q
Which LABS are significant in the DIAGNOSIS of ACUTE PANCREATITIS?
A
LIPASE, Hct, CRP, Cr, Trig, Ca
4
Q
What IMAGING modality is almost ALWAYS indicated in patients with ACUTE PANCREATITIS?
A
Abdominal US
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
6
Q
What is the LIMITATION od abdominal US for diagnosing BILIARY pancreatitis in most and especially in OBESE patients?
A
Distal CBD stones
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
8
Q
Besides ALCOHOL causing PANCREATITIS, what else does alcohol do to the pancreas?
A
SENSITIZES the pancreas to ANY OTHER ETIOLOGY
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
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)
11
Q
Which DIABETIC medications carry a RISK of ACUTE PANCREATITIS?
A
GLP-1 (-tide)
DPP-4 (-gliptin)
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
13
Q
DEATH from LATE ACUTE PANCREATITIS (2-6 weeks) is caused by?
A
PERSISTENT ORGAN FAILURE, INFECTIONS
14
Q
What are the FOUR predictors of ACUTE PANCREATITIS SEVERITY?
A
- OBESITY
- OLDER AGE
- SIRS
- ORGAN FAILURE
15
Q
What is CRITICAL in the management of ACUTE PANCREATITIS?
A
EARLY (6-12 hours from presentation) AGGRESSIVE FLUID MANAGEMENT
16
Q
Which is the PREFERRED IVF to use in treatment of ACUTE PANCREATITIS?
A
LR
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
18
Q
Are PERSISTENT FLUCTUATING levels of LIPASE or amylase contraindications to ADVANCING DIET in a patient with ACUTE PANCREATITIS?
A
NO
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
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
21
Q
In a patient with ACUTE PANCREATITIS who presents with CHOLANGITIS, when should an ERCP be done?
A
EMERGENT (under < 24 HRS)
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)
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
24
Q
Are PROPHYLACTIC ANTIBIOTICS recommended for NECROTIC pancreatic fluid collections?
A
NO
25
What is a **MATURE** pancreatic fluid collection known as?
**WALLED-OFF NECROSIS** vs acute necrotic collection (early)
26
What are the **CONCERNS** for an **INFECTED WALLED-OFF** pancreatic necotic collection?
1. **AIR** loculations inside the collection on **IMGAING**
2. Clinical **DETERIORATION**
3. **Gm STAIN** positive of fluid sampling (FNA)
27
What is the **FIRST** step in **TREATMENT** of an **INFECTED** pancreatic **NECROTIC FLUID COLLECTION**?
**DELAY >4 WEEKS + ANTIBIOTICS** (if not improving, DRAIN or DEBRIDE)
28
After **DISCHARGING** a patient who recovered from **IDIOPATHIC ACUTE PANCREATITIS**, **WHICH** patients **MUST** be followed-up with **IMAGING**?
**ALL** those **>40 YO** (21% cancer risk)
29
In **20%** of patients whom suffered an **ACUTE** episode of **PANCREATITIS**, what **COMPLICATIONS** can occur **WITHIN 60 DAYS**?
**RE-ADMISSION** for recurrence (can cause chronic pancreatitis)
30
In **25%** of patients whom suffered an **ACUTE** episode of **PANCREATITIS**, what **COMPLICATIONS** can occur **WITHIN 3 YEARS**?
Development of **DM**
31
Which patients whom suffered from **ACUTE PANCREATITIS** tend to eventually develop **CHRONIC PANCREATITIS**?
Those with **RECURRENT** episodes and **SMOKERS** (independent risk factor)
32
What is the **BEST** way to **PREVENT ACUTE BILIARY PANCREATITIS** or its **RECURRENCE**?
**SAME ADMISSION CHOLECYSTECTOMY**
33
What is the **BEST** way to **PREVENT IDIOPATHIC ACUTE PANCREATITIS** or its **RECURRENCE**?
**CHOLECYSTECTOMY** after **>2** unexplained **episodes**
34
A pathologic **FIBRO-INFLAMMATORY** syndeome diagnosed by **IMAGING**?
**CHRONIC PANCREATITIS**
35
**ALCOHOL** >4-5 drinks/day (40%) and **SMOKING** (25%) are independent **RISK** factors for?
**CHRONIC PANCREATITIS**
36
Most important **GENE** mutation in **HEREDITARY PANCREATITIS** (strong family histroy) is what?
**PRSS1** - **AUTOSOMAL DOMINANT** (gain of function - excessive TRYPSIN activity)
37
Abnormalities in **SALIVARY** glands, **KIDNEYS** with elevated **IgG4**, CT shows **SAUSAGE PANCREAS** (diffusely enlarged with smooth borders) or **CAPSULE SIGN**?
**AUTOIMMUNE PANCREATITIS** (type-1)
38
This disease of the pancreas is **HIGHLY** respopnsive to **STEROID** therapy but there is a **50%** risk of **RELAPSE**?
**AUTOIMMUNE PANCREATITIS** (type-1)
39
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**?
**AUTOIMMUNE PANCREATITIS** (type-2)
40
What is an **INDEPENDENT** and **DOSE-DEPENDENT** strong risk factor for **RECURRENT** acute pancreatitis and **CHRONIC** pancreatitis?
**SMOKING**
41
Pancreatic **CALCIFICATIONS** noted on **CT**?
**CHRONIC PANCREATIITS** (also duct diltion and parenchymal atrophy)
42
Which **IMAGING** modality is more **SENSITIVE** for **DUCTAL** changes (dilated MPD, dilated side branches) decreased T1 signal indicative of **FIBROSIS** and **ATROPHY**?
**MRI**
43
Is **EUS** a **SPECIFIC** study for the diagnosis of **CHRONIC** pancreatitis?
**NO** (too sensitive - notes changes with smoking, age, etc)
44
What is the **WHO ANALGESIC LADDER** to treat **CHRONIC PANCREATITIS** pain?
1. **OTC** (acetaminophen, ibuprophen)
2. **Alternatives** (**TCAs**, **SSRIs**, SNRIs)
3. **OPIOIDS** (**TRAMADOL**, then more potent)
45
Which **NEUROLOGIC** anlagesic has shown **EFFICACY** in treatment of **CHRONIC PANCREATITIS** pain?
**PREGABALIN** (gabapentinoid)
46
Besides **PREGABALIN**, what else has been shown to be somewhat helpful when treating **PAIN** in **CHRONIC PANCREATITIS** patients?
**ANTIOXIDANTS** (vitamins A, C, E, selenium, methionine)
47
What is the role of **SURGERY** in treating **PAIN** in **CHRONIC PANCREATITIS**?
To **RELIEVE** an **OBSTRUCTION** (PD, CBD, GOO) as well as remove occult **MALIGNANCY**
48
Which has been shown to be more **EFFICACIOUS** in relieving **PAIN** of **CHRONIC PANCREATITIS**, endoscopic approach or surgical?
**SURGICAL** (80%) - relieve obstruction in PD, CBD, GOO
49
What is **DM-IIIC**?
DM caused by **CHRONIC PANCREATITIS** (loss of ISLET cells, insulin deficiency)
50
Is there medical treatment available to reverse the effects of **CHRONIC PANCREATITIS** or its sequela (DM, etc.)?
**NO**
51
What should be **SCREENED** for **ANNUALY** in patients with **CHRONIC PANCREATITIS**?
**DM** (treat with metformin and insulin - watch for **HYPO**glycemia)
**OSTEOPOROSIS** (DXA)
52
What **SYMPTOMS** occur decades after diagnosis of **CHRONIC PANCREATITIS** and **SYMPTOMS** should be screened for?
**FAT MALDIGESTION** (steatorrhea with greasy, oily stools, weight loss, bloating and flatulence)
53
How much stool **FAT** is diagnostic for **STEATORRHEA**?
**>7-15 g in 24 HRS**
54
**Pancreatic enzyme** supplementation should be started at what **dose**?
**25,000 - 50,000 LIPASE UNITS/MEAL** and **50%** with **SNACKS**
55
At what **DEFICIENCY** of **LIPASE OUTPUT** do you see **STEATORRHEA**?
**< 10%** of normal lipase output (**90,000 UNITS**)
56
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Why **MUST** pancreatic enzyme supplements be given with **PPIs**?
So as to **AVOID** gastric acid **DEACTIVATION**
57
Metabolic **BONE DISEASE** such as **OSTEOPENIA** (40%) and **OSTEOPOROSIS** (25%) occur with this **PANCREATIC** disorder?
**CHRONIC PANCREATITIS** - chronic inflammatory state (low-trauma fractures)
58
Is it **RECOMMENDED** to **ROUTINELY SCREEN** a patient with **CHRONIC PANCREATITIS** for **PANCREATIC CANCER**?
**NO** (incidence is there but < 5%)
59
If a patiet has **HEREDITARY PANCREATITIS** (**PRSS1**) or **TROPICAL PANCREATITIS** (**SPINK1**) or developed **DM** due to **CHRONIC PANCREATITIS**, what should you **DO**?
**SCREEN** for **PANCREATIC CANCER**
60
What **VASCULAR** complication can **CHRONIC PANCREATITIS** cause?
**ISOLATED GASTRIC VARICES** (splenic vein thrombosis)
Perform **SPLENECTOMY** if bleeding - curative
61
Which **VITAMIN** defficiencies do you see with **CHRONIC PANCREATITIS**?
Fat soluble vitamins (A, **D**, E, **K**)
62
Which **MINERAL** defficiencies do you see with **CHRONIC PANCREATITIS**?
**MAGNESIUM** & **ZINK**
63
What happens nutritionally in **CHRONIC PANCREATITIS** besides vitamin and mineral deficiencies?
**LOW BMI**, **SARCOPENIA** (muscle wasting)
64
What is **HEMOSUCCUS PANCREATICUS**?
In **CHRONIC PANCREATITIS**, bleeding that communicates with the pancreatic duct and presents as **HEMOBILIA**
65
Which are the **BENIGN** pancreatic cysts?
**Pseudocyst**
**Walled-Off Necrosis**
**Serous Cystadenoma**
66
Which are the **PRE-CANCEROUS** pancreatic cysts?
**IPMN**
**Mucinous Cystadenoma**
**Solid Pseudopapillary Neoplasm**
**Pancreatic Neuroendocrine Tumor**
**Pancreatic Duct Adenocarcinoma**
67
What **TESTS** should aspirated pancreatic cysts be sent for (4)?
**CEA** (>192) - mucinous
**Amylase**
**Glucose** < 50 - mucinous
**Cytology**
68
What feature of the major papilla is **PATHOGOMONIC** for a main-duct **IPMN**?
**FISH MOUTH** (mucin)
69
What is done with **MAJORITY** of **IPMNs**?
**RADIOGRAPHIC** surveillance
70
Which **PANCREATIC CYST** has **OVARIAN STROMA**?
**MUCINOUS CYSTADENOMA** (MCN)
71
**UNILOCULAR** pancreatic cysts, usually located in **BOP** or **TOP**, **90%** found in **WOMEN** and can have scattered **CALCIFICATIONS**?
**MUCINOUS CYSTADENOMA** (MCN)
72
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**?
**SURGERY**
73
A **MIXED** solid/cystic mass in the pancreas with **CALCIFICATIONS**, seen in **YOUNG WOMEN**, where the cancer risk is 15%?
**Solid Pseudopapillary Neoplasm** (SPN) - SURGERY
74
A pancreatic lesion demonstrating **ENHANCEMENT** of the **WALLS** of the pancreatic cyst and associated with **MEN-1**?
Cystic Pancreatic **NEUROENDOCRINE TUMOR** (**>2 cm SURGERY** if NON-FUNCTIONAL, ie no symptoms associated with hormone production)
75
Microcystic **HONEYCOMB** lesion of the panceas with multiple cysts (grapes), 25% have a **CENTRAL CALCIFICATION**, **NO** malignant potential, **ONLY RESECT** if large and **SYMPTOMATIC**?
**SEROUS CYSTADENOMA**
76
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?
**PSEUDOCYSTS** (no surveillance, ONLY treat if symptomatic)
77
Pancreatic **CYST**, noted with **DILATED MPD**, possible Branch Duct - **IPMN**, next step?
**EUS** (further RISK stratification)
78
Chronic pancreatitis (calcifications on CT) with **WEIGHT LOSS** but no mass on imaging, whats the **NEXT** step?
**FECAL ELASTASE** (check for pancreatic insufficiency)
79
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?
**ERCP**
80
**RUQ** pain, s/p cholecystectomy with unchanged pain, incosistent and very mild LFT elevation, normal CBD. **NEXT** step?
**TCA** (**amitriptyline**) for **SOD** likely **Type 2**
81
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?
**CONSERVATIVE** management (not ready for drainage, or surgery)
82
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?
**EUS** (neoplasm, sludge)
83
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?
**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
**ALL ERCP** patients should receive **WHAT** periprocedurally to prevent ERCP-related **PANCREATITIS**?
**RECTAL** indomethacin
85
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?
TRIAL of **PO DIET** (no reason for NGT yet)
86
In a patient with **ACUTE NECROTIZING** pancreatitis with **LEUKOCYTOSIS** and **LOW-grade fever**, no chnages in presentation otherwise, do you start antibiotics?
**NO** (only if localizing signs of infection, sepsis, etc.)
**CONTINUE CONSERVATIVE** therapy
87
A genetic mutation in which **GENE** is likely to be present in a patient with **CHRONIC PANCREATITIS** with family history of chronic pancreatitis?
**PRSS1** (autosomal **DOMINANT**)
88
A **COMMON** mutation in this **GENE** is seen in the **MAJORITY** of **CHRONIC IDIOPATHIC PANCREATITIS** and has **NO FAMILY HISTORY** (autosomal recessive)?
**CFTR**
89
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?
**EUS**
90
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?
**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
**CYST** found in the pancreas, has internal **SEPTATIONS** and scattrered **CALCIFICATIONS**, what type of cyst is this?
**MUCINOUS CYSTIC NEOPLASM** (mucinous cystadenoma) - usually in the **TAIL** and **WOMEN**
92
Do **ENTERIC COATED** pancreatic enzymes need **PPI** or **H2** blockers added to prevent gastric acid breakdown?
**NO**
93
Patients with **CHRONIC PANCREATITIS** who have pancreatic **INSUFFICIENCY** with **WIGHT** loss whoudl also be tested for?
**OSTEOPOROSIS** (**DXA** scan)
94
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?
**CHOLECYSTECTOMY NOW** (to prevent recurrence of pancreatitis) - ERCP with sphincterotomy only if NOT an operative candidate
95
A pancreatic **CYST** is found on **EUS** to have **MURAL NODULES**, what is the **NEXT** step?
**SURGICAL RESECTION** (strong predictor of malignancy)
96
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**?
**MRI** in **1 YEAR** (imaging surveillance) - no high-risk features (dilated main duct, mural nodules) - size alone does NOT MATTER
97
In a patient with **HEMOSUCCUS PANCREATICUS** (pancreatic pseudocyst with blood inside) what is the **RECOMMNEDED** treatment?
**ANGIOGRAPHY** for embolization
98
What is the recommended **TREATMENT** for a **PLEURAL EFFUSION** caused by **CHRONIC PANCREATITIS** by pancreatico-pleural **FISTULA**?
**ERCP** with stenting of the pancreatic duct (treat the active pancreatic duct leak)
99
Pancreatic **CYST** with **MULTIPLE** small microcystic components and a **CENTRAL SCAR** is what type of cyst?
**SEROUS CYSTADENOMA**
100
Recurrent **PANCREATITIS** episodes from a **YOUNG AGE** with no family history and normal imaging and **LFTs**, what should be done **NEXT**?
**GENETIC TESTING**
101
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**?
**STEP-UP** approach with first, a **PERCUTANEOUS DRAIN** placement (too early for surgery, usualy 4 weeks or if drain fails to improve symptoms)
