Pancreas Flashcards
Epigastric pain, usually sudden, steady/severe with radiation to the back
Worse with walking or lying supine
Relieved with leaning forward and eating
N/V, sweating, weakness, abdominal distention
Often preceded by ETOH intake or heavy meal
acute pancreatitis
What puts someone at higher risk for pancreatitis?
smoking, high glycemic load, abdominal fat
What puts someone at lower risk for pancreatitis
vegetable consumption, dietary fiber, statins
Gallstones or alcohol abuse
Trypsinogen → trypsin causing autodigestion of pancreas
Mild = absence of organ failure and local/systemic complications
Moderate = transient organ failure and/or local or systemic complications (<48h) w/o persistent organ failure (>48h)
Severe = persistent organ failure that may involve one or multiple organs
acute pancreatitis
what score do you use to evaluate an acute pancreatitis patient’s mortality?
Risk for mortality = BISAP score
BUN>25
Impaired mental status
SIRS
Age >60
Pleural effusions
PE: tenderness to upper abdomen, abdominal distention, bowel sounds absent if associated ileus
Severe = fever, tachycardia, mild jaundice, dyspnea, upper abdominal mass
HOTN, pallor, cool clammy skin = poor prognosis
Cullen’s sign, Grey Turner’s sign
LABS: serum amylase and lipase elevated w/n 24 hours (best initial test)
Elevated WBC, glucose, bilirubin, AKI, alk phos, cytokines, inflammatory mediators, proteinuria, granular casts, glycosuria, hypocalcemia
ALT>150 = biliary pancreatitis
TG>1000
Abdominal CT for uncertain= sentinel loop of localized ileus; Colon cutoff sign (collapse of colon near pancreas)
EUS/MRCP if associated cholangitis or jaundice
acute pancreatitis
What are the diagnostic criteria for acute pancreatitis?
NEED ⅔:
Abdominal pain
Biochemical evidence (lipase or amylase 3x normal)
Radiographic evidence of acute pancreatitis
How do you treat acute pancreatitis?
NPO → rest pancreas
gradual feeding with low fat diet when free of abdominal pain and bowel sounds return
clear liquids → low fat diet → normal meals
IV fluid resuscitation
Pain control with NSAIDs, tylenol, meperidine
Bedrest
Hydration (LR>NS)
Gallstones = cholecystectomy
Aggressive IV fluids, hemodynamic monitoring in ICU, calcium gluconate if low calcium
+/- PBRC for volume replacement
Vasopressors if persistent hypovolemia
NG tube for nutrition
Post ERCP = rectal indomethacin + IV LR fluids
Surgical consult
Abx if area of necrosis is >30%
Intermittent epigastric pain, steatorrhea, weight loss
Anorexia, N/V, constipation, flatulence
Epigastric and LUQ pain, persistent and recurrent
Late = pancreatic calcifications, steatorrhea, diabetes
TRIAD = classifications, steatorrhea, DM
chronic pancreatitis
chronic pancreatitis is directly correlated with
heavy alcohol abuse in adults and CF in children
Progressive inflammatory changes in pancreas → permanent structural damage
TIGAR-O
chronic pancreatitis
TIGAR O
toxic-metabolics
idiopathic
genetic
autoimmune
recurrent
obstructive
LABS: glycosuria, excess fecal fat, serum alkaline phosphatase, bilirubin elevated
Confirm diagnosis with imaging = EUS, MRCP, ⋆CT scan → calcifications, ductal dilation, heterogeneity/atrophy
Specific pancreatic function testing = secretin stimulation test
Triglyceride breath test
chronic pancreatitis
How do you treat chronic pancreatitis?
Low fat diet, stop ETOH and tobacco use, pain control (NO opioids and NSAIDs) – TCAs, SSRIs, gabapentin, pregabalin
ERCP - dilation + stent
Acid reduction
Treat diabetes
Surgery
encapsulated fluid collection w/ little-no necrotic tissue, asymptomatic
after pancreatitis, acute/chronic, trauma
evaluate for likelihood of cancer, imaging, cytology
Found on CT while monitoring pancreatitis
pancreatic pseudocyst
fever, leukocytosis, localized tenderness, epigastric mass, complication of pancreatitis, “infected pseudocyst”
pancreatic abscess
how do you treat a cyst and abscess?
cyst resolves
abscess - drainage
75% of pancreatic cancer is in the
head
What are the 4 different types of pancreatic cancer?
cyst
neuroendocrine
beta cells
adenocarcinoma
What type of pancreatic cancer is most common?
adenocarcinoma from cigarette smoking, fats
vague, diffuse epigastric LUQ pain, jaundice, weight loss, anorexia, malaise, weakness, diarrhea
Abdominal pain
Jaundice
adenocarcinoma of the pancreas
confused/abnormal behavior often in the morning after missing a meal or after exercise
beta cell pancreatic cancer
“insulinomas” – hypoglycemia
Whipple triad = hypoglycemia, low glucose, relief with carbs
beta cell pancreatic cancer
“islet cell” - functional or non-functional with hormones involved: gastrin, insulin, glucagon, intestinal peptide, somatostatin, growth hormone, adrenocorticotropic
neuroendcorine pancreatic cancer
diagnosis made through low glucose, elevated insulin, elevated proinsulin, C-peptide, negative sulfonylurea
beta cell pancreatic cancer
Sister Mary Joseph nodule
Courvoisier’s sign
Trousseau sign
CA19-9 antigen for monitoring
LABS: Mild anemia, amylase & lipase elevated, abnormal liver enzymes
DX made from imaging - CT! Endoscopic US more sensitive, ERCP
Normal EUS = excludes dx
adenocarcinoma of the pancreas
pancreatic mass steps
Jaundice → transabdominal US → CT scan
How do you treat pancreatic cancer
Cyst: surgical resection
Beta: surgical resection
Diazoxide while waiting
Adenocarcinoma: surgical resection (only if mets have not made it elsewhere)
Whipple procedure if confined to head or duodenal area
Chemotherapy and radiation
Bile duct stent
Palliative care
