Pancreas

Question 1

If a patient presents with epigastric pain that is radiating to the mid-back, that came on quickly and has progressively gotten worse, what diagnosis should be on your differentials?

Answer 1

Acute pancreatitis

Question 2

What position AND tasks would make acute pancreatitis worse?

Answer 2

Laying supine; typically will be leaning forward with acute pain.

Eating makes it worse!

Question 3

What is occurring in acute pancreatitis? What type of cell has been injured?

Answer 3

Inflammation of the pancreas due to acinar cell injury

Question 4

What causes acute pancreatitis?

Answer 4

Obstruction of the pancreatic duct – gallstone

Inactivated enzymes (so pancreas eats itself)

Trauma, drugs, infection, metabolic issues, PUD, toxins like a scorpion bite

Question 5

What type of drugs would cause pancreatitis?

Answer 5

Tetracyclines, metronidazole, nitrofurantoin, thiazides, and estrogens

Question 6

What type of metabolic issues can be correlated to pancreatitis?

Answer 6

Hyperlipidemia & hypercalcemia

Question 7

What might you be looking for on PE with acute pancreatitis?

Answer 7

Tender epigastric area, distention & guarding, fever, tachycardia with dyspnea, may have jaundice

Question 8

What if a patient has Cullen’s sign?

Answer 8

Periumbilical ecchymosis = hemorrhagic pancreatitis

Question 9

What if a patient has Grey-Turner’s sign?

Answer 9

Flank ecchymosis = hemorrhagic pancreatitis

Question 10

What labs would you order for acute pancreatitis?

Answer 10

LDH (lactate dehydrogenase = non-specific, just indicates cell damage)

WBC, amylase, and lipase will all be elevated (Lipase is more sensitive!!)

LFT’s

BMP

Question 11

What imaging can you do to confirm acute pancreatitis?

Answer 11

CT = GOLD STANDARD (A is not bad; E for bad)

Question 12

If a patient presents to your office and you notice jaundice, but yet he has no pain anywhere in the abdomen. What diagnosis are you thinking?

Answer 12

Pancreatic cancer until proven otherwise

Question 13

So, you’ve determined they do have acute pancreatitis, what do you use to determine severity?

Answer 13

Ranson’s Criteria
   >55        WBC >16K         
Glucose >200     
LDH 2xnormal   
AST >6x normal               
              In hospital         
              Decrease in hematocrit               Decrease in Ca                Increase in BUN/Cr Low PO2

Question 14

How do you treat acute pancreatitis?

Answer 14

NPO! To prevent secretion of pancreatic juices. No alcohol! NG tube if vomiting, Abx if suspect infection. ERCP if obstruction!

Question 15

After being diagnosed with acute pancreatitis, are you susceptible to ever being diagnosed again?

Answer 15

Yes, prone to multiple attacks

Question 16

If a patient has epigastric/LUQ pain with diarrhea and has a history of diabetes, what diagnosis are you thinking?

Answer 16

Chronic pancreatitis

Question 17

What is the cause of chronic pancreatitis?

Answer 17

NOT GALLSTONES!! Mainly alcohol abuse or dysfunction of the sphincter of Oddi

Question 18

What is the classic triad of chronic pancreatitis?

Answer 18

Pancreatic calcification, steatorrhea, and diabetes mellitus

Question 19

What lab work can help you confirm diagnosis of chronic pancreatitis?

Answer 19

Secretin Stimulation Test = GOLD STANDARD for early diagnosis

Amylase/lipase = normal at first; then DECREASES with each episode

Question 20

What imaging can you do to confirm diagnosis of chronic pancreatitis? What will you see?

Answer 20

Plain Abd XR can see calcification CT see calcifications &”fat stranding” or heterogeneous appearance of pancreas

Question 21

How do you treat chronic pancreatitis?

Answer 21

STOP ALCOHOL; pancreatic enzyme supplements

Question 22

What other questions would you need to ask your patient with jaundice and no pain?

Answer 22

Weight loss, how the stool/urine looks (pale stool & dark urine)

Question 23

If on PE you can feel the gallbladder of your patient who is jaundice, what is this known as?

Answer 23

Couvoisier sign (jaundice with a palpable gallbladder)
Virchow’s Node (supraclavicular node)
Trouseau’s Sign (superficial thrombophlebitis)

Question 24

How do you confirm diagnosis of pancreatic cancer?

Answer 24

CT scan, ERCP (head of pancreas), and angiography

Question 25

What labs would you order in pancreatic cancer?

Answer 25

Elevated bilirubin & ALK PHOS, and tumor marker CA19-9

Question 26

How do you treat pancreatic cancer?

Answer 26

Whipple surgery; often palliative care