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GI2 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

Zymogens

A

store the enzymes in pancreas

released by pancreatic ductal cells into the pancreatic duct where they are secreted into small intestine

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2
Q

trypsinogen

A

cleaved to trypsin and activates other pancreatic enzymes

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3
Q

how does pancreas protects itself from its self-digestion?

A

Pancreatic enzymes are created as proenzymes/zymogens

Packaged into crystal structures with protease inhibitors

Crystal granules have acidic pH and low calcium levels

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4
Q

Acute Pancreatitis

Etiologies:

A 
gallstones (MC), 
alcohol, 
hypertriglyceridemia (thousands), 
medications, 
ERCP complication
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5
Q

Gallstone Pancreatitis (Choledocholithiasis)

patho

A

gallstones migrate down into cystic duct –> common bile duct

stones lodge into CBD after pancreatic duct origin
o Cause both obstructive jaundice and acute pancreatitis

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6
Q

what size stone MC causes gallstone pancreatitis

A

small gallstones

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7
Q

Alcoholic Pancreatitis patho

A

EtOH increases synthesis of pancreatic enzymes + over sensitized pancreas to CCK

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8
Q

TG pancreatitis patho

A

> 1000 (>500 is increased risk)

milky serum = lipase activation and fat is toxic

common in uncontrolled DM, hereditary lipid disorder, pregnancy

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9
Q

Medication pancreatitis mechanisms

A

Immunologic reaction

Direct toxic effects or accumulation of toxic metabolite

Pancreatic ischemia

Increased viscosity of pancreatic juice

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10
Q

Hypercalcemia patho

A

activation of trypsinogen or by calcium deposition into ducts, MC with acute increase in [Ca

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11
Q

pancreas divisum

A

anatomic variant where dorsal and ventral pancreas fail to form causing separate pancreatic ducts

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12
Q

general patho pancreatitis (6)

A
  1. Impaired secretion of duodenum and premature activation of pancreatic enzymes in duct
  2. Generalized auto digestion of pancreas and peripancreatic fat
  3. Local inflammation causes pancreatic ischemia, vascular leak, edema of pancreas
  4. Local inflammation causes extravasation of proteinaceous fluid and large amount of fluid leaks into peritoneal space
  5. Leukocytes flood area and inflammatory cytokines are produced
  6. Inflammatory mediators spill into bloodstream and result in SIRS
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13
Q

pancreatitis Complications:

A 
ARDS
myocardial depression
renal failure
shock
metabolic complications
bacterial translocation
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14
Q

metabolic complications of pancreatitis

A

hypocalcemia, hyperlipidemia, hypoglycemia

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15
Q

bacterial translocation pancreatitis

A

bacteria from gut are able to move into lymphatic system and cause systemic infection

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16
Q

pain of acute pancreatitis

A

epigastrium and LUQ

bores thru abdomen into back

Aggravated when lying down, relieved when sitting up and bending forward

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17
Q

clinical presentation of pancreatitis

A

pain in LUQ, mild guarding and distention

n/v

tachycardia

fever

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18
Q

Grey’s Turners sign

A

flank ecchymosis

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19
Q

indicators of hemorrhagic pancreatitis

A

Grey’s Turner’s Sign or Cullen’s sign

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20
Q

Cullen’s sign

A

(periumbilical ecchymosis)

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21
Q

labs specific for pancreatitis

A

lipase and amylase

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22
Q

lipase

A

MORE specific than amylase but non-specific for pancreatitis

gasteroenteritis, vomiting, chronic pancreatitis all elevate

levels don’t = severity

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23
Q

pancreatitis must have 2 of 3:

A

Elevated lipase

Radiologic evidence of pancreatic inflammation

Clinical picture of acute pancreatitis present

24
Q

evaluation of pancreatitis (imaging + 5)

A

Abdominal CT scan + search for cause
1. Tox Screen (look for EtOH and drug use)

  1. RUQ U/S to look for gallstones if pt has elevated ALT/ST, MRCP to look for CBD stones
  2. Medication list review
  3. Lipid panel for hypertriglyceridemia
  4. No cause found = biliary microlithiasis
25
Q

pancreatitis tx (5)

A
  1. Pancreatic rest
  2. Parenteral pain meds
  3. High volume IV fluid replacement
    o Determined by vitals and lytes
  4. +/- insulin replacement
  5. NPO, enteral feeding (prevents bacterial translocation)

Prophylactic ABX are NOT routinely used

26
Q

tx Gallstone Pancreatitis:

A

moderate – severe = urgent ERCP with sphincterotomy followed by lap chole in few days

27
Q

tx Alcoholic Pancreatitis:

A

absolutely need to avoid alcohol completely, monitor withdrawal (Benzos)

28
Q

tx Med Pancreatitis:

A

discontinue medication, general care

29
Q

tx HyperTG Pancreatitis:

A
  1. insulin infusion +/- 5% dextrose,
  2. Gemfibrozil bid,
  3. therapeutic plasmapheresis
30
Q

systems infected by Autoimmune Pancreatitis

A

Pancreatic symptoms
Biliary symptoms
systemic features

31
Q

Autoimmune pancreatitis

Pancreatic features:

A

mass enlargement and pancreatic duct strictures

32
Q

Autoimmune pancreatitis

Biliary features:

A

obstructive jaundice,
biliary strictures,
transaminase elevation in cholestatic pattern,
mimic pancreatic CA or CCC

33
Q

autoimmune pancreatitis

Systemic features

A

Sjogren’s syndrome,
lung nodules,
autoimmune thyroiditis,
nephritis

34
Q

autoimmune pancreatitis Characteristic appearance on imaging

A

CT or MRI show diffuse enlargement of pancreas with featureless borders

Tissue biopsy

35
Q

autoimmune pancreatitis treatment

A

glucocorticoids

36
Q

Complications

A

infection of pancreas and peri pancreatic tissue

fluid collection = pseudocyst

37
Q

bacteria that often cause pancreatic infection

A 
E. coli,
Pseudomonas, 
Staphylococcus, 
Klebsiellosis, 
Streptococcus, 
Enterobacter, 
anaerobes
38
Q

abscesses

A

Formed by necrotic pancreatic tissue and gut flora, req. drainage or debridement

Distinguished from pseudocysts bc it has WBC in needle drainage and on CT will have lots of debris, not uniform

39
Q

Pancreatic Pseudocysts

A

collection of fluid >4 weeks

result of pancreatitis that has pancreatic juice with high concentrations of digestive enzymes encased in granulation tissue

40
Q

pancreatic pseudocyst

Tx:

A 
watchful waiting (4-6 weeks) then surgical, percutaneous, or endoscopic drainage 
Mc in cysts > 7 cm
41
Q

pancreatic pseudocyst

complications

A

Complications:

Expansion = abdominal pain or obstruction

Secondarily infected = abscess

Pancreatic ascites and pleural effusions

Erosion thru blood vessel = bleeding or pseudoaneurysm (esp. splenic vein)

42
Q

severe pancreatitis

graded by

A

ranson criteria

43
Q

ranson criteria how to

A

score patient at 0hrs of presentation and 48hrs after

not used due to need to wait 48 hrs

44
Q

severe pancreatitis tx

A

ICU, monitor for complication, anticipator and supportive

pancreas is necrotic = debridement

45
Q

chronic pancreatitis

A

Progressive inflammatory changes cause patchy fibrosis and diminished pancreatic function

Can result from any etiology that causes acute pancreatitis

Increases risk of developing pancreatic cancer

46
Q

chronic pancreatitis

Presentation:

A

persistent pain that wax and wanes in intensity, constant but less severe than AP

47
Q

chronic pancreatitis S/S:

A

Pancreatic insufficiency:

Fat malabsorption:

Diabetes (brittle)

48
Q

manifestations of pancreatic insufficiency in chronic pancreatitis

A

inability to digest complex foods or absorb partially digested products

49
Q

manifestations of Fat malabsorption in chronic pancreatitis

A

steatorrhea and fat soluble vitamin deficiency (A,D,E,K, B-12)

50
Q

chronic pancreatitis workup

A

fecal fat test

pancreatic calcification on imaging

diabetes

51
Q

tx of chronic pancreatic

A

pain control

avoidance of overstimulation

pancreatic enzyme supplementation

52
Q

pain meds steps in chronic pancreatitis

A
  1. NSAIDs
  2. TCAs
  3. Gabapentin
  4. Opiates
53
Q

pancreatic enzyme supplementation

A

Lipase/protease/amylase

Creon, 
zenpep, 
pancreaze, 
ultresa, 
pertzye
54
Q

Distinguishing between Acute and Chronic

A

Lack of severe pain (chronic)

Normal levels of pancreatic enzymes bc chronic pancreatitis is a PATCHY process

55
Q

medications associated w/ pancreatitis

A 
DPP-IV
Valproate
Tetracyclines
Corticosteroids
Estrogen 
GLP - 1 
Lasix
Sulfa drugs
56
Q

drugs associated with pancreatitis

A 
Chlorothorazidine 
Cimetidine/Tangament
HCTZ
Flagyl
Macrobid

GI2 (6 decks)

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