Pancreas Flashcards
Zymogens
store the enzymes in pancreas
released by pancreatic ductal cells into the pancreatic duct where they are secreted into small intestine
trypsinogen
cleaved to trypsin and activates other pancreatic enzymes
how does pancreas protects itself from its self-digestion?
Pancreatic enzymes are created as proenzymes/zymogens
Packaged into crystal structures with protease inhibitors
Crystal granules have acidic pH and low calcium levels
Acute Pancreatitis
Etiologies:
gallstones (MC), alcohol, hypertriglyceridemia (thousands), medications, ERCP complication
Gallstone Pancreatitis (Choledocholithiasis)
patho
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
what size stone MC causes gallstone pancreatitis
small gallstones
Alcoholic Pancreatitis patho
EtOH increases synthesis of pancreatic enzymes + over sensitized pancreas to CCK
TG pancreatitis patho
> 1000 (>500 is increased risk)
milky serum = lipase activation and fat is toxic
common in uncontrolled DM, hereditary lipid disorder, pregnancy
Medication pancreatitis mechanisms
Immunologic reaction
Direct toxic effects or accumulation of toxic metabolite
Pancreatic ischemia
Increased viscosity of pancreatic juice
Hypercalcemia patho
activation of trypsinogen or by calcium deposition into ducts, MC with acute increase in [Ca
pancreas divisum
anatomic variant where dorsal and ventral pancreas fail to form causing separate pancreatic ducts
general patho pancreatitis (6)
- Impaired secretion of duodenum and premature activation of pancreatic enzymes in duct
- Generalized auto digestion of pancreas and peripancreatic fat
- Local inflammation causes pancreatic ischemia, vascular leak, edema of pancreas
- Local inflammation causes extravasation of proteinaceous fluid and large amount of fluid leaks into peritoneal space
- Leukocytes flood area and inflammatory cytokines are produced
- Inflammatory mediators spill into bloodstream and result in SIRS
pancreatitis Complications:
ARDS myocardial depression renal failure shock metabolic complications bacterial translocation
metabolic complications of pancreatitis
hypocalcemia, hyperlipidemia, hypoglycemia
bacterial translocation pancreatitis
bacteria from gut are able to move into lymphatic system and cause systemic infection
pain of acute pancreatitis
epigastrium and LUQ
bores thru abdomen into back
Aggravated when lying down, relieved when sitting up and bending forward
clinical presentation of pancreatitis
pain in LUQ, mild guarding and distention
n/v
tachycardia
fever
Grey’s Turners sign
flank ecchymosis
indicators of hemorrhagic pancreatitis
Grey’s Turner’s Sign or Cullen’s sign
Cullen’s sign
(periumbilical ecchymosis)
labs specific for pancreatitis
lipase and amylase
lipase
MORE specific than amylase but non-specific for pancreatitis
gasteroenteritis, vomiting, chronic pancreatitis all elevate
levels don’t = severity
pancreatitis must have 2 of 3:
Elevated lipase
Radiologic evidence of pancreatic inflammation
Clinical picture of acute pancreatitis present
evaluation of pancreatitis (imaging + 5)
Abdominal CT scan + search for cause
1. Tox Screen (look for EtOH and drug use)
- RUQ U/S to look for gallstones if pt has elevated ALT/ST, MRCP to look for CBD stones
- Medication list review
- Lipid panel for hypertriglyceridemia
- No cause found = biliary microlithiasis
pancreatitis tx (5)
- Pancreatic rest
- Parenteral pain meds
- High volume IV fluid replacement
o Determined by vitals and lytes - +/- insulin replacement
- NPO, enteral feeding (prevents bacterial translocation)
Prophylactic ABX are NOT routinely used
tx Gallstone Pancreatitis:
moderate – severe = urgent ERCP with sphincterotomy followed by lap chole in few days
tx Alcoholic Pancreatitis:
absolutely need to avoid alcohol completely, monitor withdrawal (Benzos)
tx Med Pancreatitis:
discontinue medication, general care
tx HyperTG Pancreatitis:
- insulin infusion +/- 5% dextrose,
- Gemfibrozil bid,
- therapeutic plasmapheresis
systems infected by Autoimmune Pancreatitis
Pancreatic symptoms
Biliary symptoms
systemic features
Autoimmune pancreatitis
Pancreatic features:
mass enlargement and pancreatic duct strictures
Autoimmune pancreatitis
Biliary features:
obstructive jaundice,
biliary strictures,
transaminase elevation in cholestatic pattern,
mimic pancreatic CA or CCC
autoimmune pancreatitis
Systemic features
Sjogren’s syndrome,
lung nodules,
autoimmune thyroiditis,
nephritis
autoimmune pancreatitis Characteristic appearance on imaging
CT or MRI show diffuse enlargement of pancreas with featureless borders
Tissue biopsy
autoimmune pancreatitis treatment
glucocorticoids
Complications
infection of pancreas and peri pancreatic tissue
fluid collection = pseudocyst
bacteria that often cause pancreatic infection
E. coli, Pseudomonas, Staphylococcus, Klebsiellosis, Streptococcus, Enterobacter, anaerobes
abscesses
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
Pancreatic Pseudocysts
collection of fluid >4 weeks
result of pancreatitis that has pancreatic juice with high concentrations of digestive enzymes encased in granulation tissue
pancreatic pseudocyst
Tx:
watchful waiting (4-6 weeks) then surgical, percutaneous, or endoscopic drainage Mc in cysts > 7 cm
pancreatic pseudocyst
complications
Complications:
Expansion = abdominal pain or obstruction
Secondarily infected = abscess
Pancreatic ascites and pleural effusions
Erosion thru blood vessel = bleeding or pseudoaneurysm (esp. splenic vein)
severe pancreatitis
graded by
ranson criteria
ranson criteria how to
score patient at 0hrs of presentation and 48hrs after
not used due to need to wait 48 hrs
severe pancreatitis tx
ICU, monitor for complication, anticipator and supportive
pancreas is necrotic = debridement
chronic pancreatitis
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
chronic pancreatitis
Presentation:
persistent pain that wax and wanes in intensity, constant but less severe than AP
chronic pancreatitis S/S:
Pancreatic insufficiency:
Fat malabsorption:
Diabetes (brittle)
manifestations of pancreatic insufficiency in chronic pancreatitis
inability to digest complex foods or absorb partially digested products
manifestations of Fat malabsorption in chronic pancreatitis
steatorrhea and fat soluble vitamin deficiency (A,D,E,K, B-12)
chronic pancreatitis workup
fecal fat test
pancreatic calcification on imaging
diabetes
tx of chronic pancreatic
pain control
avoidance of overstimulation
pancreatic enzyme supplementation
pain meds steps in chronic pancreatitis
- NSAIDs
- TCAs
- Gabapentin
- Opiates
pancreatic enzyme supplementation
Lipase/protease/amylase
Creon, zenpep, pancreaze, ultresa, pertzye
Distinguishing between Acute and Chronic
Lack of severe pain (chronic)
Normal levels of pancreatic enzymes bc chronic pancreatitis is a PATCHY process
medications associated w/ pancreatitis
DPP-IV Valproate Tetracyclines Corticosteroids Estrogen GLP - 1 Lasix Sulfa drugs
drugs associated with pancreatitis
Chlorothorazidine Cimetidine/Tangament HCTZ Flagyl Macrobid
