Pancreas Flashcards
What vascularity supplies the pancreas
Celiac axis and SMA
What innervates the pancreas
ANS
What are the pancreas’s Exocrine functions
Amylase: breakdown starch
Lipase: breakdown fat
Protease: breakdown proteins
What stimulates the pancreas to release it’s juices
Gastric acid
CCK
Vagal stimulation
What is in pancreatic “juice”
Electrolytes, bicarbonate, digestive enzymes
It neutralizes gastric acid and provides basic environment for pancreatic enzymes
What is the pancreas’s Endocrine function
Insulin released in response to increased blood glucose (increases permeability of cell membranes to glucose= lower blood glucose)
Glucagon released in response to low blood sugar (causes conversion of glycogen to glucose in the liver= increase blood sugar)
Where is amylase found
secreted from pancreatic *acinar cells, into duodenum to digest starch
Also in saliva, ovaries, skeletal muscle, and gallbladder (sensitive but not specific to pancreatic disease)
How do amylase levels change
Normal: 60-120
Abnormal levels w/in 12 hours of pancreatic injury
Return to normal in 48-72 hours
What causes amylase to leak into circulation
Damage to acinar cells (pancreatitis) or obstruction of pancreatic flow (CA or CBD stones)
What happens to amylase in chronic pancreatitis
Usually not increased in circulation because with chronic, acinar cells are destroyed- so there is no amylase even made!
Where is Lipase found
Secreted by pancreas into duodenum to breakdown TG into fatty acids
More specific but can also be found in renal failure or intestinal infarct
How do Lipase levels change
Normal: 0-160
non-pancreatic elevation: <3 of upper limit normal
Acute pancreatitis: Rise 24-48 hrs post injury
Return to normal in 5-7 days
What is acute pancreatitis
Inflammatory disease w/ autodigestion of pancreas by proteolytic enzymes prematurely activated in pancreas
What causes acute pancreatitis
MC: alcohol and gallstones*** Also blunt trauma, ERCP Hypertriglyceridemia**, hypercalcemia Ischemia, vasculitis mumps, CMV, EBV, HIV, varicella
What toxins can cause acute pancreatitis
Alcohol*
Thiazide diuretics , Estrogen, sulfonamides, Salicylates, Valproic acid, 6-MP, anti-HIV meds, Scorpion venom
How does acute pancreatitis present (oldcarts)
O: acute, after eating meal L: midepigastric radiating to back D: constant C: steady, boring A: lying supine worsens Sx R: sitting and leaning forward makes it better Sx: anorexia, n/v, abdominal distention
Clinically how does acute pancreatitis present
fever, tachy/tachy, +/- hypotension Jaundice 2/2 biliary obstruction Hypoactive/absent bowel sounds Significant midepigastric ttp w/ or w/o guarding/rebound Cullen's sign: periumbilical ecchymosis Grey-turner sign: flank ecchymosis
Lab workup for acute abdominal pain should always include
Amylase and Lipase!!
Diagnostics for acute pancreatitis will show
Elevated: amylase, lipase, WBC, HCT, Creatinine, Glucose (mild), LFT (transient)
Decreased: Calcium, O2 (on ABG)
What LFT’s strongly suggest acute pancreatitis
ALT >150 gallstone pancreatitis
High bilirubin: gallstone pancreatitis
What radiographs get you get to find acute pancreatitis
XR: normal vs ileus
CT: pancreatic edema, calcifications, pseudocysts, necrosis, abscess
MRCP
*Endoscopic US: best test, highest sensitivity
What are XR beneficial for in acute pancreatitis
CXR: R/o pulmonary infiltrates or pleural effusions!
Abd XR is likely to r/o obstruction (stones), ileus (sentinel loop), or perforation
CT abdomen is used for
Diagnosis, showing enlargement of pancreas, blurring of fat planes/fat stranding
ID severity of disease
ID complications (necrosis, pseudocysts, abscess, hemorrhage)
Why are MRI/MRCP better than CT
Lower risk nephrotoxicity
Increased characterization of fluid collections, necrosis, abscess, and pseudocysts
Better view of biliary and pancreatic ducts (good if you can’t see CBD stone on CT/US and you expect biliary pancreatitis)
What are indications for an ERCP
Visualize biliary and pancreatic duct anatomy
Obtain cytology or biopsy
Therapeutic (stone removal, stent insertion, sphincterotomy)
On ERCP you may visualize
CBD stricture w/ dilation of hepatic ducts
Extrahepatic biliary obstruction
What are MCC of extrahepatic biliary obstruction
Gallstones
Pancreatitis
Pancreatic cancer
How do you manage acute pancreatitis
Admit
Tx underlying cause
NPO (may provide enteral or parenteral depending on length of NPO)- advance diet when no longer need IV narcotics
IVF**
Meperidine for pain control (demerol)
If infected necrosis is a concern, give Abx (Imipenem*)
Sx of early complications are
Decreased UO, rising creatinine
Respiratory failure
Worsening pain, fever or leukocytosis
(so monitor labs closely!!)
Local complications of acute pancreatitis are
Pseudocyst: fluid/debris collection w/ fibrotic wall- no epithelial lining
Abscess: Infected pseudocyst/necrotic area (fever, highWBC, Sx worsening)
Necrosis: non-viable tissue
Hemorrhage
Ascites (from leaking duct or pseudocyst)
What are Sx of pancreatic pseudocyst
Abdominal pain
early satiety
N/V
What can happen to a pseudocyst and how do you treat
Can spontaneously resolve or rupture
Can be complicated by rupture, hemorrhage, or infection
Surgery vs drainage to Tx, bases on Sx or infection
What are systemic complications of acute pancreatitis
Respiratory failure/ARDS pulmonary edema pleural effusions atelectasis Renal failure Hypotension/shock Ileus Hyperglycemia hypocalcemia
What is Ranson’s criteria
Method used to predict mortality from acute pancreatitis, not diagnose
0-2: <1% mortality
3-4: 15% mortality
5-6: 40% mortality
7-8: 100% mortality
Overall mortality is 10-15% for acute pancreatitis
Initial signs on Ranson’s criteria are
55+ y/o WBC >16K Glucose >200 AST >250 LDH >350
Delayed signs on Ranson’s criteria are
HCT drop >10% BUN increase >5mg Calcium <8mg pO2 <60 Sr Albumin <3.2 Fluid sequestration 4-5L
How can you prevent acute pancreatitis recurrence
Do ERCP if there is a CBD stone
elective cholecystectomy is biliary pancreatitis
Alcoholic pancreatitis: no alcohol
high TG: diet modify and lipid lowering meds
Drug induced: remove offending drug
What is chronic pancreatitis
repeat episodes of acute inflammation leading to permanent structural damage and ductal obstruction
Gradual loss= Exo and Endocrine insufficiency
What causes chronic pancreatitis
MC: Alcohol** Repeat episodes of acute pancreatitis Cystic fibrosis Hereditary Idiopathic
What are Sx of chronic pancreatitis
*Epigastric pain
Early: similar to acute pancreatitis
Late: becomes continuous
Aggravators: alcohol, largely fatty meals
What does Exocrine insufficiency lead to
malabsorption;
Steatorrhea (greasy, foul smelling stool 2/2 high excretion of fecal fat
Weight loss: fear of eating and malabsorption
What does endocrine insufficiency lead to
Diabetes;
Polyuria, phagia, etc.
Insulin dependence
Brittle DM (alpha and beta cells affected)
What is the chronic pancreatitis Classic Triad*
Diabetes (late)
Steatorrhea
Pancreatic calcifications
Diagnostics for chronic pancreatitis show
Slightly increased (or normal): amylase/Lipase
Mild elevation: Bilirubin and Alk Phos
High glucose
What tests can you run for chronic pancreatitis
Secretin stimulation test (abn if 60% of exocrine Fxn lost)- expensive, not really used
Fecal fat test (72 hour quantitative fecal fat)
Plain films for chronic may show
Scattered calcifications
CT for chronic pancreatitis may show
Calcifications
Ductal dilation
Pseudocysts
MCRP for chronic may show
Pancreatic and biliary ducts
Used more and more for evaluating and diagnosing
ERCP for chronic may show
Chain of lakes
It is the gold standard but very invasive
Can use the esophageal US for similar results and less risk of pancreatitis
How do you manage chronic pancreatitis
Behavior modify: No alcohol or high fat foods
Early ID of complications is key
Manage diabetes
Treat malabsorption w/ pancreatic enzyme supplements
Pain relief for chronic pancreatitis can be achieved by
Pancreatic enzyme supplements (try 1st)
Amitriptyline or SSRI
Narcotics (long acting preferred- Contin or Fentanyl patch)
Endoscopic procedure (ductal dilation, stenting)
Nerve block (celiac plexus w/ ethanol or steroids)
Lithotripsy (not good evidence)
Surgical resection (if CA suspected or when other Tx fail)
What is the pathology of pancreatic carcinoma
Most are adenocarcinoma*
15% of cysts are neoplasms
Refer ALL patients w/ a pancreatic lesion to GI surgery
RF for pancreatic carcinoma are
Male
African American
Age >45
Smoking, Alcohol, Chronic pancreatitis, diabetes, obesity, FHx
How does pancreatic carcinoma present
Vague, non-specific Bloating Abdominal pain (MC Sx) Gnawing epigastric pain radiating to back early satiety weight loss Painless jaundice** Pruritis, alcoholic stools (pale), dark urine Acute pancreatitis Steatorrhea
THIS is pancreatic cancer until proven otherwise
Painless jaundice
PE findings for pancreatic cancer are
Cachectic
Jaundice
Icterus (eyes)
Virchow’s node (left supraclavicular LAD)
Ascites
Courvoisier’s sign (palpable non-ttp gallbladder)
Lab studies for pancreatic cancer are
Elevated bilirubin and Alk Phos (esp. obstructive jaundice)
Mild increase in amylase and lipase
Mild anemia
Glucose intolerance
CA 19-9 (tumor marker, will be elevated relative to tumor size)
How do you diagnose pancreatic cancer
US: dilated CBD, pancreatic head mass
CT/helical CT: test of choice for staging disease and to ID eligibility for resection
MRCP: as sensitive as ERCP but w/o complication risk. Can’t get tissue sample
ERCP: double duct sign (stricture of CBD and pancreatic ducts), can get tissue Bx
Endo US: eval local tumor/vascular involvement, beft for FNA biopsy
How do you treat pancreatic carcinoma
Whipple! resection is the only potential cure
Palliation of Sx of pancreatic carcinoma are
Biliary obstruction (pruritis and biliary stent) Weight loss (cachexia, exocrine insufficiency) Pain (narcotics, chemo vs radiation
What is the prognosis of pancreatic cancer
Poor- 5% five year survival
Better if lesion is resectable (will need chemo and radiation)
Unresectable lesion: 8-12 months if locally invasive, 3-6 months if metastatic
