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Summer FDTN Exam 5 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

What vascularity supplies the pancreas

A

Celiac axis and SMA

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2
Q

What innervates the pancreas

A

ANS

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3
Q

What are the pancreas’s Exocrine functions

A

Amylase: breakdown starch
Lipase: breakdown fat
Protease: breakdown proteins

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4
Q

What stimulates the pancreas to release it’s juices

A

Gastric acid
CCK
Vagal stimulation

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5
Q

What is in pancreatic “juice”

A

Electrolytes, bicarbonate, digestive enzymes

It neutralizes gastric acid and provides basic environment for pancreatic enzymes

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6
Q

What is the pancreas’s Endocrine function

A

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)

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7
Q

Where is amylase found

A

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)

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8
Q

How do amylase levels change

A

Normal: 60-120
Abnormal levels w/in 12 hours of pancreatic injury
Return to normal in 48-72 hours

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9
Q

What causes amylase to leak into circulation

A

Damage to acinar cells (pancreatitis) or obstruction of pancreatic flow (CA or CBD stones)

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10
Q

What happens to amylase in chronic pancreatitis

A

Usually not increased in circulation because with chronic, acinar cells are destroyed- so there is no amylase even made!

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11
Q

Where is Lipase found

A

Secreted by pancreas into duodenum to breakdown TG into fatty acids
More specific but can also be found in renal failure or intestinal infarct

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12
Q

How do Lipase levels change

A

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

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13
Q

What is acute pancreatitis

A

Inflammatory disease w/ autodigestion of pancreas by proteolytic enzymes prematurely activated in pancreas

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14
Q

What causes acute pancreatitis

A 
MC: alcohol and gallstones*** 
Also blunt trauma, ERCP
Hypertriglyceridemia**, hypercalcemia 
Ischemia, vasculitis 
mumps, CMV, EBV, HIV, varicella
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15
Q

What toxins can cause acute pancreatitis

A

Alcohol*

Thiazide diuretics , Estrogen, sulfonamides, Salicylates, Valproic acid, 6-MP, anti-HIV meds, Scorpion venom

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16
Q

How does acute pancreatitis present (oldcarts)

A 
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
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17
Q

Clinically how does acute pancreatitis present

A 
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
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18
Q

Lab workup for acute abdominal pain should always include

A

Amylase and Lipase!!

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19
Q

Diagnostics for acute pancreatitis will show

A

Elevated: amylase, lipase, WBC, HCT, Creatinine, Glucose (mild), LFT (transient)
Decreased: Calcium, O2 (on ABG)

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20
Q

What LFT’s strongly suggest acute pancreatitis

A

ALT >150 gallstone pancreatitis

High bilirubin: gallstone pancreatitis

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21
Q

What radiographs get you get to find acute pancreatitis

A

XR: normal vs ileus
CT: pancreatic edema, calcifications, pseudocysts, necrosis, abscess
MRCP
*Endoscopic US: best test, highest sensitivity

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22
Q

What are XR beneficial for in acute pancreatitis

A

CXR: R/o pulmonary infiltrates or pleural effusions!

Abd XR is likely to r/o obstruction (stones), ileus (sentinel loop), or perforation

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23
Q

CT abdomen is used for

A

Diagnosis, showing enlargement of pancreas, blurring of fat planes/fat stranding
ID severity of disease
ID complications (necrosis, pseudocysts, abscess, hemorrhage)

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24
Q

Why are MRI/MRCP better than CT

A

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)

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25
Q

What are indications for an ERCP

A

Visualize biliary and pancreatic duct anatomy
Obtain cytology or biopsy
Therapeutic (stone removal, stent insertion, sphincterotomy)

26
Q

On ERCP you may visualize

A

CBD stricture w/ dilation of hepatic ducts

Extrahepatic biliary obstruction

27
Q

What are MCC of extrahepatic biliary obstruction

A

Gallstones
Pancreatitis
Pancreatic cancer

28
Q

How do you manage acute pancreatitis

A

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*)

29
Q

Sx of early complications are

A

Decreased UO, rising creatinine
Respiratory failure
Worsening pain, fever or leukocytosis
(so monitor labs closely!!)

30
Q

Local complications of acute pancreatitis are

A

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)

31
Q

What are Sx of pancreatic pseudocyst

A

Abdominal pain
early satiety
N/V

32
Q

What can happen to a pseudocyst and how do you treat

A

Can spontaneously resolve or rupture
Can be complicated by rupture, hemorrhage, or infection
Surgery vs drainage to Tx, bases on Sx or infection

33
Q

What are systemic complications of acute pancreatitis

A 
Respiratory failure/ARDS
pulmonary edema
pleural effusions 
atelectasis 
Renal failure 
Hypotension/shock 
Ileus 
Hyperglycemia 
hypocalcemia
34
Q

What is Ranson’s criteria

A

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

35
Q

Initial signs on Ranson’s criteria are

A 
55+ y/o 
WBC >16K
Glucose >200 
AST >250 
LDH >350
36
Q

Delayed signs on Ranson’s criteria are

A 
HCT drop >10% 
BUN increase >5mg 
Calcium <8mg 
pO2 <60 
Sr Albumin <3.2 
Fluid sequestration 4-5L
37
Q

How can you prevent acute pancreatitis recurrence

A

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

38
Q

What is chronic pancreatitis

A

repeat episodes of acute inflammation leading to permanent structural damage and ductal obstruction
Gradual loss= Exo and Endocrine insufficiency

39
Q

What causes chronic pancreatitis

A 
MC: Alcohol**
Repeat episodes of acute pancreatitis 
Cystic fibrosis 
Hereditary 
Idiopathic
40
Q

What are Sx of chronic pancreatitis

A

*Epigastric pain
Early: similar to acute pancreatitis
Late: becomes continuous
Aggravators: alcohol, largely fatty meals

41
Q

What does Exocrine insufficiency lead to

A

malabsorption;
Steatorrhea (greasy, foul smelling stool 2/2 high excretion of fecal fat
Weight loss: fear of eating and malabsorption

42
Q

What does endocrine insufficiency lead to

A

Diabetes;
Polyuria, phagia, etc.
Insulin dependence
Brittle DM (alpha and beta cells affected)

43
Q

What is the chronic pancreatitis Classic Triad*

A

Diabetes (late)
Steatorrhea
Pancreatic calcifications

44
Q

Diagnostics for chronic pancreatitis show

A

Slightly increased (or normal): amylase/Lipase
Mild elevation: Bilirubin and Alk Phos
High glucose

45
Q

What tests can you run for chronic pancreatitis

A

Secretin stimulation test (abn if 60% of exocrine Fxn lost)- expensive, not really used
Fecal fat test (72 hour quantitative fecal fat)

46
Q

Plain films for chronic may show

A

Scattered calcifications

47
Q

CT for chronic pancreatitis may show

A

Calcifications
Ductal dilation
Pseudocysts

48
Q

MCRP for chronic may show

A

Pancreatic and biliary ducts

Used more and more for evaluating and diagnosing

49
Q

ERCP for chronic may show

A

Chain of lakes
It is the gold standard but very invasive
Can use the esophageal US for similar results and less risk of pancreatitis

50
Q

How do you manage chronic pancreatitis

A

Behavior modify: No alcohol or high fat foods
Early ID of complications is key
Manage diabetes
Treat malabsorption w/ pancreatic enzyme supplements

51
Q

Pain relief for chronic pancreatitis can be achieved by

A

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)

52
Q

What is the pathology of pancreatic carcinoma

A

Most are adenocarcinoma*
15% of cysts are neoplasms
Refer ALL patients w/ a pancreatic lesion to GI surgery

53
Q

RF for pancreatic carcinoma are

A

Male
African American
Age >45
Smoking, Alcohol, Chronic pancreatitis, diabetes, obesity, FHx

54
Q

How does pancreatic carcinoma present

A 
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
55
Q

THIS is pancreatic cancer until proven otherwise

A

Painless jaundice

56
Q

PE findings for pancreatic cancer are

A

Cachectic
Jaundice
Icterus (eyes)
Virchow’s node (left supraclavicular LAD)
Ascites
Courvoisier’s sign (palpable non-ttp gallbladder)

57
Q

Lab studies for pancreatic cancer are

A

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)

58
Q

How do you diagnose pancreatic cancer

A

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

59
Q

How do you treat pancreatic carcinoma

A

Whipple! resection is the only potential cure

60
Q

Palliation of Sx of pancreatic carcinoma are

A 
Biliary obstruction (pruritis and biliary stent) 
Weight loss (cachexia, exocrine insufficiency) 
Pain (narcotics, chemo vs radiation
61
Q

What is the prognosis of pancreatic cancer

A

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

Summer FDTN Exam 5 (12 decks)

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