Pancreas Flashcards
- Describe the classic symptoms of pancreatic cancer.
How is it treated?
What is the cell of origin?
The classic patient is a smoker in the 40- to 80-year-old range who has lost weight and has jaundice. Other signs and symptoms include depression, epigastric pain, migratory thrombophlebitis (Trousseau syndrome, which may also be seen with other visceral cancers), and a palpable, nontender gallbladder (Courvoisier sign).
Pancreatic cancer is more common in men than in women, in diabetic than in nondiabetic patients, and in blacks than in whites.
Surgery (Whipple procedure) is rarely curative and the prognosis is generally dismal. Chemotherapy is minimally successful at prolonging survival.
The cells of origin in pancreatic cancer are ductal epithelial cells.
.What is the most common islet cell tumor of the pancreas? How is it diagnosed?
Insulinomas (beta-cell tumors) are the most common islet cell tumors. Look for two parts of the Whipple triad: hypoglycemia (glucose <50 mg/dL) and resultant symptoms of the central nervous system (confusion, stupor, loss of consciousness). As a good doctor, you provide the third part of the Whipple triad: administration of glucose to relieve symptoms. Ninety percent of insulinomas are benign; they should be cured with resection, if possible. In your workup, take a history and check the C-peptide level first to make sure that the patient is not diabetic and taking too much insulin or a patient with a factitious disorder. C-peptide levels are high with insulinoma and sulfonylurea overdose and low with factitious insulin administration (commercial preparations of insulin do not have C-peptide).
Name the other two islet cell tumors. What should islet cell tumors make you think about?
- Glucagonomas (alpha cell tumors)
cause hyperglycemia with high glucagon levels and migratory necrotizing skin erythema. 2. VIPomas (tumors that secrete VIP) cause watery diarrhea, hypokalemia, and achlorhydria. Watch for multiple endocrine neoplasia (MEN) syndrome in patients with islet cell tumors.
Describe the typical history and the physical examination and laboratory findings for pancreatitis. How is it treated?
Look for epigastric pain that radiates to the back in an alcohol abuser or a patient with a history of (or risk factors for) gallstones. Serum amylase and/or lipase levels should be elevated. If these values are not given, order the tests! Other common signs include decreased bowel sounds, localized ileus (sentinel loop of bowel on abdominal radiography) nausea, vomiting, and/or anorexia. Treat pancreatitis supportively. Narcotics are often needed for pain control; hydromorphone and fentanyl are now common choices; meperidine, which has a risk of seizures, has traditionally been favored over morphine because of concern about sphincter of Oddi spasms, although clinical evidence of this is lacking. Do not feed the patient initially; place a nasogastric tube as needed for nausea and vomiting, and give intravenous fluids and any other supportive care needed. Watch for the complications of pseudocyst and pancreatic abscess, both of which can be diagnosed by CT scanning and may require surgical intervention. Increasing evidence of the benefit of early nutrition in patients with pancreatitis is emerging.
What causes acute pancreatitis?
More than 80% of cases are due to alcohol or gallstones. Other causes include hypertriglyceridemia, viral infections (mumps, Coxsackie virus), trauma, hypercalcemia, PUD, medications (e.g., isoniazid, furosemide, simvastatin, steroids, azathioprine), and scorpion bites.
Other than pancreatic disease, what else can cause elevated levels of amylase?
Damage to the salivary glands or bowel, renal failure, and ruptured tubal pregnancy may cause elevated amylase levels. Lipase is more specific for pancreatic pathology, and elevation of both amylase and lipase levels in the same patient is usually due to pancreatitis. The boards may try to trick you with isolated elevation of the amylase level.
What are the complications of acute pancreatitis?
Complications include pseudocyst formation (drain surgically if symptomatic and persistent for several weeks), abscess or infection (treat with antibiotics and drainage if needed), and chronic pancreatitis.
What causes chronic pancreatitis? How is it treated?
Chronic pancreatitis in the United States is almost always due to alcoholism and usually results from repeated bouts of acute pancreatitis. Gallstones do not cause chronic pancreatitis. Chronic pancreatitis may lead to diabetes, steatorrhea (excessive fat in the stool due to lack of pancreatic enzymes), calcification of the pancreas (which may be seen on a plain abdominal radiograph), and fat-soluble vitamin deficiencies (caused by malabsorption). The incidence of pancreatic cancer is slightly higher in patients with pancreatitis, although smoking is a greater risk factor than alcohol for pancreatic cancer. Treat chronic pancreatitis with alcohol abstinence, oral pancreatic enzyme replacement, and fat-soluble vitamin supplements.
