Pancreas Flashcards
physiology of secretin
secreted into the blood by S sells of the small intestine in response to duodenal pH.
secretin binds to duct cells to create a bicarb-rich secretion into pancreatic ducts
physiology of cholecystokinin
cholecystokinin is a hormone secreted by the Ito cells of the small intestine into the bloodstream in response to a meal and bind to acinar cells of the pancreas.
zymogen granules are secreted from acing cells into the pancreatic duct
recommended fluid for resuscitation in acute pancreatitis?
LR
pancreatic serous cystadenomas. benign or malignant?
serous cystadenomas are benign. they are glycogen rich and just need to be observed
secretin physiology
secretin is secreted by S-cells in the proximal duodenum.
secretin is released when duodenal pH falls below 4.5
secretin causes increased chloride output and secretin is required to stimulate pancreatic bicarb secretion
how do you categorize chronic pancreatitis?
what are their treatments?
large duct chronic pancreatitis vs small duct pancreatitis
large duct chronic pancreatitis:
drainage procedure such as lateral pancreatico-jejunostomy (better pain control than ERCP w/ pancreatic stenting)
small duct chronic pancreatitis:
total pancreatectomy w/ islet autotransplantation can be considered
pts w/ focal disease and pain can be managed by surgical resection of the diseased ductal segment (Whipple, distal pancreatectomy)
what are the indications for resection when you have IPMN?
Indications for resection:
- main duct IPMN (high potential for malignant transformation)
- symptomatic branch-duct IPMN (pancreatitis) a/w obstructive jaundice, main duct involvement, have a solid component w/n the cyst, or have concerning features on EUS-FNA
under what circumstances should you resect for side branch IPMN?
main duct IPMN, which has a high potential for malignant transformation and should be resected if possible. Resection is also indicated for branch-duct IPMN’s which are symptomatic (e.g. pancreatitis), associated with obstructive jaundice or main duct involvement, have a solid component within the cyst, or have concerning features on EUS-FNA.
h/o necrotizing pancreatitis
isolated gastric varices that bleed
tx?
splenectomy for splenic vein thrombosis
most common type of functioning pancreatic endocrine tumor?
insulinoma (1-2 cases/million/yr)
pt presents w/ acute pancreatitis and concurrent cholangitis. how quickly should pt get ERCP?
w/n 24hrs of admission
pt has pancreatic mass, polyarthritis, panniculitis, and subcutaneous nodules. what do they likely have?
acinar cell carcinoma - a rare pancreatic tumor
pancreatic pseudopapillary tumor.
typical pt?
imaging findings?
tx?
pancreatic pseudopapillary tumor
- young females in 20-30s
- may see well-encapsulated mass w/ peripheral calcification on CT in 30% of pts
- EUS-FNA shows fluid CEA is low
- surgical resection for tx
pancreatic serous cystadenoma
- typical pt?
- imaging findings?
- other labs?
- tx
pancreatic serous cystadenoma
- females age 50-60s
- imaging w/ cystic appearance and central fibrous scar (only seen in 30% of pts)
- low yield on EUS-FNA cytology, but low CEA
- benign, but if symptomatic, can consider surgery
for pts with chronic pancreatitis, what is their risk of pancreatic cancer?
for pts w/ chronic pancreatitis greater than or equal to 5 yrs, the risk of pancreatic cancer is 8-fold the risk of the general population
T or F. all pts w/ biliary pancreatitis need an ERCP
False
only biliary pancreatitis pts w/ evidence of cholangitis or biliary obstruction require ERCP
fluid resuscitation model for acute pancreatitis
oal-directed fl therapy for the first 24hrs from presentation: LR 20mL/kg bolus followed by 3mL/kg/hr with repeat bolus (20mL/kg followed by 3mL/ Kg/hr) at 12hrs into therapy if increases in HCT, BUN, or Cr are seen.
what is the strongest environmental risk factor for pancreatic adenoma?
smoking
interventions to minimize post-ERCP pancreatitis?
rectal indomethacin
if pancreatic duct has been cannulated repeatedly, prophylactic PD stent placement
what is hemosuccus pancreaticus and how do you treat it?
bleeding from the main pancreatic duct. This can be due to a pseudoaneurysm in the peripancreatic arterial circulation, or bleeding from small vessels within a pseudocyst or fluid collection that communicates with the pancreatic duct.
tx: angiogram w/ embolization
vitamin B12 absorption physiology
intrinsic factor (made by parietal cells; atrophic gastritis)
B12 must be released from binding w/ R-protein, via pancreatic proteases (chronic pancreatitis can’t break down/activate R-protein)
B12 and IF bind.
B12 absorbed in the terminal ileum (Crohn’s, ideal resection)
describe presentation, findings, tx of type 2 autoimmune pancreatitis?
Type 2 AIP patients usually present with acute pancreatitis and/ or obstructive jaundice due to mass-like lesion in the pancreatic head.
Characteristic features include: association with inflammatory bowel disease, mass-like lesion or other focal features on imaging, biopsy showing granulocyte-epithelial lesions with absent or very mildly positive IgG4 staining. Unlike type 1 AIP, type 2 involves only the pancreas.
Type 2 AIP, like type 1 AIP, is very responsive to treatment with glucocorticoids.
Surgical resection is not indicated given the high likelihood of response to medical therapy.
in pts w/ azathioprine-induced acute pancreatitis, what do you do?
stop the AZA
do not rechallenge w/ AZA or w/ other mercaptopurines
new DM, diarrhea, rash (blistering red, around mouth and perineum), weight loss
glucagonoma
a rare neuroendocrine tumor from pancreatic alpha-2 cells
insulin resistance, diarrhea, weight loss.
necrolytic migratory erythema - limbs, personal, perineum. seen in up to 80% of pts w/ glucagonoma
what is the risk of pancreatic adenoCa in pts w/ hereditary pancreatitis?
hereditary pancreatitis (caused by mutation in cationic trypsinogen gene - PRSS1) carries a 40-60 fold increased lifetime risk for pancreatic adenoCa
hereditary pancreatitis is an auto-dom condition w/ incomplete penetrance
