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Gastroenterology > Pancreas Dz > Flashcards

Pancreas Dz Flashcards

1
Q

This is the acute inflammatory process of the pancrease with variable involvement of regional tissues or remote organ systems.

A

Pancreatitis

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2
Q

This is the acute inflammatory process of the pancrease with variable involvement of regional tissues or remote organ systems.

A

Pancreatitis

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3
Q

What is diagnostic criteria for Pancreatitis?

A
  1. Symptoms like epigastric pain consistent with the dz
  2. Serum Amylase or lipase greater than 3x the upper limit of normal
  3. Imaging: CT or MRI

**Need two of the three to dx

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4
Q

This type of pancreatitis involved no organ failure.

A

Mild Pancreatitis

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5
Q

This type of pancreatitis involves persistent organ failure. (Shock, Pulm insufficiency, Renal Failure, GI bleed)

A

Severe Pancreatitis

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6
Q

This type of pancreatitis involved transient organ failure or local complications.

A

Moderate Pancreatitis

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7
Q

What are local complications of pancreatitis?

A
  1. Necrosis
  2. Abscess
  3. Pseudocyst
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8
Q

This stage of pancreatitis involves a protracted course related to necrosis (organ failure infected necrosis and/or complications from surgery.

A

Stage 2

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9
Q

This stage of pancreatitis involved inflammatory cascade lasting a week. Severeity related to extra-pancreatic organ failure related to SIS infection is uncommon.

This can lead to resolution, fluid collection, ischemia (and therefore necrosis)

A

Stage 1

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10
Q

What is the most important enzyme/molecule involved in pancreatitis?

A

Trypsin

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11
Q

What can cause pancreatic injury?

A
  1. Alcohol
  2. Gallstones
  3. Release of Active Enzymes
  4. Other
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12
Q

Pancreatic Injury can cause Multiple Organ Failure by what methods?

A
  1. Granulocyte and Macrophage Activation
  2. Degradative Enzymes
  3. Activation of Proteotype Cascades in Blood
  4. Endothelial Damage
  5. Circulatory Effects

***Important to note that it’s pretty circular, when one thing happens it can cause other things to happen which will worsen the pancreas and other organs.

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13
Q

What are some predisposing factors for Pancreatitis?

A
  1. Obstruction (gall stones, tumors, diverticula, annular pancreas, choledochocele)
  2. Alcohol/Toxins/Drugs
  3. Metabolic: hypercalcemia or triglycerides
  4. Trauma
  5. Infections
  6. Vascular
  7. Post ERCP
  8. Pancreaticobiliary tract dz
  9. Familial Pancreatitis
  10. Idiopathic
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14
Q

Important drugs to know that can cause Pancreatitis!

A
  1. Azathioprine/6-MP
  2. Vaproic Acid
  3. Pentamidine/Didanosine
  4. Estrogen
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15
Q

What is the big difference between the anatomy of a normal pancreas and pancreas divisum?

A

The dorsal and ventral duct in the normal pancrease fork off of a main vessel, whereas the pancreas divisum’s ventral duct is not clearly demarcated/connected

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16
Q

What are the clinical features of Pancreatitis?

A
  1. Abdominal pain, nausea, vomiting
  2. SIRS
  3. Tenderness, guarding, occasionally rigidity
  4. Palpable mass eg pseudocyst
  5. Cullens, Grey Turner sign
  6. Signs of other organ failure
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17
Q

How do you evaluate a patient with suspected pancreatitis?

A
  1. Take a careful history
  2. Physical Exam
  3. Labs: Chemistries, CBC, BMP, TG
  4. Imaging: XRay, US, CT/MRI
  5. Endoscopic US: Preferably after a month or so
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18
Q

In a patient with pancreatitis, what levels of amylase and lipase should we see in the serum?

A

Elevated!!!

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19
Q

Evaluation of Acute Pancreatitis

A

Factor Scoring Systems:

  1. Ranson
  2. Glasgow
  3. APACHE II
  4. BISAP (BUN, Impaired MS, SIRS, Age, Pleural Effusion)
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20
Q

How do you treat Acute Pancreatitis?

A
  1. Put pancreas at rest
  2. Aggressive Fluid Resuscitation (Cr, HCT, BUN)
  3. Relieve Pain
  4. Abx – Not initially
  5. Nutrition (not they may not be able to eat, so you will want to do an enteral or IV feed ASAP)
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21
Q

What factors would indicate a bad prognosis for acute pancreatitis?

A
  1. Hypotension
  2. Respiratory Failure
  3. Hypocalcemia
  4. Need for massive fluid and colloid replacement
  5. Elevated serum LDH or CRP
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22
Q

When is an Endoscopic Retrograde Cholangiopancreatography definitely beneficial?

A
  1. Cholangitis

2. Visualized Stone in the CBD

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23
Q

When is an Endoscopic Retrograde Cholangiopancreatography not beneficial?

A
  1. Mild Dz
  2. Resolved
  3. Routine pre CCY (Cholecystectomy)
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24
Q

When is an Endoscopic Retrograde Cholangiopancreatography possibly beneficial?

A

Severe pancreatitis, high suspicious of stone

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25
Q

T/F: ERCP can induce acute pancreatitis

A

True! 5-8%

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26
Q

What is the role of imaging in a patient with suspected acute pancreatitis?

A
  1. Confirm dx
  2. Grade severity
  3. Exclude other intraabdominal process
  4. Dx local complications such as necrosis, abscess, or pseudocyst
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27
Q

4 types of fluid collections in the pancreas

A
  1. Acute Fluid Collections
  2. Pseudocysts
  3. Pancreatic Necrosis
  4. Pancreatic Abscess
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28
Q

What is the most common cause of Chronic Pancreatitis?

A

Alcohol

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29
Q

What are other factors that can cause chronic pancreatitis?

A
  1. Calcific Pancreatitis of the tropics
  2. Hereditary
  3. Hyperparathyroidism
  4. CF
  5. Pancrease Divisum
  6. Misc.
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30
Q

What are two ways to classify chronic pancreatitis?

A
  1. Big Duct

2. Small Duct

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31
Q

Big Duct chronic pancreatitis is most generalize by:

A

EtOH etiology
Common in males
Common Exocrine or Endocrine Insuffiency

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32
Q

Small Duct chronic pancreatitis is most generalize by:

A

Idiopathic etiology
Common in Females
Rare Exocrine or Endocrine Insuffiency

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33
Q

Which classification of chronic pancreatitis is more easily diagnosed?

A

Big Duct

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34
Q

What imaging tests can we use to diagnose chronic pancreatitis?

A

Endoscopic US, ERCP, CT, MRI/MRCP, US, and/or KUB

How well did you know this?
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35
Q

What functional tests can be done to diagnose chronic pancreatitis?

A
  1. Secretin/CCK Test
  2. Fecal Elastase
  3. Fecal Chymotrypsin
  4. Serum trypsin
  5. Fecal Fat
  6. Serum Glucose
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36
Q

What does the secretin test test for? What would these levels look like for a patient with Chronic Pancreatitis?

A

Measures bicarb secretion by the pancreas.
Chronic Pancreatitis: Low Bicarb concentration
Carcinoma: High Bicarb concentration

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37
Q

How do you treat the pain in chronic pancreatitis?

A
  1. Abstinence
  2. Analgesics
  3. Medical Therapy – enzymes, octeotide, antioxidants
  4. Endoscopic Therapy
  5. Neurolysis
  6. Sx (Drainage or resection)
38
Q

_____% of patients with painful small duct chronic pancreatitis (44%) had concomitant gastroparesis.

A

44

39
Q

What is diagnostic criteria for Pancreatitis?

A
  1. Symptoms like epigastric pain consistent with the dz
  2. Serum Amylase or lipase greater than 3x the upper limit of normal
  3. Imaging: CT or MRI

**Need two of the three to dx

40
Q

This type of pancreatitis involved no organ failure.

A

Mild Pancreatitis

41
Q

This type of pancreatitis involves persistent organ failure. (Shock, Pulm insufficiency, Renal Failure, GI bleed)

A

Severe Pancreatitis

42
Q

This type of pancreatitis involved transient organ failure or local complications.

A

Moderate Pancreatitis

43
Q

What are local complications of pancreatitis?

A
  1. Necrosis
  2. Abscess
  3. Pseudocyst
44
Q

This stage of pancreatitis involves a protracted course related to necrosis (organ failure infected necrosis and/or complications from surgery.

A

Stage 2

45
Q

This stage of pancreatitis involved inflammatory cascade lasting a week. Severeity related to extra-pancreatic organ failure related to SIS infection is uncommon.

This can lead to resolution, fluid collection, ischemia (and therefore necrosis)

A

Stage 1

46
Q

What is the most important enzyme/molecule involved in pancreatitis?

A

Trypsin

47
Q

What can cause pancreatic injury?

A
  1. Alcohol
  2. Gallstones
  3. Release of Active Enzymes
  4. Other
48
Q

Pancreatic Injury can cause Multiple Organ Failure by what methods?

A
  1. Granulocyte and Macrophage Activation
  2. Degradative Enzymes
  3. Activation of Proteotype Cascades in Blood
  4. Endothelial Damage
  5. Circulatory Effects

***Important to note that it’s pretty circular, when one thing happens it can cause other things to happen which will worsen the pancreas and other organs.

49
Q

What are some predisposing factors for Pancreatitis?

A
  1. Obstruction (gall stones, tumors, diverticula, annular pancreas, choledochocele)
  2. Alcohol/Toxins/Drugs
  3. Metabolic: hypercalcemia or triglycerides
  4. Trauma
  5. Infections
  6. Vascular
  7. Post ERCP
  8. Pancreaticobiliary tract dz
  9. Familial Pancreatitis
  10. Idiopathic
50
Q

Important drugs to know that can cause Pancreatitis!

A
  1. Azathioprine/6-MP
  2. Vaproic Acid
  3. Pentamidine/Didanosine
  4. Estrogen
51
Q

What is the big difference between the anatomy of a normal pancreas and pancreas divisum?

A

The dorsal and ventral duct in the normal pancrease fork off of a main vessel, whereas the pancreas divisum’s ventral duct is not clearly demarcated/connected

52
Q

What are the clinical features of Pancreatitis?

A
  1. Abdominal pain, nausea, vomiting
  2. SIRS
  3. Tenderness, guarding, occasionally rigidity
  4. Palpable mass eg pseudocyst
  5. Cullens, Grey Turner sign
  6. Signs of other organ failure
53
Q

How do you evaluate a patient with suspected pancreatitis?

A
  1. Take a careful history
  2. Physical Exam
  3. Labs: Chemistries, CBC, BMP, TG
  4. Imaging: XRay, US, CT/MRI
  5. Endoscopic US: Preferably after a month or so
54
Q

In a patient with pancreatitis, what levels of amylase and lipase should we see in the serum?

A

Elevated!!!

55
Q

Evaluation of Acute Pancreatitis

A

Factor Scoring Systems:

  1. Ranson
  2. Glasgow
  3. APACHE II
  4. BISAP (BUN, Impaired MS, SIRS, Age, Pleural Effusion)
56
Q

How do you treat Acute Pancreatitis?

A
  1. Put pancreas at rest
  2. Aggressive Fluid Resuscitation (Cr, HCT, BUN)
  3. Relieve Pain
  4. Abx – Not initially
  5. Nutrition (not they may not be able to eat, so you will want to do an enteral or IV feed ASAP)
57
Q

What factors would indicate a bad prognosis for acute pancreatitis?

A
  1. Hypotension
  2. Respiratory Failure
  3. Hypocalcemia
  4. Need for massive fluid and colloid replacement
  5. Elevated serum LDH or CRP
58
Q

When is an Endoscopic Retrograde Cholangiopancreatography definitely beneficial?

A
  1. Cholangitis

2. Visualized Stone in the CBD

59
Q

When is an Endoscopic Retrograde Cholangiopancreatography not beneficial?

A
  1. Mild Dz
  2. Resolved
  3. Routine pre CCY (Cholecystectomy)
60
Q

When is an Endoscopic Retrograde Cholangiopancreatography possibly beneficial?

A

Severe pancreatitis, high suspicious of stone

61
Q

T/F: ERCP can induce acute pancreatitis

A

True! 5-8%

62
Q

What is the role of imaging in a patient with suspected acute pancreatitis?

A
  1. Confirm dx
  2. Grade severity
  3. Exclude other intraabdominal process
  4. Dx local complications such as necrosis, abscess, or pseudocyst
63
Q

4 types of fluid collections in the pancreas

A
  1. Acute Fluid Collections
  2. Pseudocysts
  3. Pancreatic Necrosis
  4. Pancreatic Abscess
64
Q

What is the most common cause of Chronic Pancreatitis?

A

Alcohol

65
Q

What are other factors that can cause chronic pancreatitis?

A
  1. Calcific Pancreatitis of the tropics
  2. Hereditary
  3. Hyperparathyroidism
  4. CF
  5. Pancrease Divisum
  6. Misc.
66
Q

What are two ways to classify chronic pancreatitis?

A
  1. Big Duct

2. Small Duct

67
Q

Big Duct chronic pancreatitis is most generalize by:

A

EtOH etiology
Common in males
Common Exocrine or Endocrine Insuffiency

68
Q

Small Duct chronic pancreatitis is most generalize by:

A

Idiopathic etiology
Common in Females
Rare Exocrine or Endocrine Insuffiency

69
Q

Which classification of chronic pancreatitis is more easily diagnosed?

A

Big Duct

70
Q

What imaging tests can we use to diagnose chronic pancreatitis?

A

Endoscopic US, ERCP, CT, MRI/MRCP, US, and/or KUB

71
Q

What functional tests can be done to diagnose chronic pancreatitis?

A
  1. Secretin/CCK Test
  2. Fecal Elastase
  3. Fecal Chymotrypsin
  4. Serum trypsin
  5. Fecal Fat
  6. Serum Glucose
72
Q

What does the secretin test test for? What would these levels look like for a patient with Chronic Pancreatitis?

A

Measures bicarb secretion by the pancreas.
Chronic Pancreatitis: Low Bicarb concentration
Carcinoma: High Bicarb concentration

73
Q

What causes the pain in chronic pancreatitis?

A
  1. Stenosis of the common bile duct
  2. Stenosis of the duodenum
  3. Acute Inflammation
  4. Neural inflammation
  5. Increased pressure in the parenchyma, duct, or pseudocyst
74
Q

How do you treat the pain in chronic pancreatitis?

A
  1. Abstinence
  2. Analgesics
  3. Medical Therapy – enzymes, octeotide, antioxidants
  4. Endoscopic Therapy
  5. Neurolysis
  6. Sx (Drainage or resection)
75
Q

_____% of patients with painful small duct chronic pancreatitis (44%) had concomitant gastroparesis.

A

44

76
Q

T/F: Narcotic therapy will make the severe abdominal pain and delayed gastric emptying assc with Chronic Pancreatitis

A

True!

77
Q

Endoscopic Therapy (stents?) are most effective in treating what?

A

Pain Relief (60-80%)

78
Q

What are the risks of stent therapy?

A
  1. Stent occlusion or migration
  2. Pancreatitis
  3. Ductal and parenchymal changes (about 2/3)
79
Q

This procedure bypasses the duct and creates an anastomosis directly with the duodenum.

A

Lateral Pancreaticojejunostomy

80
Q

95% of all pancreatic cancers are ________.

A

Exocrine! (Ductal adenocarcinoma, cystic, acinar cell carcinoma, pseudopapillary, colloid, adenosquamous)

81
Q

The rest of the pancreatic tumors are:

A

1-2% Endocrine
1% Lymphoma
Mets (RCC, Breast, Melanoma)
Sarcomas

82
Q

85-90% of all pancreas tumors are __________. Yet ductal cells only 10-15% of gland mass.

A

Pancreatic Adenocarcinoma

83
Q

Risk Factors for Pancreatic Cancer

A
  1. Black&raquo_space; White (~2:1)
  2. Cationic Trypsinogen: 40% have cancer by 70 yo
  3. Rare < 45 yo
  4. 7% of Pancreatic Ca = Familial
  5. High fat, low fruit/veg diet
  6. Smokers
84
Q

How would a patient with pancreatic cancer present?

A

Pain radiating to the back
Weight Loss
New onset DM
Nausea, Vomiting

85
Q

How do you dx pancreatic cancer?

A

CT (Pancreas Protocol)
Endoscopic US - Biopsy, Staging, CPN/CPB
US - Biopsy of Liver Mets
ERCP - Not required – cT better

*Avoid ERCP is sx would be performed in 7-10 days

86
Q

In a patient with obstructive jaundice and pancreatic cancer, what are the effects of ERCP?

A
  1. Preoperative biliary drainage (may cause more post-op wound infection, prolongs hospital stay and costs, risks of cholangitis/pancreatitis)
  2. Good for Cholangitis, Pruritis, Delay in Sx
87
Q

What is a big issue with pancreatic cancer

A

Develops late in the course of the dz, usually unresectable.

88
Q

How would you treat pancreatic cancer?

A
  1. Endoscopic: SEMS (duodenal/biliary)
  2. Sx: Gastrojejunostomy
  3. Jejunal Feeding tube with gastric decompression tube
89
Q

Risk Factors for Pancreatic Cancer

A

General: Age, males, smoking, obesity
Ethnicity: Ashkenazi jewish/ AA descent
Family history esp FPC (2 or >2 first degree relatives with PC)
Genetic syndromes: FAP/HNPCC/hereditary pancreatitis and breast/ovarian, Peutz-jeghers

90
Q

Tests for Pancreatic Cancer:

A

Genetics: clusters of PC or other cancers (breast, ovarian, melanoma)
Biomarkers: CA19-9

Gastroenterology (12 decks)

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