Pancreas - Exam 4 Flashcards
What cavity is the pancreas located in?
retroperitoneal
_____ connects the main pancreatic duct to the duodenum
major duodenal papilla
What are the exocrine functions of the pancreas? What the generic responsibilities of each?
Pancreatic protease-> protein digestion, lipase -> triglycerides and amylase -> carbohydrate digestion
What are the endocrine functions of the pancreas?
Insulin and glucagon
________ secrete pancreatic enzymes into the pancreatic duct while ______ lining the small pancreatic ducts secrete ______.
Acinar cells
epithelial cells
bicarbonate
What are the two major pancreatic proteases?
trypsin and chymotrypsin
Pancreatic _______ responsible for hydrolysis of triglyceride molecule into _______ and _______ which can be absorbed via intestinal mucosa
Lipase
monoglyceride
two free fatty acids
Pancreatic ______ responsible for carbohydrate utilization via hydrolysis of _____ to _____
Amylase
starch
maltose
________ multiple spherical groups of epithelial cells embedded as nodules in the endocrine pancreas which are surrounded by a rich capillary plexus. Most numerous in the ____ and make up 2% of the pancreas.
Islets of Langerhans
tail
_______ (15-20% of the islets)secrete _______ which raises blood glucose levels by accelerating conversion of liver glycogen into glucose.
Alpha cells
glucagon
______ (60-70% of the islets) secrete _____ which influences carbohydrate metabolism enabling glucose utilization
Beta cells
insulin
______ (5-10% of the islets) secrete _______ which inhibits insulin and glucagon secretion
Delta cells
somatostatin
Which cell type is the most abundant in the pancreas?
Beta cells 60-70%
______ is the leading cause of gastrointestinal-related hospitalization in the United States
acute pancreatitis
What are the top 2 causes of acute pancreatitis? Which one is the MC?
Gallstone is MC
heavy alcohol intake: NOT a single binge drink
______ may reduce the risk of non biliary pancreatitis
Coffee drinking
**What are the 10 causes of acute pancreatitis? What is the acronmyn to help remember them?
I GET SMASHED
Idiopathic causes
G = Obstruction by Gallstones
E = is Ethanol, or alcohol use, and it is not sure how it leads to pancreatitis.
T = Trauma
S = Steroids
M = infection with Mumps virus
A = Autoimmune diseases, like systemic lupus erythematosus and rheumatoid arthritis.
S = Scorpion sting, which also damages the pancreas directly.
H = Hypertriglyceridemia and Hypercalcemia.
E = Trauma from an ERCP
D = Drugs, like didanosine, Corticosteroids, Alcohol, Valproic acid, Azathioprine, and Diuretics
Drugs Causing A Violent Abdominal Distress
aka but mostly alcohol and gallstones
What are the 3 pathophys causes behind acute pancreatitis?
Edema or obstruction at ampulla of Vater
premature or overactivation of pancreatic enzymes
autodigestions (when enzymes are activated in the pancreas acinar cell compartment rather than the intestinal lumen)
What is the pathophys of gallstone induced acute pancreatitis? What does it lead to? What enzyme in particular?
Early event is blockade of secretion of pancreatic enzymes while the synthesis of them continues
leads to autodigestive injury to the gland
trypsin
________ happens d/t pancreatic enzymes that damage the vascular endothelium. Name some changes seen. What do these changes lead to?
Microcirculatory injury, vasoconstriction, capillary stasis, decreased oxygen saturation, progressive ischemia
changes lead to increased vascular permeability and swelling of the gland
In summary, activated ______, ________, and the release of ________ lead to a rapid worsening of pancreatic damage and necrosis
pancreatic enzymes
microcirculatory impairment
inflammatory mediators
How does acute pancreatitis present? Describe the timing. What makes it better? What makes it worse?
Epigastric abdominal pain that radiates to the back
sudden onset, steady and severe
worse with activity and lying supine
improves with leaning forward
What are 2 pt history points that would be consistent with acute pancreatitis?
Binge or heavy drinking just prior to symptoms, history of consuming a fatty meal just prior to symptom onset
______ will be seen in acute pancreatitis if it is associated with ampulla of vater blockage
jaundice
**What is the cullen’s sign?
ecchymotic discoloration observed in the periumbilical region
**What is the Grey Turner sign?
ecchymotic discoloration observed along the flank
What do the presence of Cullen’s sign and Grey Turner sign suggest?
Retroperitoneal bleeding
**What are the 2 ways to classify acute pancreatis?
According to morphology and according to severity
**According to the Atlanta classifications, what are the 2 options for acute pancreatitis?
Acute interstitial edematous pancreatitis : blood supply is maintained and Necrotizing
acute pancreatitis : blood supply is not maintained
**What are the acute pancreatitis classifications according to severity?
** What are the 2 labs that you need to get if concerned about acute pancreatitis? Which one is more sensitive?
Serum amylase and serum lipase -> more sensitive
What are 2 findings on xray that would point towards acute pancreatitis? Give a brief interpretation of each
“Sentinel Loop” and “Colon Cut-Off Sign”
“Sentinel Loop” - Dilated air filled small intestine near the pancreas
“Colon Cut-Off Sign” - Gas filled segment of transverse colon abruptly ending near pancreas due to functional spasm of descending colon secondary to pancreatic inflammation
When would an US be helpful in acute pancreatitis?
Helpful if looking for stone in suspected biliary pancreatitis but otherwise NOT helpful
What would a CT scan show in acute pancreatitis?
Enlarged pancreas and signs of inflammation associated with acute pancreatitis.
What are the essentials of dx for acute pancreatitis?
What is needed to dx acute pancreatis? Do you need imaging?
In patients with characteristic abdominal pain and elevation in serum lipase/amylase to 3 times or greater than the upper limit of normal
No imaging is required to establish the diagnosis
When would you order imaging if acute pancreatitis is suspected? What imaging would you order?
Abdominal pain is NOT characteristic, amylase/lipase levels are less than 3x ULN
abdominal CT WITH contrast
______ is the criteria used in acute pancreatitis to assess severity and prognosis
Ranson’s Criteria
**What are the parameters for Ranson’s criteria?
______ is the simplest criteria when determining the severity/prognosis of AP. What is the criteria?
BISAP
What is the tx for mild AP? What do you NOT want to give the pt? Why?
once s/s resolves plus clear liquids and slowly advancing diet
DO NOT GIVE MORPHINE because Morphine may cause sphincter of Oddi spasm
What is the tx for severe AP?
What are 3 complications of AP?
Pancreatic abscess
Acute peripancreatic fluid collection
Pancreatic Pseudocyst
When does a pancreatic pseudocyst occur? Describe it.
Occur more than 4 weeks after onset
Encapsulated collection of fluid with well defined inflammatory wall Fluid collections outside of the pancreas
What does chronic pancreatitis involve?
A syndrome involving inflammation, fibrosis, and loss of acinar and islet cells
What is the MC etiology in chronic pancreatitis?
Alcoholism +/- smoking
What is the MC eitology of chronic pancreatitis in children?
Cystic fibrosis
What is the pathophys behind chronic pancreatitis? What does the persistent inflammation cause?
Persistent inflammation of the pancreas resulting in permanent structural damage
changes to structures including fibrosis
atrophy and calcification that leads to IRREVERSIBLE damage
What is the clinical presentation of chronic pancreatitis?
Chronic, steady or intermittent epigastric, LUQ pain- radiates to back; worse 15-20 min after eating
65% of chronic pancreatitis pts either have ______ or ______.
Osteopenia or osteoporosis
______ is the MC reason for hospitalization in chronic pancreatitis. What would prompt a search for a complication of chronic pancreatitis?
PAIN
A change in pattern or sudden worsening of pain
In CP, what is the cause of the pain due to?
The cause of pain is due to increased pressure, ischemia, and inflammation of the pancreas
What will serium amylase/lipase levels show in CP?
Slightly elevated but can also be NORMAL
What is the most frequently utilized imaging study in chronic pancreatitis? What will endoscopic US show?
CT because able to image entire pancreas and pancreatic ducts
“honeycombing” of pancreas
What are 6 complications of chronic pancreatis? What is the main cause of death?
Pseduocysts
DM
malabsorption deficiency
opioid addiction
disability
reduced life expectancy
pancreatic carcinoma- main cause of death
What is the non-invasive tx for chronic pancreatitis?
Low fat diet, avoid alcohol, manage pain, pancreatic digestive enzymes, insulin as needed, tx any malabsorptive disorders
What are the invasive tx options for CP?
ERCP for stone extraction or decompression of pancreatic duct, Puestow procedure for dilated pancreatic duct, Whipple procedure, surgical drainage of pseudocysts, pain management
What is the Puestow Procedure?
“filet” open the pancreas and sew it to the jejunum
**Where is the major of pancreatic cancer located? Which location indicates a poorer prognosis?
75% in head, 25% in body and tail-> poorer prognosis
**What cell type is pancreatic carcinoma most likely?
85% are adenocarcinoma
What does an older pt with new onset DM make you think?
Possible pancreatic cancer
What is the MC presentation of pancreatic cancer?
Vague epigastric pain with radiation to back, typically gnawing, visceral with insidious onset. Can also be asymptomatic until metastasis has occurred
**What is Courvoisier sign? What is it due to?
Painless Jaundice and Enlarged palpable gallbladder, Due to tumor of pancreatic head causing obstruction of common bile duct
In advanced carcinoma of the pancreas, what node may be palpable?
hard periumbilical nodule called the Sister Mary Joseph node.
What cancer maker may or may not be positive in pancreatic cancer? What will amylase and lipase levels look like?
+ or - CA 19-9 tumor marker, Amylase, Lipase - normal to mildly elevated
What is the first line imaging in pancreatic cancer?
CT, can also do CT with FNA for cytologic studies
What is the “double duct?”
Simultaneous dilation of pancreatic and common bile duct that is confirmatory for pancreatic cancer on ERCP if CT was inconclusive
What is the tx for pancreatic cancer is dz is local and in the head? Give a brief description.
Whipple procedure then chemo/radiation, Removal pancreatic head, duodenum, first 15cm of jejunum, common bile duct, gallbladder, and a partial gastrectomy
What is the tx for pancreatic cancer if the cancer is in the tail? What do you need to do first?
Distal pancreatectomy with splenectomy, staging laparascopy first to visualize
What makes pancreatic cancer non-resectable?
Liver, peritoneum, and omentum mets, Encasement of superior mesenteric artery/vein, Extension into inferior vena cava
What is the screening recommendation for pancreatic cancer?
Patients with a family history (1st degree relative) with pancreatic cancer should have screening CT age 40-45 or 10 years before onest of cancer in the family member
________ and ______ are the keys in pancreatic cancer
Early recognition and prevention
What are the 4 pt education points for pancreatic cancer prevention?
Don’t smoke, limit alcohol, maintain a healthy weight, know your family hx, be familiar with common symptoms ( jaundice, unexplained weight loss, stomach pain that radiates to the back
What is the difference between ERCP and MRCP?
ERCP is more invasive, uses sedation but can visualize and treat the cause at the same time (stone removal) vs MRCP only visualizes but does NOT use sedation
