pancreas pathophys

Question 1

Which pancreatic enzymes are active when secreted

Answer 1

amylase and lipase

Question 2

What causes acute pancreatitis

Answer 2

when pancreatic enzymes are inappropriately and prematurely activated resulting in autolysis of the gland. This may result in severe inflammation and/or necrosis of pancreatic tissue. Caused when pancreatic duct is obstructed resulting in stagnation of pancreas enzymes in duct lumen and activation of enzymes

Question 3

acute pancreatitis symptoms

Answer 3

severe pain in the upper abdomen, sometimes radiating to the back, and nausea/vomiting. Low-grade fevers may accompany this. The pain is usually intolerable

Question 4

Consequence of acute pancreatitis

Answer 4

Lipase released from dying acinar cells breaks down fat, liberating free fatty acids which precipitate with calcium and form insoluble soaps. In severe pancreatitis, there may be frank coagulation necrosis of the gland and/or hemorrhage into the retroperitoneum

Question 5

acute pancreatitis histology

Answer 5

necrosis of pancreatic tissue is associated with intense infiltrates of neutrophils and apoptosis of epithelial cells

Question 6

acute pancreatitis diagnosis

Answer 6

history/PE, serum levels of amylase and lipase which are elevated b/c enzymes leak out of inflammed pancreas into blood. Ultrasound, CT

Question 7

Acute pancreatitis treatment

Answer 7

NPO, IV pain meds, time (self limited). If gallstones, cholecystectomy to remove gallbladder or ERCP to extract stones.

Question 8

alcohol induced acute pancreatitis pathogenesis

Answer 8

damage of acinar cell > release of enzymes > lipase causes fat necrosis, proteases cause vascular damage

Question 9

Stone induced acute pancreatitis pathogenesis

Answer 9

obstruction > secretagogue effect > leakage of enzymes through injured ductule > lipase causes fat necrosis and proteases cause vascular destruction

Question 10

complications of acute pancreatitis

Answer 10

ileus (paralysis of gut), intra-abd hemorrhage, pseudocyst formation. Pancreatic necrosis, bowel obstruction, shock, respiratory or renal failure, death

Question 11

what is a pancreatic pseudocyst

Answer 11

•Collection of pancreatic fluid, debris surrounded by wall of granulation tissue - lacks epithelial lining. Results from ductal disruption, necrosis or both. Most resolve with time.

Question 12

What respiratory disease is associated with pancreatic necrosis

Answer 12

Adult respiratory distress syndrome (ARDS). Delayed onset, leads to respiratory failure. Fully reversible, treatment is support

Question 13

Causes of chronic pancreatitis

Answer 13

repeated acute pancreatitis, usually from chronic alcohol use.

Question 14

clues to gallstone pancreatitis

Answer 14

elevated liver enzymes, dilated bile duct

Question 15

Chronic pancreatitis macro and microscopic features

Answer 15

macro: hard fibrous tissue, atrophy of gland, pancreatic juice is viscous with calcifications, possible pseudocysts, ductal strictures Micro: boad bands of scar tissue, lymphocytes and/or plasma cells, strictures of ducts, calcified pancreatic duct stones

Question 16

Chronic pancreatitis symptoms

Answer 16

chronic pain (epigastric radiates to back), malabsorption resulting in steatorrhea, permanent loss of pancreatic function (hypo or hyperglycemia)

Question 17

Which features of chornic pancreatitis cause pain, exocrine failure, nausea, endocrine failure

Answer 17

Ductal strictures/stones cause pain and exocrine failure. Pancreatic pseudocysts cause pain, nausea/vomiting (depending on what’s compressed). Acinar destruction causes exocrine failure. Diabetes causes endocrine failure (late)

Question 18

Other causes of chronic pancreatitis

Answer 18

Cystic fibrosis, hereditary pancreatitis, hyperlipidemia

Question 19

pancreatic insufficiency symptoms and nutrients involved

Answer 19

weight loss (fat), steatorrhea (fat), bleeding problems (Vit K), anemia (Vit B12), weakness/edema (protein), watery diarrhea (CHO, protein)

Question 20

Mechanisms of steatorrhea

Answer 20

decreased lipase and colipase in duodenum. Decreased duodenal pH leads to inactivation of pancreas enzymes and bile acid precipitation

Question 21

Chronic pancreatitis diagnosis

Answer 21

history, PE, plain X ray shows pancreatic calcifications, CT shows dilated duct, atrophy, calcifications and pseudocysts. Secretin test, ERCP, endoscopic US are all more accurate

Question 22

What is secretin test

Answer 22

secretin given IV- [HCO3] increase of less than 80 mEq/l suggests pancreatic obstruction or failure

Question 23

Chronic pancreatitis treatment

Answer 23

ethanol avoidance, pancreas enzyme replacement for steatorrhea, treat duct obstruction with dilation stent or stone removal, celiac nerve block for pain, surgery, pancreatectomy with islet cell transplant in young patients

Question 24

Pancreatic cancer presentation

Answer 24

Jaundice, dark urine, pruritus - Bile duct obstruction (tumors in head). Late Abdominal or back pain - Capsular distension or nerve invasion. Weight loss. Nausea/vomiting (late) – Duodenal or gastric obstruction. Hormonal excess (neuroendocrine) -insulin, glucagon, gastrin, VIP

Question 25

Pancreatic neuroendocrine tumor

Answer 25

slow growing, good prognosis. Islet cell origin. Symptoms of hormonal excess. Octreotide scan used for small NETs

Question 26

Autoimmune pancreatitis

Answer 26

Diffuse or focal enlargement of pancreatic parenchyma. Infiltration by IgG-4 + plasma cells and lymphocytes. Males, typically ages 40-70

Question 27

Autoimmune pancreatitis symptoms

Answer 27

abdominal pain, jaundice, weight loss, (rarely) pancreatitis

Question 28

Autoimmune pancreatitis diagnosis and treatment

Answer 28

•Diagnosis: CT/MRI, serum IgG-4, EUS, ERCP, and occasionally FNA/biopsy. Treatment: PO corticosteroids x 6 weeks, biliary stenting for symptom relief