Pancreatic Disease Flashcards
What is the exocrine function of the pancreas?
Digestive:
- Amylase-break down starch
- Lipase-Breakdown fat
- Proteases-breakdown proteins
What does “Pancreatic juice” contain?
- Electrolytes
- Bicarb
- Gastric Acid
*Neutralized gastric acid & provides basic environment for pancreatic enzymes
What is the release of pancreatic juice stimulated by?
- Gastric acid
- Cholecystokinin
- Vagal Stimulation
Endocrine function of the pancreas?
- Insulin: Lowe blood sugar
2. Glucagon: increase blood sugar
What kind of cells is amylase recreated form?
Pancreatic Acinar cells into the duodenum for starch digestion
When would you see an increase in amylase?
- Pancreatitis: damage to acinar cells
2. Obstruction of pancreatic duct flow: CA or CBD stones
How soon do you see an increase in amylase? When does it return to normal?
Rise=2 hrs of injury
Return to normal=48-72 hrs
NON-pancreatic elevation in Lipase
<3x ULN
How soon do you see an increase in lipase following injury? How long does it stay elevated?
Rise=24-28 hrs
Remain elevated=5-7 days
What accounts for 75% of acute pancreatitis
- Alcohol=#1 Drug/Toxin etiology
2. Gallstones= #1 Mechanical etiology
MC Metabolic etiology in acute pancreatitis?
Hypertriglyceridemia= >500
acute pancreatitis clinical presentation
- Acute midepgiastric pain: Constant, boring
- radiates to back
- +/- following a meal
- Aggravated: lying supine
- Relieved: Sitting and leaning forward
- N/V, anorexia
Vital signs in acute pancreatitis
- Fever
- Tachycardia
- Hypotension
- Tachypnea
Abdomen PEx findings in acute pancreatitis
- Hypoactive or absent bowel sounds
- Significant mid-epigastric tenderness
- Necrotizing hemorrhage: Cullen’s sign, Grey-Turner’s sign
Lab findings in acute pancreatitis
- Amylase & Lipase: 3x normal*
- Leukocytosis: WBC 15-20K
- Hct: Elevated
- Cr: Elevated
- Calcium: decrease, hypocalcemia
- Glucose: slightly elevated
What lab findings are strongly suggestive of gallstone pancreatitis?
- ALT>150
2. Elevated bilirubin
What MAY you find on an abdominal x-ray in acute pancreatitis
Sentinel loop= localized ileus= dilated small bowel in LUQ
What would you want to use a CXR for in the setting of suspected acute pancreatitis
Rule out:
- Pulmonary infiltrates
- Pleural effusions
What is the diagnostic test of choice in acute pancreatitis? Findings?
CT abdomen
- Enlargement of pancreas
- Blurring of fat planes/fat stranding
What complications can an abdominal CT identify?
- Necrosis
- Pseudocysts
- Abscess
- Hemorrhage
What are some of the advantages of MRI/MRCP over CT?
- lower risk of nephrotoxicity
- Helpful if CBD stone not visualized on CT/US and biliary pancreatitis expected
- Increased characterization of fluid
What are the indications for ERCP?
- Visualization of biliary and pancreatic ductal anatomy
- Cytology or Bx can be obtained
- Therapeutic: Stone removal, stent insertion, sphincterotomy
When can you only use an ERCP?
Once acute sx’s have resolved
Acute pancreatitis Treatment
“Rest the Pancreas”
- NPO
- IV fluids: Hydration!
- Pain control: Meperidine (Demerol)
When are abx indicated in the treatment of acute pancreatitis?
Infected necrosis
List the 5 local complications of Acute Pancreatitis
- Pseudocyst: Collection of fluid & derby
- Pancreatic abscess: Fever + Elevated WBC
- Pancreatic necrosis
- Hemorrhage: Cullen/Grey turner sign
- Ascites: leaking duct or pseudocyst
Si/sx’s of Pancreatic Pseudocyst
- Abd pain
- N/V
- Early Satiety*
Indications for surgery vs. drainage with pancreatic pseudocyst?
- Symptomatic
2. Infected
List the pulmonary complications in Acute Pancreatitis
- Respiratory failure/ARDS
- Pulmonary edema
- Pleural effusions
- Atelectasis
List the renal complication in Acute Pancreatitis
Renal failure
List the Cardiac complication in Acute Pancreatitis
Hypotension/Shock
List the GI complication in Acute Pancreatitis
ileus
List the metabolic complications in Acute Pancreatitis
- Hyperglycemia
2. Hypocalcemia
What is the mortality rate with a Ransons Criteria Score of 0-2?
<1%
What is the mortality rate with a Ransons Criteria Score of 3-4
15%
What is the mortality rate with a Ransons Criteria Score of 5-6
40%
What is the mortality rate with a Ransons Criteria Score of 7-8
100%
What is the OVERALL mortality of acute pancreatitis?
10-15%
What is the MCC for chronic pancreatitis?
Alcohol
What is the PREDOMINANT sx in CHRONIC pancreatitis?
Epigastric Pain=80%
What is the Classic triad of sx’s in Chronic Pancreatitis?
- Steatorrhea d/t exocrine dysfunction: Greasy, foul smelling stool
- Diabetes d/t endocrine dysfunction= Insulin insufficiency
- Pancreatic calcifications: visualized on abdomen x-ray
Lab findings in Chronic Pancreatitis
- Elevated glucose
- NORMAL: Amylase & Lipase
- MILDY elevated: Bilirubin & Alk phos
What is the preferred diagnostic lab test?
Fecal Fat Testing: Elevated 72 hr quantitative fecal fat
What is the Gold Standard imaging for the diagnosis of Chronic Pancreatitis?
ERCP
ERCP findings
“Chain of lakes”
Chronic Pancreatitis management/tx
- Behavior mod: abstinence from alcohol, small low fat meals
- Manage DM: Insulin
- Malabsorption tx: Pancreatic enzyme supplements
Chronic Pancreatitis pain relief treatment options
- Amitriptyline or SSRI
- Narcotic pain meds: Long acting- MS Contain vs. Fentanyl Patch
- Nerve blocks: Celiac Plexus
Chronic Pancreatitis surgical treatment options
- Endoscopic procedures: Ductal dilation, stenting
2. Surgical resection: If CA suspected
Where are the majority of pancreatic tumors located?
Head of pancreas
What type of pancreatic cancer is the majority?
Adenocarcinomas
List the Race/Sex risk factors for Pancreatic Carcinoma
- Males
- AA
- Increasing age= >45
List the other risk factors for Pancreatic Carcinoma
- Smoking
- Alcohol
- Chronic pancreatitis
- DM
- Obesity
- FHx
What is the MC presenting sx in Pancreatic Carcinoma?
Abdominal pain: Gnawing, epigastric pain radiating to back
Other presenting sx’s in Pancreatic Carcinoma?
- PAINLESS jaundice
- Early satiety/anorexia, wt. loss
- Pruritis
- Acholic (pale) stools
- Dark urine
PEx findings in Pancreatic Carcinoma?
- Virchow’s node: Left Supraclavicular LN
2. Courvoisier’s Sign: Palpable non-tender GB
What tumor marker is used to evaluate Pancreatic Carcinoma?
CA 19-19
What is the Test of Choice in Pancreatic Carcinoma for staging disease & identify eligibility for resection
CT Scan/Helical CT
Detects >80% of masses
What is considered the PRIMARY diagnostic tool/imaging in Pancreatic Carcinoma
ERCP
ERCP findings in Pancreatic Carcinoma
“Double Duct sign”: Stricture of both CBD & pancreatic ducts
What do you need to make sure you obtain with an ERCP?
Tissue sample
What can an endoscopic US (EUS) evaluate for?
- Tumor involvement
- Vascular involvement
*best for FNA bx
What is the only potential cure in Pancreatic Carcinoma?
Whipple procedure (pancreaticoduodenectomy)
+ Chemo
+/- Radiation
What is the 5 year survival in Pancreatic Carcinoma?
<5%= Very poor!