Pancreatic Disease Flashcards
1
Q
Endocrine function of pancreas
A
Islet of langerhans
Produce & secrete hormones
- insulin (responds to increased glucose)
- glucagon (response to low blood glucose)
2
Q
Exocrine function of pancreas
A
Acinar cells: synthesize and secrete digestive enzymes (amylase, lipase, protease)
Pancreatic juice: electrolytes, bicarb, digestive enzymes, neutralize gastric acid, provide basic environment
3
Q
Epidemiology of acute pancreatitis
A
developed > developing M=F alcohol induced >M gallstone induced >F few have recurrence
4
Q
Etiology of acute pancreatitis
A
Gallstones*
Chronic alcohol abuse*
Idiopathic
Others: "I get smashed" Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion/Snakes Hyperlipidemia/Hypercalcemia ERCP Drugs
5
Q
Pathophys behind acute pancreatitis
A
high pancreatic levels of activated trypsin –> pancreatic auto-digestion, injury and inflammation –> increased inflammation –> may lead to: remote organ injury/failure, systemic inflammatory response, multi-ogran failure, DEATH
6
Q
Presentation of acute pacnreatitis
A
acute, persistent & severe
epigastric and may radiate to back (boring)
worse w/ intake or lying supine
Better w/ sitting, leaning forward w/ knees flex
N/V
Anorexia (decreased oral intake)
Other: abdominal swelling, diaphoresis, hematemesis, SOB
7
Q
PE for acute pancreatitis
A
Tachycardia Tachypnea Fever Hypotension Epigastric or upper quadrant pain/guarding/decreased BS \+/- jaundice, pallor, diaphoresis
Severe necrotizing pancreatitis: cullen’s sign, grey turner’s sign, panniculitis
8
Q
Other PE findings that lead to cause of pancreatitis
A
ileus: abdominal distention, hypoactive bowels
choledocholithiasis or edema pancreatic head - scleral icterus
alchol abus - hepatomegaly
HLD - xanthomas
mumps - partoid swelling
9
Q
Cullen’s sign
A
ecchymosis in the periumbilical region
10
Q
Grey-Turner’s sign
A
ecchymosis of the flanks
11
Q
Panniculitis
A
erythematous nodules
12
Q
Labs for acute pancreatitis
A
CBC - elevated WBC CMP- glucose (high/low), hypercalcemia Cr Bilirubin - elevated LFT Pancreatic enzymes: amylase/lipase CRP >150 @ 48 hrs = severe pancreatitis
13
Q
severe pancreatitis
A
> 150 mg/dL @ 48 hrs
14
Q
Amylase
A
- Rises in 6-12 hrs, peaks in 48 hrs and normalizes in 3-5 days
- 20% will have normal level
- Sensitivity 67-83%, specificity 85-98%
15
Q
Lipase
A
- Rises in 4-8 hrs, peaks at 24 hrs and normalizes in 8-14 days
- More specific to pancreatic injury
- Sensitivity/specificity 82-100%
16
Q
Most specific to pancreatic injury
A
lipase
17
Q
Urine trypsinogen-2 dipstick test
A
rapid, noninvasive
high sensitivity and specificity
18
Q
ALT
A
> 150 U/L in first 48 hrs of symptom onset = >85% PPV of gallstone pancreatitis
19
Q
Who should get genetic testing for acute pancreatitis
A
family hx of pancreatitis
<35 YO at age of onset
- all patients w/ genetic testing should have genetic counseling before and after *
20
Q
Dx of acute pancreatitis
A
- Abdominal X-Ray – gallstones, sentinel loop
- Abdominal Ultrasound - gallstones
- Abdominal CT – inflammation, calcification, pseudocyst, necrosis, abscess
- Magnetic Resonance Cholangiopancreatography (MRCP)
- Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Endoscopic Ultrasound (EUS)
21
Q
Normal first dx test for pancreatitis
A
US
22
Q
Unexplained acute pancreatitis
A
risk of malignancy = CT w/ Contrast (“pancreas protocol”), MRI w/ MRCP, EUS
23
Q
Recurrent pancreatitis
A
EUS (initially) and/or
ERCP (neoplasm or stricture)
24
Q
Sentinel Loop
A
small bowel inflammation and air from ileus formation
25
CT of pancreas
enlargement of pancrea
identifies severity of disease
Identifies complications: necrosis, pseudocyst, abscess, hemorrhage
Not routine if meet clinical/lab criteria
26
Advantages of MRCP
lower risk of nephrotoxicity
increased characterization (fluid collection, necrosis, asbcess, pseudocyst)
better few of biliary/pancreatic ducts -- if CBD stone not visualized on CT/US
27
ERCP use
visualize biliary & pancreatic ductal anatomy
Obtain cytology or biopsy
Use: stone removal, stent insertion
28
EUS use
```
if cause unclear
Evaluate for:
- pancreatic duct abnormalities
- tumors involving ampulla
- pancreatic CA
- microlithiasis in GB or common bile duct
- early chronic pancreatitis
```
if abnormal consider ERCP
29
Dx of acute pancreatitis
2 of the following:
1. ) clinical presentation: acute persistent, severe, epigastric pain; often radiates to back
2. ) elevated lipase/amylase 3x nml
3) Consistent imaging findings (CR, MRI, US
* if you have 1 and 2, no imaging needed
30
Tx of acute pancreatitis
supportive/symptomatic
Aggressive hydration (fluid resuscitation, crystalloids)
Monitor (VS, I&O, Labs)
NPO (until pain, N/V controlled; NG tube?)
Control pain - IV opidios
Antiemetic
Abx (if infective necrosis) - IMIPENIM (good pancrea penetration)
31
Abx for infectious pancreatitis
imipenim (primaxin)
32
Goal of aggressive hydration in pancreatitis
decrease morbidity/mortality
| prevent necrosis
33
Indications of complications of acute pancreatitis
decrease urinary output/rising creatinine
Respiratory failure
Worsening condition (increased pain, fever, leukocytosis)
34
Complications of acute pancreatitis
```
Local
- peripancreatic fluid collection
-pancreatic pseudocyst
- necrosis
- gastric outlet dysfunction
- splenic and portal vein thrombosis
SIRS (systemic inflammatory response syndrome)
Organ failure (CV, Respiratory, renal)
```
35
Indications of complications of acute pancreatitis
decrease urinary output/rising creatinine
Respiratory failure
Worsening condition (increased pain, fever, leukocytosis)
36
Complications of acute pancreatitis
```
Local
- peripancreatic fluid collection
-pancreatic pseudocyst
- necrosis
- gastric outlet dysfunction
- splenic and portal vein thrombosis
SIRS (systemic inflammatory response syndrome)
Organ failure (CV, Respiratory, renal)
```
37
When to suspect complications
- persistent/recurrent abdominal pain
- increase in pancreatic enzyme level after initial decrease
- new or worsening organ dysfunction
- sepsis (fever and increased WBC's)
38
What is a pancreatic pseudocyst
palpable mass in the mid-epigastric area; in 10% of patients w/ pancreatitis
39
Sx of pancreatic pseudocyst
abdominal pain
early satiety
N/V
40
Complications of pancreatic pseudocyst
rupture
hemorrhage
infection
41
Tx of pancreatic pseudocyst
surgery vs. drainage
| indicated if symptomatic or infected
42
Types of pancreatitis
interstitial edematous acute pancreatitis - inflammation of parenchyma and peripancreatic tissue w/o necrosis
necrotizing acute pancreatitis - inflammation associated w/ pancreatic parenchymal necrosis and/or peripancreatic necrosis
43
Levels of pancreatitis
Mild- no organ failure
Mod- transient organ failure <48hrs
Severe- organ failure >48 hrs; > 1 local & systemic complication
44
Findings at initial assessment that are associated w/ severe disease
```
>55 YO
obesity
AMS
comorbidities
Labs:
- BUN >20 or rising
- hematocrit >44% or rising
- increased Cr
Rad:
- many or large extrapancreatic fluid collections, pleural effusions, pulmonary infiltrates
```
SIRS - present on admission; persists >48 hrs (simple and accurate
45
Ranson Criteria
for pancreatitis mortalitiy:
Initial signs:
- >55
- WBC >16,000
- Glucose >200 mg/ml
- AST >250
- LDH >350
Delayed signs (next 48 hrs)
- HCT drop > 10%
- BUN increases >5
- Calcium <8 mg/dl
- pO2 <60 mmHg
- serum albumin <3.2 mg/dl
- fluid sequestration 4-5 L
46
Results of ranson criteria
<3: 0-3% mortality
>=3: 11-15% mortality
>=6: 40%
47
APACHE score
Acute Physiology and Chronic Health Examination Score
- decreases values in 1st 48 hrs = mild
- increasing values in 1st 48 hours = severe
does not differentiate b/w interstitial and necrotizing
48
Mortality levels
mild acute: <1%
Moderate: 5%
Severe: up to 30%
49
Causes of death in acute pancreatitis
first 2 weeks - SIRS/organ failure
| after 2 weeks- sepsis and other related complications
50
Recurrence prevention
treat underlying cause
Gallstone - ERCP, elective cholecystectomy
Alcoholic- abstinence
Hypertriglycerides- diet mod, lipid lowering meds
Drug induced- discontinue offending med
51
Cause of chronic pancreatitis
repeated episodes of acute inflammation
52
Physiological effects of chronic pancreatitis
exocrine insufficiency leads to malabsortpion
- steatorrhea (greasy, foul stool)
- weight loss (fear of eating, malabsorption)
Endocrine leads to diabetes
- poly sx
- insulin dependent
- brittle DM-alpha and beta cells affected (hypoglycemic events)
53
Most common etiology of chronic pancreatitis
alcohol induced
```
Other:
CF
hereditary
idiopathic
smoking
```
54
Presentation of chronic hepatitis
early - episodic similar to acute pancreatitis
late - may become continues
aggravators: alcohol large high fat meals
Classic triad: Diabetes, steatorrhea, calcifications
55
Triad for chronic pancreatitis
diabetes
steatorrhea
calcifications
56
Aggravators for chronic pancreatitis
alcohol
| large high fat meals
57
Labs for chronic pancreatitis
amylase/lipase - normal or slightly increased
bilirubin/ALP - mildly elevated
Increased glucose
Secretin Stimulation test (not often used)
Increased fecal fat testing *** (72 hr quantitative)
Fecal elastase (test of choice for steatorrhea)
58
Test of choice for steatorrhea
fecal elastase
59
Gold standard test for chronic hepatitis
72 hours quantitative fecal fat
60
ERCP of chronic pancreatitis
Chain-of-lakes (pathgnomonic) - Alternating stenosis and dilatation of pancreatic duct
61
Management of chronic pancreatitis
behavior mod (abstain from alc, smoking cessation, low fat meals)
early identification of complications
Tx of complications (DM, malabsorption, pancreatic enzyme supplements)
Pain relief (amitryptyline or SSRI)
Endoscopic procedure (dilation/stenting)
resection
62
Drugs for chronic pancreatitis
amitryptiline
| SSRI
63
Complications of chronic pancreatitis
* Chronic pain
* Pseudocyst
* Abscess formation
* Fistula formation
* Pancreatic Ascites
* Mesenteric venous thrombosis
64
Epidemiology of pancreatic CA
M>F
Rare before 45 YO
poor prognosis
65
Etiology of pancreatic CA
abnormal glucose metabolism
insulin resistance
obesity
chronic pancreatitis
66
Types of pancreatic CA
exocrine (most common)
| endocrine
67
Exocrine pancreatic CA
tumors of the pancreatic ductal and acinar cells and their stem cells;
usually DUCTAL ADENOCARCINOMA
most involve HEAD OF PANCREAS
Most present w/ advance or metastatic disease
68
Most common type of pancreatic CA
ductal adenocarcinoma
69
most common location for pancreatic CA
head of pancreas
70
Risk factors for pancreatic CA
```
cigarette smoking
high body mass
lack of physical activity
nonhereditary chronic pancreatitis
pancreatic cyst
ETOH
advanced age
```
71
Presentation of pancreatic CA
epigastric pain
jaundice
weight loss
```
Others:
asthenia, anorexia, nausea
back pain, dark urine
steatorrhea, hepatomegaly
RUQ/epigastric mass
ascites
```
72
PE for pancreatic CA
```
abdominal pain
palpable gallbladder (nontender, Courvoisier sign)
Jaundice/icterus
```
73
Courvoisier's sign
```
pancreatic CA
(choledocholithiasis too)
```
74
Labs for pancreatic CA
LFTs
Bilirubin
Lipase (if epigastric pain) - indicates acute pancreatitis
CA 19-9**
75
Imaging for pancreatic CA
US (jaundice)
MRCP/ERCP if suspicious for choledocholithiasis
Epigastric pain + weight loss (w/o jaundice) - Triple Phase thin slice enhanced CT of abdomen w/ 3D reconstruction!!!
US- can't detect tumors <3cm
76
mass on US: what do you do next?
abdominal CT - confirms presence, extent of disease
77
When do you not need further testing of mass after CT
mass appears typical
enough info to assess resectability
patient is fit for major surgery
78
Best for tissue diagnosis
EUS
79
Test of choice for staging and ID eligibility for resction
Contrast enhanced helical CT
80
Only potential cure of pancreatic carcinoma
Surgical resection (whipple procedure- pancreaticoduodeectomy)
81
Prognosis of pancreatic CA
```
poor <5% 5 year survival
20% w/ resection - will need chemo/radiation
w/o resection:
-8-12 mo if local
-3-6 mo if metastatic
```
