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Clin Med III Exam 2 > Pancreatic Disease > Flashcards

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)

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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

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3
Q

Epidemiology of acute pancreatitis

A 
developed > developing
M=F
alcohol induced >M
gallstone induced >F
few have recurrence
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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
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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

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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

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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

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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

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9
Q

Cullen’s sign

A

ecchymosis in the periumbilical region

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10
Q

Grey-Turner’s sign

A

ecchymosis of the flanks

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11
Q

Panniculitis

A

erythematous nodules

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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
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13
Q

severe pancreatitis

A

> 150 mg/dL @ 48 hrs

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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%
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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%
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16
Q

Most specific to pancreatic injury

A

lipase

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17
Q

Urine trypsinogen-2 dipstick test

A

rapid, noninvasive

high sensitivity and specificity

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18
Q

ALT

A

> 150 U/L in first 48 hrs of symptom onset = >85% PPV of gallstone pancreatitis

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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 *
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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)
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21
Q

Normal first dx test for pancreatitis

A

US

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22
Q

Unexplained acute pancreatitis

A

risk of malignancy = CT w/ Contrast (“pancreas protocol”), MRI w/ MRCP, EUS

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23
Q

Recurrent pancreatitis

A

EUS (initially) and/or

ERCP (neoplasm or stricture)

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24
Q

Sentinel Loop

A

small bowel inflammation and air from ileus formation

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25
Q

CT of pancreas

A

enlargement of pancrea
identifies severity of disease
Identifies complications: necrosis, pseudocyst, abscess, hemorrhage

Not routine if meet clinical/lab criteria

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26
Q

Advantages of MRCP

A

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

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27
Q

ERCP use

A

visualize biliary & pancreatic ductal anatomy
Obtain cytology or biopsy
Use: stone removal, stent insertion

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28
Q

EUS use

A 
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

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29
Q

Dx of acute pancreatitis

A

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
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30
Q

Tx of acute pancreatitis

A

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)

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31
Q

Abx for infectious pancreatitis

A

imipenim (primaxin)

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32
Q

Goal of aggressive hydration in pancreatitis

A

decrease morbidity/mortality

prevent necrosis

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33
Q

Indications of complications of acute pancreatitis

A

decrease urinary output/rising creatinine
Respiratory failure
Worsening condition (increased pain, fever, leukocytosis)

34
Q

Complications of acute pancreatitis

A 
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
Q

Indications of complications of acute pancreatitis

A

decrease urinary output/rising creatinine
Respiratory failure
Worsening condition (increased pain, fever, leukocytosis)

36
Q

Complications of acute pancreatitis

A 
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
Q

When to suspect complications

A
  • persistent/recurrent abdominal pain
  • increase in pancreatic enzyme level after initial decrease
  • new or worsening organ dysfunction
  • sepsis (fever and increased WBC’s)
38
Q

What is a pancreatic pseudocyst

A

palpable mass in the mid-epigastric area; in 10% of patients w/ pancreatitis

39
Q

Sx of pancreatic pseudocyst

A

abdominal pain
early satiety
N/V

40
Q

Complications of pancreatic pseudocyst

A

rupture
hemorrhage
infection

41
Q

Tx of pancreatic pseudocyst

A

surgery vs. drainage

indicated if symptomatic or infected

42
Q

Types of pancreatitis

A

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
Q

Levels of pancreatitis

A

Mild- no organ failure
Mod- transient organ failure <48hrs
Severe- organ failure >48 hrs; > 1 local & systemic complication

44
Q

Findings at initial assessment that are associated w/ severe disease

A 
>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
Q

Ranson Criteria

A

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
Q

Results of ranson criteria

A

<3: 0-3% mortality
>=3: 11-15% mortality
>=6: 40%

47
Q

APACHE score

A

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
Q

Mortality levels

A

mild acute: <1%
Moderate: 5%
Severe: up to 30%

49
Q

Causes of death in acute pancreatitis

A

first 2 weeks - SIRS/organ failure

after 2 weeks- sepsis and other related complications

50
Q

Recurrence prevention

A

treat underlying cause
Gallstone - ERCP, elective cholecystectomy
Alcoholic- abstinence
Hypertriglycerides- diet mod, lipid lowering meds
Drug induced- discontinue offending med

51
Q

Cause of chronic pancreatitis

A

repeated episodes of acute inflammation

52
Q

Physiological effects of chronic pancreatitis

A

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
Q

Most common etiology of chronic pancreatitis

A

alcohol induced

Other:
CF 
hereditary
idiopathic
smoking
54
Q

Presentation of chronic hepatitis

A

early - episodic similar to acute pancreatitis
late - may become continues
aggravators: alcohol large high fat meals

Classic triad: Diabetes, steatorrhea, calcifications

55
Q

Triad for chronic pancreatitis

A

diabetes
steatorrhea
calcifications

56
Q

Aggravators for chronic pancreatitis

A

alcohol

large high fat meals

57
Q

Labs for chronic pancreatitis

A

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
Q

Test of choice for steatorrhea

A

fecal elastase

59
Q

Gold standard test for chronic hepatitis

A

72 hours quantitative fecal fat

60
Q

ERCP of chronic pancreatitis

A

Chain-of-lakes (pathgnomonic) - Alternating stenosis and dilatation of pancreatic duct

61
Q

Management of chronic pancreatitis

A

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
Q

Drugs for chronic pancreatitis

A

amitryptiline

SSRI

63
Q

Complications of chronic pancreatitis

A
  • Chronic pain
  • Pseudocyst
  • Abscess formation
  • Fistula formation
  • Pancreatic Ascites
  • Mesenteric venous thrombosis
64
Q

Epidemiology of pancreatic CA

A

M>F
Rare before 45 YO
poor prognosis

65
Q

Etiology of pancreatic CA

A

abnormal glucose metabolism
insulin resistance
obesity
chronic pancreatitis

66
Q

Types of pancreatic CA

A

exocrine (most common)

endocrine

67
Q

Exocrine pancreatic CA

A

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
Q

Most common type of pancreatic CA

A

ductal adenocarcinoma

69
Q

most common location for pancreatic CA

A

head of pancreas

70
Q

Risk factors for pancreatic CA

A 
cigarette smoking
high body mass
lack of physical activity
nonhereditary chronic pancreatitis
pancreatic cyst
ETOH
advanced age
71
Q

Presentation of pancreatic CA

A

epigastric pain
jaundice
weight loss

Others:
asthenia, anorexia, nausea
back pain, dark urine
steatorrhea, hepatomegaly
RUQ/epigastric mass
ascites
72
Q

PE for pancreatic CA

A 
abdominal pain
palpable gallbladder (nontender, Courvoisier sign)
Jaundice/icterus
73
Q

Courvoisier’s sign

A 
pancreatic CA
(choledocholithiasis too)
74
Q

Labs for pancreatic CA

A

LFTs
Bilirubin
Lipase (if epigastric pain) - indicates acute pancreatitis
CA 19-9**

75
Q

Imaging for pancreatic CA

A

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
Q

mass on US: what do you do next?

A

abdominal CT - confirms presence, extent of disease

77
Q

When do you not need further testing of mass after CT

A

mass appears typical
enough info to assess resectability
patient is fit for major surgery

78
Q

Best for tissue diagnosis

A

EUS

79
Q

Test of choice for staging and ID eligibility for resction

A

Contrast enhanced helical CT

80
Q

Only potential cure of pancreatic carcinoma

A

Surgical resection (whipple procedure- pancreaticoduodeectomy)

81
Q

Prognosis of pancreatic CA

A 
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

Clin Med III Exam 2 (8 decks)

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