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X Clin Med III Exam 2 > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

Endocrine part of the pancreas

A

Islet of Langerhans

Produces and secretes hormone (insulin when increased blood glucose and glucagon when low blood glucose)

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2
Q

Exocrine part of the pancreas

A 
Acinar cells to synthesize and secrete digestive enzymes into duodenum)
Pancreatic juice (electrolytes, bicarb and digestive enzymes to neutralize gastric acid and create basic environment)
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3
Q

What are the digestive enzymes from the pancreas?

A

Amylase: breakdown starch
Lipase: breakdown fat
Protease: breakdown protein

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4
Q

When do you see acute pancreatitis more?

A

In developed countries due to diet
Male is alcohol induced while female is gallstone induced
Usually only one episode (not much recurrence)

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5
Q

Causes of acute pancreatitis

A

Gallstones
Chronic alcohol abuse
Idiopathic (less)
Others: smoking, hypertriglyceridemia, hypercalcemia, meds, abd trauma or blunt trauma, infection, vascular disease, tumor, genetics or toxins

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6
Q

Pneumonic for causes of acute pancreatitis

A 
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion/snakes
Hyperlipidemia/hypercalcemia
ERCP
Drugs
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7
Q

How does acute pancreatitis happen?

A

High levels of activated trypsin–pancreatic auto-digestion, injury and inflammation–increased inflammation–leads to remote organ injury, systemic inflamm response, multi organ failure and death

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8
Q

Abd pain associated with acute pancreatitis

A 
Acute, after eating
Midepigastric and radiates to back
Constant
Steady and boring
Worse when lying supine, food or alcohol
Better when sitting and leaning forward
Associated with anorexia, n/v, abd distension, jaundice , pallor or diaphoresis
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9
Q

PE for acute pancreatitis

A

Tachycardia, tachypnea, fever, hypotension

Guarding and decreased bowel sounds

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10
Q

Cause of acute pancreatitis based on finding: abd distension and hypoactive bowel sounds

A

Ileus

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11
Q

Cause of acute pancreatitis based on finding: scleral icterus

A

Choledocholithiasis or edema of pancreatic head

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12
Q

Cause of acute pancreatitis based on finding: hepatomegaly

A

Alcoholic abuse

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13
Q

Cause of acute pancreatitis based on finding: xanthomas

A

Hyperlipidemia

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14
Q

Cause of acute pancreatitis based on finding: parotid swelling

A

Mumps

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15
Q

What signs are seen with severe necrotizing pancreatitis?

A

Cullens: ecchymosis in periumbilical region
Grey turner: ecchymosis of flanks
Panniculitis: erythematous nodules

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16
Q

Labs in acute pancreatitis

A 
Elevated WBC
Hyper or hypoglycemia
Hypercalcemia
Elevated bilirubin
ALT elevated
Elevated amylase and lipase
CRP >150 mg/dL at 48 hrs is severe
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17
Q

Amylase in acute pancreatitis

A

Rises in 6-12 hrs, pks in 48 hrs and normalizes in 3-5 days

Not as sensitive (some have normal)

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18
Q

Lipase in acute pancreatitis

A

Rises in 4-8 hrs, pks at 24 hrs and normalizes in 8-14 days

More sensitive to pancreatic injury

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19
Q

Urine trypsinogen-2 dipstick test for acute pancreatitis

A

Rapid and noninvasive

High sensitivity and specificity

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20
Q

Alanine aminotransferase (ALT) with acute pancreatitis

A

> 150 U/L in first 48 hrs of sx onset has a high predictinf value for gallstone pancreatitis

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21
Q

When should you consider genetic testing with acute pancreatitis?

A

Strong family hx
<35 YO when onset
*should have genetic counseling before and after

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22
Q

Imaging done for acute pancreatitis

A 
Abd x-ray: gall stones and sentinel loop
Abd us: gallstones
Abd CT: inflammation, calcification, pseudocyst, necrosis, abscess
MRCP
ERCP
Endoscopic US
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23
Q

What is a sentinel loop?

A

Small bowel inflammation and air from ileus formation

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24
Q

First diagnostic done with suspected pancreatitis

A

U/s

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25
Q

Diagnostics done with unexpained acute pancreatitis

A

Risk of malignancy so:
Abd CT with IV contrast (pancreas protocol)
MRI with MRCP
EUS

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26
Q

Diagnostics for recurrent pancreatitis

A

Consider EUS and/or ERCP (neoplasm or stricture)

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27
Q

Use of abdominal CT with acute pancreatitis

A

Diagnoses enlargment of the pancreas
IDs severity
IDs complications

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28
Q

What complications of acute pancreatitis can be seen on CT?

A

Necrosis
Pseudocyst
Abscess
Hemorrhage

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29
Q

What is done next when pt meets clinical and lab criteria for acute pancreatitis?

A

Nothing! (early CT is not recommended)

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30
Q

Why not use CT for most cases of acute pancreatitis?

A

Most are uncomplicated
No evidence that improves clinical outcomes
Complications really only appreciated 3 days after onset
IV contrast may worsen it

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31
Q

Why advantages does MRCP have over CT?

A

Lower risk of nephrotoxicity
Increased characterization for fluid collections, necrosis, abscess or pseudocyst
Better view of biliary and pancreatic ducts (like if CBD stone not seen on CT or US)

32
Q

ERCP

A

Therapeutic because can also do stone removal and stent insertion

33
Q

Why use endoscopic u/s for acute pancreatitis

A 
IF cause not clear and want to look for:
Pancreatic ductal abnormalities
Tumors involving ampulla
Pancreatic cancer
Microlithiasis in CB or CBD
Early chronic pancreatitis
34
Q

Diagnostic criteria for acute pancreatitis

A 
Clinical presentation (acute persistent, severe epigastric pain often going to back)
Elevated lipase or amylase 3x normal
Consistent imaging (not needed if have first 2)
35
Q

Tx of acute pancreatitis

A

Inpatient
Hydration (prevent necrosis): fluid resuscitation and crystalloids
Monitor: I&Os, vitals and labs
NPO until pain and n/v controlled (IV opioids and antiemetics)
Abx if infective necrosis-imipenim
Early ID of complications (decreased urine output, resp failure, worsening)

36
Q

Complications associated with acute pancreatitis

A 
Local (peripancreatic fluid collection, pseudocyst, necrosis, gastric outlet dysfunction, splenic and portal vein thrombosis)
Systemic inflammatory response syndrome
Organ failure (CV, resp, renal)
37
Q

When should a CT be done with acute pancreatitis to ID complications?

A 
>72 hrs after sx onset:
Persistent or recurrent abd pain
Increased in enzymes after initial decrease
New or worsening organ dysfunction
Sepsis
38
Q

What is a pancreatic pseudocyst?

A

Palpable mass in mid epigastric area that may cause abd pain, early satiety and n/v

39
Q

Tx of pancreatic pseudocyst

A

Surgery vs drainage (sxs or infected!)

Complicated by rupture, hemorrhage or infection

40
Q

Classifications of acute pancreatitis

A

Interstitial edematous acute pancreatitis

Necrotizing acute pancreatitis

41
Q

What is interstitial edematous acute pancreatitis?

A

Acute inflammation of pancreatic parenchyma and peripancreatic tissues without necrosis

42
Q

What is necrotizing acute pancreatitis?

A

Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis

43
Q

Severity classifications of acute pancreatitis

A

Mild: no organ failure or complications
Moderately severe: transient organ failure <48 hrs, no local or systemic complications
Severe: organ failure >48 hrs, > 1 local and > 1 systemic complication

44
Q

Findings at first assessment to be associated with severe disease

A

> 55 YO, obese, AMS and comorbidities
Labs: BUN>20 or rising, hematocrit >44% or rising, increased Cr
Seeing many large extrapancreatic fluid collections, pleural effusions or pulm infiltrates

45
Q

What is Ransons criteria for acute pancreatitis?

A

Initial signs: >55, WBC>16,000, glucose >200, AST>250, LDH>350
Delayed signs (48 hrs): HCT drop >10%, BUN up > 5 mg, Ca <8, pO2<60 mmHg, serum albumin <3.2 and fluid sequestration 4-5 L
Mortality 40% when more than 6 (>3 is 11-15%)

46
Q

What is the APACHE score for acute pancreatitis?

A

Decreasing values in first 48 hrs is mild and increasing is severe
Can’t differentiate interstitial and necrotizing

47
Q

Causes of death with acute pancreatitis

A

First 2 wks: SIRS or organ failure

After 2 wks: sepsis or other related complications

48
Q

How to prevent recurrence of acute pancreatitis

A

Treat the underlying cause:
Gallstones: ERCP if in CBD or cholecystectomy
Alcholic: abstinence
HyperTAGs: modify diet and lipid lowering med
Drug induced: stop med

49
Q

What is chronic pancreatitis?

A

Repeated episodes of acute inflammation

Gradual loss of pancreatic function leads to exocrine and endocrine insufficiency

50
Q

Exocrine insufficiency of chronic pancreatitis

A

Leads to malabsorption causing steatorrhea and weight loss

51
Q

Endocrine insufficiency of chronic pancreatitis

A

Leads to diabetes (sxs of polys, usually insulin dependent, affect DM-alpha and beta cells)

52
Q

Most common cause of chronic pancreatitis

A

Alcohol induced disease (can be CF, hereditary, idiopathic or smoking)

53
Q

Classic triad of chronic pancreatitis

A

DM
Steatorrhea
Calcifications on imaging

54
Q

Pain of chronic pancreatitis

A

Epigastric pain:
Early is similar to acute episodes
Late may have continuous attacks
Aggravated by alcohol and large high fat meals

55
Q

Labs in chronic pancreatitis

A

Amylase and lipase normal to slight elevation
Bilirubin and alk phos may be slightly elevated
Increased glucose
Secretion stimulation test (abnormal if good amt of exocrine function is lost)
Increased fecal fat testing

56
Q

What is fecal fat testing?

A

72 hr quantitative fecal fat is preferred over qualitative testing of spot sample (gold standard)

57
Q

Test of choice for steatorrhea

A

Fecal elastase

58
Q

What is seen on abd CT in chronic pancreatitis?

A

Calcifications
Ductal dilation
Pseudocysts

59
Q

MRCP for chronic pancreatitis?

A

Good for pancreatic and biliary ducts!

Used more now!

60
Q

Pathognomonic for chronic pancreatitis on ERCP

A

Chain of lakes (gold standard?)

Only really used when think itll help therapeutically

61
Q

Management for chronic pancreatitis

A 
Behavior (stop alcohol, smoking and do small low fat meals)
Tx complications (DM and malabsorption-pancreatic enzyme supplements)
Pain relief (amitriptyline or SSRI or pain specialist for opioids, nerve block or celiac plexus ethanol/steroids)
Dilatation and stenting, resection
62
Q

Complications of chronic pancreatitis

A 
Chronic pain
Pseudocyst
Abscess formation
Fistula formation
Pancreatic ascites
Mesenteric venous thrombosis
63
Q

Causes of pancreatic cancer

A

Abnormal glucose metabolism
Insulin resistance
Obesity
Chronic pancreatitis

64
Q

Most common type of pancreatic cancer

A

Exocrine (all tumors related to pancreatic ductal and acinar cells and their stem cells)
Small amt is endocrine

65
Q

Where does pancreatic cancer occur?

A

Usually ductal adenocarcinoma of pancreas
Can also involved head
Most are presenting with locally advanced or metastatic disease

66
Q

Major risk factors of pancreatic cancer

A 
Cig smoking
High body mass
Lack of physical activity
Nonhereditary chronic pancreatitis
Pancreatic cysts
(others etoh and old age)
67
Q

Most common presentation of pancreatic cancer

A

Epigastric pain
Jaundice
Weight loss
Others (asthenia, anorexia, nausea, back pain, dark urine, steatorrhea, hepatomegaly, RUQ/epigastric mass, Courovisiers, ascites)

68
Q

What seen on PE for pancreatic cancer?

A

Abd pain
Palpable gallbladder (nontender-courvoisier)
Jaundice and icterus

69
Q

Labs for pancreatic cancer

A 
Assay of serum aminotransferases
Alk phos
Bilirubin
Serum lipase (if epigastric pain)
CA 19-9 (tumor marker in pancreatic cancer and pretty sensitive)
70
Q

Preferred imaging when presenting with pancreatic cancer with jaundice

A 
Abd us (detect biliary tract dilation, level of obstruction and mass)
If thinking choledocho, do MRCP or ERCP
71
Q

Preferred imaging when presenting with pancreatic cancer with epigastric pain and weight loss (no jaundice)

A

Triple phase thin sliced enhanced helical CT of abd with 3D reconstruction
(us lacks sensitivity for small tumors and can’t ID necrosis)

72
Q

What to do if find mass on US?

A

Abd CT (confirm it and assess extent)

73
Q

When do you need no further testing after CT due to mass found on US?

A

If mass is typical
Enough info to assess resectability
Pt is fit for major surgery

74
Q

Other imaging that can be used for pancreatic cancer

A

ERCP if therapeutic (double duct sign)
MRCP (can’t do ERCP)
EUS (best for tissue diagnosis)
Contrast enhanced helical CT (TOC for staging and ID eligibility for resection, FNA)

75
Q

Only potential cure for pancreatic carcinoma

A

Surgical resection (whipple procedure or pancreaticoduodenectomy- remove 1/2 stomach, GB, pancreas and top 15 cm of duodenum

76
Q

Management for pancreatic cancer

A

Biliary obstruction: stent or decompress bile duct
Gastric obstruction so n/v or anorexia: decompress stomach or surgical palliation
Pain: narcotics, chemo or radiation

77
Q

Prognosis of pancreatic cancer

A

Five yr survival is very low (if resect lesions than it is a little higher)
Median survival with unresectable lesion: 8-12 mos if locally invasive and 3-6 mos if metastatic

X Clin Med III Exam 2 (9 decks)

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