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X Clin Med III Exam 2 > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

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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
Diagnostics done with unexpained acute pancreatitis
Risk of malignancy so: Abd CT with IV contrast (pancreas protocol) MRI with MRCP EUS
26
Diagnostics for recurrent pancreatitis
Consider EUS and/or ERCP (neoplasm or stricture)
27
Use of abdominal CT with acute pancreatitis
Diagnoses enlargment of the pancreas IDs severity IDs complications
28
What complications of acute pancreatitis can be seen on CT?
Necrosis Pseudocyst Abscess Hemorrhage
29
What is done next when pt meets clinical and lab criteria for acute pancreatitis?
Nothing! (early CT is not recommended)
30
Why not use CT for most cases of acute pancreatitis?
Most are uncomplicated No evidence that improves clinical outcomes Complications really only appreciated 3 days after onset IV contrast may worsen it
31
Why advantages does MRCP have over CT?
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
ERCP
Therapeutic because can also do stone removal and stent insertion
33
Why use endoscopic u/s for acute pancreatitis
``` 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
Diagnostic criteria for acute pancreatitis
``` 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
Tx of acute pancreatitis
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
Complications associated with acute pancreatitis
``` Local (peripancreatic fluid collection, pseudocyst, necrosis, gastric outlet dysfunction, splenic and portal vein thrombosis) Systemic inflammatory response syndrome Organ failure (CV, resp, renal) ```
37
When should a CT be done with acute pancreatitis to ID complications?
``` >72 hrs after sx onset: Persistent or recurrent abd pain Increased in enzymes after initial decrease New or worsening organ dysfunction Sepsis ```
38
What is a pancreatic pseudocyst?
Palpable mass in mid epigastric area that may cause abd pain, early satiety and n/v
39
Tx of pancreatic pseudocyst
Surgery vs drainage (sxs or infected!) | Complicated by rupture, hemorrhage or infection
40
Classifications of acute pancreatitis
Interstitial edematous acute pancreatitis | Necrotizing acute pancreatitis
41
What is interstitial edematous acute pancreatitis?
Acute inflammation of pancreatic parenchyma and peripancreatic tissues without necrosis
42
What is necrotizing acute pancreatitis?
Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis
43
Severity classifications of acute pancreatitis
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
Findings at first assessment to be associated with severe disease
>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
What is Ransons criteria for acute pancreatitis?
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
What is the APACHE score for acute pancreatitis?
Decreasing values in first 48 hrs is mild and increasing is severe Can't differentiate interstitial and necrotizing
47
Causes of death with acute pancreatitis
First 2 wks: SIRS or organ failure | After 2 wks: sepsis or other related complications
48
How to prevent recurrence of acute pancreatitis
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
What is chronic pancreatitis?
Repeated episodes of acute inflammation | Gradual loss of pancreatic function leads to exocrine and endocrine insufficiency
50
Exocrine insufficiency of chronic pancreatitis
Leads to malabsorption causing steatorrhea and weight loss
51
Endocrine insufficiency of chronic pancreatitis
Leads to diabetes (sxs of polys, usually insulin dependent, affect DM-alpha and beta cells)
52
Most common cause of chronic pancreatitis
Alcohol induced disease (can be CF, hereditary, idiopathic or smoking)
53
Classic triad of chronic pancreatitis
DM Steatorrhea Calcifications on imaging
54
Pain of chronic pancreatitis
Epigastric pain: Early is similar to acute episodes Late may have continuous attacks Aggravated by alcohol and large high fat meals
55
Labs in chronic pancreatitis
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
What is fecal fat testing?
72 hr quantitative fecal fat is preferred over qualitative testing of spot sample (gold standard)
57
Test of choice for steatorrhea
Fecal elastase
58
What is seen on abd CT in chronic pancreatitis?
Calcifications Ductal dilation Pseudocysts
59
MRCP for chronic pancreatitis?
Good for pancreatic and biliary ducts! | Used more now!
60
Pathognomonic for chronic pancreatitis on ERCP
Chain of lakes (gold standard?) | Only really used when think itll help therapeutically
61
Management for chronic pancreatitis
``` 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
Complications of chronic pancreatitis
``` Chronic pain Pseudocyst Abscess formation Fistula formation Pancreatic ascites Mesenteric venous thrombosis ```
63
Causes of pancreatic cancer
Abnormal glucose metabolism Insulin resistance Obesity Chronic pancreatitis
64
Most common type of pancreatic cancer
Exocrine (all tumors related to pancreatic ductal and acinar cells and their stem cells) Small amt is endocrine
65
Where does pancreatic cancer occur?
Usually ductal adenocarcinoma of pancreas Can also involved head Most are presenting with locally advanced or metastatic disease
66
Major risk factors of pancreatic cancer
``` Cig smoking High body mass Lack of physical activity Nonhereditary chronic pancreatitis Pancreatic cysts (others etoh and old age) ```
67
Most common presentation of pancreatic cancer
Epigastric pain Jaundice Weight loss Others (asthenia, anorexia, nausea, back pain, dark urine, steatorrhea, hepatomegaly, RUQ/epigastric mass, Courovisiers, ascites)
68
What seen on PE for pancreatic cancer?
Abd pain Palpable gallbladder (nontender-courvoisier) Jaundice and icterus
69
Labs for pancreatic cancer
``` Assay of serum aminotransferases Alk phos Bilirubin Serum lipase (if epigastric pain) CA 19-9 (tumor marker in pancreatic cancer and pretty sensitive) ```
70
Preferred imaging when presenting with pancreatic cancer with jaundice
``` Abd us (detect biliary tract dilation, level of obstruction and mass) If thinking choledocho, do MRCP or ERCP ```
71
Preferred imaging when presenting with pancreatic cancer with epigastric pain and weight loss (no jaundice)
Triple phase thin sliced enhanced helical CT of abd with 3D reconstruction (us lacks sensitivity for small tumors and can't ID necrosis)
72
What to do if find mass on US?
Abd CT (confirm it and assess extent)
73
When do you need no further testing after CT due to mass found on US?
If mass is typical Enough info to assess resectability Pt is fit for major surgery
74
Other imaging that can be used for pancreatic cancer
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
Only potential cure for pancreatic carcinoma
Surgical resection (whipple procedure or pancreaticoduodenectomy- remove 1/2 stomach, GB, pancreas and top 15 cm of duodenum
76
Management for pancreatic cancer
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
Prognosis of pancreatic cancer
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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