Pancreatic Disease Flashcards
Endocrine part of the pancreas
Islet of Langerhans
Produces and secretes hormone (insulin when increased blood glucose and glucagon when low blood glucose)
Exocrine part of the pancreas
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)
What are the digestive enzymes from the pancreas?
Amylase: breakdown starch
Lipase: breakdown fat
Protease: breakdown protein
When do you see acute pancreatitis more?
In developed countries due to diet
Male is alcohol induced while female is gallstone induced
Usually only one episode (not much recurrence)
Causes of acute pancreatitis
Gallstones
Chronic alcohol abuse
Idiopathic (less)
Others: smoking, hypertriglyceridemia, hypercalcemia, meds, abd trauma or blunt trauma, infection, vascular disease, tumor, genetics or toxins
Pneumonic for causes of acute pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion/snakes Hyperlipidemia/hypercalcemia ERCP Drugs
How does acute pancreatitis happen?
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
Abd pain associated with acute pancreatitis
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
PE for acute pancreatitis
Tachycardia, tachypnea, fever, hypotension
Guarding and decreased bowel sounds
Cause of acute pancreatitis based on finding: abd distension and hypoactive bowel sounds
Ileus
Cause of acute pancreatitis based on finding: scleral icterus
Choledocholithiasis or edema of pancreatic head
Cause of acute pancreatitis based on finding: hepatomegaly
Alcoholic abuse
Cause of acute pancreatitis based on finding: xanthomas
Hyperlipidemia
Cause of acute pancreatitis based on finding: parotid swelling
Mumps
What signs are seen with severe necrotizing pancreatitis?
Cullens: ecchymosis in periumbilical region
Grey turner: ecchymosis of flanks
Panniculitis: erythematous nodules
Labs in acute pancreatitis
Elevated WBC Hyper or hypoglycemia Hypercalcemia Elevated bilirubin ALT elevated Elevated amylase and lipase CRP >150 mg/dL at 48 hrs is severe
Amylase in acute pancreatitis
Rises in 6-12 hrs, pks in 48 hrs and normalizes in 3-5 days
Not as sensitive (some have normal)
Lipase in acute pancreatitis
Rises in 4-8 hrs, pks at 24 hrs and normalizes in 8-14 days
More sensitive to pancreatic injury
Urine trypsinogen-2 dipstick test for acute pancreatitis
Rapid and noninvasive
High sensitivity and specificity
Alanine aminotransferase (ALT) with acute pancreatitis
> 150 U/L in first 48 hrs of sx onset has a high predictinf value for gallstone pancreatitis
When should you consider genetic testing with acute pancreatitis?
Strong family hx
<35 YO when onset
*should have genetic counseling before and after
Imaging done for acute pancreatitis
Abd x-ray: gall stones and sentinel loop Abd us: gallstones Abd CT: inflammation, calcification, pseudocyst, necrosis, abscess MRCP ERCP Endoscopic US
What is a sentinel loop?
Small bowel inflammation and air from ileus formation
First diagnostic done with suspected pancreatitis
U/s
Diagnostics done with unexpained acute pancreatitis
Risk of malignancy so:
Abd CT with IV contrast (pancreas protocol)
MRI with MRCP
EUS
Diagnostics for recurrent pancreatitis
Consider EUS and/or ERCP (neoplasm or stricture)
Use of abdominal CT with acute pancreatitis
Diagnoses enlargment of the pancreas
IDs severity
IDs complications
What complications of acute pancreatitis can be seen on CT?
Necrosis
Pseudocyst
Abscess
Hemorrhage
What is done next when pt meets clinical and lab criteria for acute pancreatitis?
Nothing! (early CT is not recommended)
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
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)
ERCP
Therapeutic because can also do stone removal and stent insertion
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
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)
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)
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)
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
What is a pancreatic pseudocyst?
Palpable mass in mid epigastric area that may cause abd pain, early satiety and n/v
Tx of pancreatic pseudocyst
Surgery vs drainage (sxs or infected!)
Complicated by rupture, hemorrhage or infection
Classifications of acute pancreatitis
Interstitial edematous acute pancreatitis
Necrotizing acute pancreatitis
What is interstitial edematous acute pancreatitis?
Acute inflammation of pancreatic parenchyma and peripancreatic tissues without necrosis
What is necrotizing acute pancreatitis?
Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis
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
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
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%)
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
Causes of death with acute pancreatitis
First 2 wks: SIRS or organ failure
After 2 wks: sepsis or other related complications
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
What is chronic pancreatitis?
Repeated episodes of acute inflammation
Gradual loss of pancreatic function leads to exocrine and endocrine insufficiency
Exocrine insufficiency of chronic pancreatitis
Leads to malabsorption causing steatorrhea and weight loss
Endocrine insufficiency of chronic pancreatitis
Leads to diabetes (sxs of polys, usually insulin dependent, affect DM-alpha and beta cells)
Most common cause of chronic pancreatitis
Alcohol induced disease (can be CF, hereditary, idiopathic or smoking)
Classic triad of chronic pancreatitis
DM
Steatorrhea
Calcifications on imaging
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
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
What is fecal fat testing?
72 hr quantitative fecal fat is preferred over qualitative testing of spot sample (gold standard)
Test of choice for steatorrhea
Fecal elastase
What is seen on abd CT in chronic pancreatitis?
Calcifications
Ductal dilation
Pseudocysts
MRCP for chronic pancreatitis?
Good for pancreatic and biliary ducts!
Used more now!
Pathognomonic for chronic pancreatitis on ERCP
Chain of lakes (gold standard?)
Only really used when think itll help therapeutically
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
Complications of chronic pancreatitis
Chronic pain Pseudocyst Abscess formation Fistula formation Pancreatic ascites Mesenteric venous thrombosis
Causes of pancreatic cancer
Abnormal glucose metabolism
Insulin resistance
Obesity
Chronic pancreatitis
Most common type of pancreatic cancer
Exocrine (all tumors related to pancreatic ductal and acinar cells and their stem cells)
Small amt is endocrine
Where does pancreatic cancer occur?
Usually ductal adenocarcinoma of pancreas
Can also involved head
Most are presenting with locally advanced or metastatic disease
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)
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)
What seen on PE for pancreatic cancer?
Abd pain
Palpable gallbladder (nontender-courvoisier)
Jaundice and icterus
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)
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
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)
What to do if find mass on US?
Abd CT (confirm it and assess extent)
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
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)
Only potential cure for pancreatic carcinoma
Surgical resection (whipple procedure or pancreaticoduodenectomy- remove 1/2 stomach, GB, pancreas and top 15 cm of duodenum
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
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
