Pancreatic Diseases Flashcards
Review of Pancreatic Anatomy and Physiology
- exocrine function
- endocrine function
Exocrine : pancreatic enzymes released directly into the small instestine (at the duodenuem) and other epitheliail structures (its role in digestion)
- this approximates 80% of the pancreatic function: as dictated by the Acinir cells within the pancreas
- Acinir Cells: secrete alkaline substances to neutralize the acidic chyme from the stomach & they release enzymes which aid in digestion of food
- enymes include: amylase, lipase, tripsinogen, etc.
Endocrine: the pancreatic enzymes which are secreted directly into the bloodstream
- the islets of Langerhans are the cells responsible for secreting glucagon, insulin
- the alpha cells release glucagon: increase blood glucose
- the beta cells release insulin: decrease blood glucose
- somatostain from the delta cells inhibit insulin and glucagon and the F cells secrete polypeptides
Acute Pancreatitis
- Etiology
- Symptoms
- Labs
Etiology
- most commonly; acute pancreatits is due to gallstones or heavy alcohol use
- the gallstones get stuck in the ducts; and block the ability to release the pancreatic contents, the alcohol damages the liver
- it is known that smaller stones actaully effect the pancreas more
- these issues impact the pancreas’s ability to function - leading to deterioration of the acinr cells (PPP)
Symptoms
- acute, severe onset of boring pain in the epigastric area - upper abd. pain
- pain can radiate to the back
- (gallstone: usually a more localized pain with ABRUPT onset while alcohol: diffuse, radiation pain which comes on over hours)
- nausea/vomiting
- severe acute pancreatitis: fever, tachypnea, tachycardia, hypoxemia and hypotension
Labs
- elevated amylase & lipase (lipase is more sensitive) - becuase the pancreas is secreting these but they leak into the blood instead of into the duodeneum
- leukocytosis (inflammation)
- hypoglycemia, hyperlipidemia & hypocalcemia: fact binds to calcium inside the pancreas when its necrosing
Acute Pancreatitis
- Diagnosis
- Presentation Catergories
Diagnosis
demonstrating 2 of the following 3 is sufficient for a diagnosis
1. aucte onset of severe, persistant, epigastric pain in the epigastric & radiation to the back
2. elevated serum lipase or amylase 3x the upper limit of normal
3. findings of acute pancreatits on imaging (CT, MRI or US) (PPP = sentinel loop (xray), enlarged pancreas, lost margins,etc.)
on CT: acute interstitial edematous pancreatits: large pancreas with contrast CT, edema, FAT STRANDING, abnormal
Presentation of Acute Pancreatits
- Early = 1st week & Late = after the 1st week
- mild = no organ failure
- moderate = organ failure within < 48 hours
- severe = organ failure longer than 48 hours
- oedematous = acute inflammatory process
- necrosis = necrotic and inflammatory
Acute Pancreatits
Treatment
Complications
Treatment
inital treatment = supportive thearpy
- fluid replacement
- pain control (avoid NSAIDS, use IV opioids if needed)
- place them on NPO then soft diet after 24 hr. if tolerable – if continues consider TPN for 48/72 hr.
- antibiotics are not recommended but if secondary infection present - use
eventaully… if there is a stone you need to remove it
- ECRP or sphoncterotomy within 24 hr.
Complications
can be local or systemic complications
Local
- pancreatic pseudocyst
- acute necrotic collection
- walled off necrosis (WAN) can occur > 4 weeks
- peri-pancreatic fluid collection
Systemic
- ARDS
- compartment syndrome
- AKI
- DIC
the severity of pancreatits can be predicted through the Ranson’s Criteria most commonly
- but always caustion use becuase they have high rates of false postivies
some (15-25%) will go onto develop moderate or severe pancreatits
Chronic Pancreatits
Etiology
Symptoms
Etiology
- a chronic, progressive inflammation of the pancreas which leads to the loss of both exocrine and endocrine functioning
- a mutli-factoral dysfunction of the pancreas due to alcohol use, smoking, genetic predispostion, (CF in children), etc.
Symptoms
- an indulent progress of recurrent attcks of pain which get worse over time
- episodic epigastric pain
- weight loss
- steatorrhea and fatty stools with diarrhea
- progressive loss of endocrine function can result in pancreatic diabetes
Chronic Pancreatits
Diagnosis
Treatment
Diagnosis
diagnosis made based on the following factors
1. chronic abdominal pain and a potential history or recurrent acute pancreatitis
2. signs of exocrine dysfunction: weight loss, steatorrhea, diarrhea & even pancreatogenic diabetes
3. chronic pancreatitis can be identifyined on imaging (CT, MRI and MRCP) if asymptomatic pt.
typically a clinical diagnosis
(no specifics on the labs/imaging give you clues) often the amylase/lipase will be normal
Treatment focused on treating pain and improving the malabsorbtion of nutrients
First Line:
- lifestyle changes: small, frequent low fat meals, no alcohol or tobacco
- pharmacologica: replace the fat-soluable vitamins and enzymes lost
Second line:
- non-opiod regimes for pain (TCS, NSAIDS, pregabalin)
- manage the diabetes if it develops
Surgical intervention
- if there is abcess, fistula, ascites, obstruction of CBD, bleeding of splenic vein thrombosis = surgery to remove part of pancreas
Pancreatic Cancer
Etiology
Symptoms
Etiology
- a carcinoma from the pancreatic duct (exocrine functioning area)
- usually adenomcarcinoma & the head
- surgical resection is the only curitive treatment
Risk Factors
- older age ( > 55)
- men
- obesity
- DM
- tobacco use & alcohol
- chronic pancreatits
- family history of genetic (MEN I, etc.)
Symptoms (PPP = when symptomatic = its advanced pz)
- jaundice, pruritis
- weight loss and anorexia
- abd. pain
- recent T2DM onset
- rarely: sister mary jones nodules and virchows nodes of the lymph
Pancreatic Cancer
- Diagnosis & Workup
- Treatment
Dignosis
- imagins: CT or US
- Labs (LFTs, Lipase, CBC, BMP, troponins)
- do not use the CA-19 for diagnosis; it can be use to treat treatment and staging only
those with jaundice …. get US of billilary tree
those without jauindce but ahve weight loss/pain …Get CT
Confirmation of the Dx.
- upper endoscopy with FNA – but can be skipped if they have high susspicison and can resecet the tumor
- METs = PETs
Treament surgical is the only definative
- if it is deemed not surgical (too advanced) = neoadjunctive chemo +/or radiation
- if tumor in head of pancrease = Whipple procedure (pancreaticoduodectomy)
- if tumor int body or tail = distal pancreatectomy with splenecomty
addition post or pre-op chemo can be given (5FU, gemcitabine, radiothearpy)
