Pancreatic Diseases Flashcards
What is Pancreatitis?
Sudden, inappropriate enzymatic destruction (autodigestion) of the pancreas that may extend to peripancreatic tissue and surrounding structures
Complications include infection, loss of pancreatic function, and multi-organ failure.
What is the spectrum of Pancreatitis?
Mild abdominal pain to death
What is the main pancreatic duct called?
Duct of Wirsung
Where does the main pancreatic duct exit?
Major duodenal papilla (ampulla of Vater)
What is the role of zymogens in acinar cells?
Sequestered within intracellular granules that contain protease inhibitors to prevent premature activation and autodigestion
What are common causes of Acute Pancreatitis?
- Choledocholithiasis (40%)
- Alcohol (35%)
- Endoscopic retrograde cholangiopancreatography (ERCP) (4%)
- Medications (2%)
- Abdominal trauma (1.5% of cases)
What is the mechanism of alcohol-induced pancreatitis?
Increased acinar secretion of pancreatic enzymes and decreased ductal epithelial cell fluid and bicarbonate secretion leading to autodigestion
Name some medications that can cause pancreatitis.
- Furosemide
- Estrogens
- Sulfonamides
- Tetracycline
- Azathioprine
- Valproic acid
- Didanosine
- Ethacrynic acid
- Pentamidine
What are uncommon causes of Acute Pancreatitis?
- Hypertriglyceridemia >1000 mg/dL
- Mechanical obstruction
- Toxins
- Infection
- Congenital issues
- Vascular problems
- Genetic mutations
- Miscellaneous factors
What are the typical symptoms of pancreatitis?
- Sudden abdominal pain
- Indigestion
- Abdominal fullness
- Abdominal distension
- Nausea
- Vomiting
- Clay-colored stools
- Decreased urine output
- Frequent hiccups
- Syncope
- Subjective fever
What are some associated symptoms of pancreatitis?
- Acute myocardial infarction
- Cholangitis
- Cholecystitis
- Diabetic ketoacidosis
- Gastric outlet obstruction
- Gastric volvulus
- Hepatitis
- Intestinal infarction
- Pancreatic cancer
- Perforated peptic ulcer
- Tubo-ovarian abscess
What are physical examination findings in pancreatitis?
- Fever (76%)
- Tachycardia (65%)
- Abdominal distention
- Epigastric tenderness and/or mass with voluntary guarding
- Hypoactive bowel sounds
- Abdominal muscle spasm
- Hypotension
- Respiratory distress
- Cullen’s and Grey Turner’s signs
What criteria are used to suspect pancreatitis?
Suspect in any patient with 2 of the following: * Typical epigastric pain
* Increase in serum lipase or amylase ≥ 3x normal
* Imaging study suggesting pancreatitis
How long does amylase remain elevated in pancreatitis?
12-48 hours
What is more specific than amylase for diagnosing pancreatitis?
Lipase
What laboratory findings are associated with pancreatitis?
- ↑ glucose due to beta cell injury
- ↓ Ca2+ due to saponification of fat in necrosis
- ↑ WBC
- ↑ Hgb/Hct
- ↑ Na+
- ↑↓ K+
- ↑ BUN associated with ↑ mortality
- ↑ ALT, AST, ALP, bilirubin in gallstone AP
- ↑ CRP >2x normal predicts severe pancreatitis
True or False: The peak of elevation of amylase and lipase correlates with disease severity.
False
Fill in the blank: The accessory duct flows into the _______.
Minor duodenal papilla
What imaging study should be performed in all patients with acute pancreatitis to determine etiology?
Abdominal ultrasound
It may show gallstones and dilation of the common bile duct.
When is a CT scan indicated in cases of pancreatitis?
Severe cases, unclear diagnosis, or no improvement in 48-72 hours
CT measures extent of inflammation and necrosis.
What is the most common abnormal finding on abdominal x-ray in pancreatitis?
Sentinel loop
Indicates localized ileus from nearby inflammation.
What does the colon cut off sign indicate?
Paucity of air in the colon distal to the splenic flexure
It is another finding associated with pancreatitis.
What imaging modality is used to evaluate the gallbladder and ducts?
MRCP (Magnetic Resonance Cholangiopancreatography)
It is useful when ERCP may worsen existing pancreatitis.
What is the role of ERCP in pancreatitis?
Diagnostic and therapeutic, but can cause or worsen pancreatitis
It images the gallbladder and pancreatic ducts.
What are Ranson’s criteria for assessing the severity of pancreatitis?
Age >55, WBC >16,000, Serum glucose >200, Serum LDH >350, AST >250, HCT decreased by >10%, BUN increased by >5 mg/dL, Serum calcium <8 mg/dL, PaO2 <60 mmHg, Base deficit >4 meq/L, Estimated fluid sequestration >6 L
≥3 criteria predict mortality risk, necrosis, and organ dysfunction.
What is the most common cause of fatalities in patients with acute pancreatitis?
Pancreatic abscess
It can lead to hypovolemic shock and disseminated intravascular coagulation (DIC).
What are the complications associated with pancreatic necrosis?
Hypocalcemia, infection, and potential need for surgical debridement
Antibiotics do not change outcomes in sterile necrosis.
What are the suggested signs of a pancreatic pseudocyst?
Recurrent abdominal pain, loss of appetite, palpable tender abdominal mass, increasing amylase, lipase, and/or bilirubin
Diagnosed by CT.
What are common complications of acute pancreatitis?
Abdominal compartment syndrome, acidosis, acute renal failure, ascites, bowel infarction, development of chronic pancreatitis, gastric varices, ileus, mesenteric venous thrombosis, pancreatic arterial pseudoaneurysms, splenic vein thrombosis
These complications arise due to the inflammatory response and damage caused by pancreatitis.
True or False: Antibiotics are effective in treating sterile necrosis in pancreatitis.
False
Antibiotics have not been shown to change outcomes in sterile necrosis.
What is the significance of BISAP in pancreatitis assessment?
It largely replaced Ranson’s criteria and APACHE score
Presence of ≥3 predicts mortality risk.
Fill in the blank: The _______ is the most common finding on abdominal x-ray in pancreatitis.
Sentinel loop
What is Suboccipital release?
A technique used in osteopathic manipulative treatment (OMT) to relieve tension in the suboccipital region
Often used to alleviate headaches and neck pain.
What is Myofascial release?
A manual therapy technique that targets the fascia to relieve tension and pain
Specifically applied to the abdomen and diaphragm in this context.
What is Paraspinal inhibition?
A technique focusing on the thoracic segments T5-9 to reduce muscle tension
Aims to improve spinal function and reduce pain.
What are Chapman reflexes?
Viscerosomatic reflex points that are used in osteopathic diagnosis and treatment
Associated with specific organs and conditions.
What is Counterstrain?
A technique used to treat tenderpoints by placing the patient in a position of comfort
Helps to reduce muscle tension and pain.
What is the purpose of sacral rock?
A technique in OMT aimed at enhancing the mobility of the sacrum and relieving pelvic tension
Often used in labor and delivery.
What is the recommended fluid replacement for patients?
Fluid and electrolyte replacement with crystalloids, e.g., normal saline 250-500 cc/hour
Colloids should be avoided.
What is the guideline regarding enteral feeding?
Encourage enteral feeding and avoid parenteral (IV) nutrition
Promotes better outcomes in patients.
When should early cholecystectomy be performed?
In those with gallstone pancreatitis during the current admission
Aims to prevent complications.
What is the role of pancreatic biopsy?
To perform Gram stain and culture for suspected pancreatic infection (necrosis)
Guides antibiotic therapy.
When should ERCP be limited?
To patients with cholangitis or suspicion of continued biliary obstruction
Should be held in patients without these indications.
Is antibiotic therapy indicated in uncomplicated acute pancreatitis?
No, it is not indicated without evidence of extrapancreatic infection
Prophylactic antibiotics have not shown benefit.
What is the mortality rate of mild, self-limited pancreatitis?
Less than 1%
Severe cases can have mortality rates up to 30%.
What are the classic symptoms of chronic pancreatitis?
Steatorrhea, pancreatic calcifications, and diabetes
Suggestive of pancreatic insufficiency.
What are common causes of chronic pancreatitis?
- Alcohol consumption
- Smoking
- Hypercalcemia
- Hyperlipidemia
- Medications
- Toxins
The amount and length of alcohol intake correlate with risk.
What does the acronym TIGAR-O stand for in chronic pancreatitis etiology?
- T: Toxic and metabolic
- I: Idiopathic
- G: Genetics
- A: Autoimmune
- R: Recurrent pancreatitis
- O: Obstructive
Highlights various causes of chronic pancreatitis.
What are common imaging findings in chronic pancreatitis?
- Fibrosis and calcifications
- Pancreatic duct dilatation and strictures
- Pancreatic enlargement
- Pseudocyst formation
Imaging is crucial for diagnosis.
What is the primary treatment focus for chronic pancreatitis?
Pain control and managing complications
Treatment options include surgery and lifestyle changes.
What supportive treatments are indicated in acute pancreatitis?
- Early enteral feeding
- Early cholecystectomy in those with stones
Management is crucial to reduce mortality.
