Pancreatic Disorders Flashcards
Pancreas:
- function of endocrine gland?
- function of exocrine gland?
- what hormone stimulates the release of bicarb and water from the pancreas?
- when is CCK released from pancreas?
Endocrine: 2%, secretes insulin(Beta), glucagon (alpha), somatostatin (Delta)
Exocrine: secretes digestive enzymes (1.5L /day for digestion of fats, starch, and proteins)
Sectretin is released from the duodenal mucosa in response to acid chyme in the duodenum and stimulates the release of bicarb and water.
CCK released in response to fats and proteins in proximal intestine
Acute Pancreatitis
- etiologies
- MC cause in women
- MC cause in men
Etiologies:
- Mechanical: gallstones, biliary sludge, stenosis of ampulla
- Toxic: alcohol, scorpion bite venom
- Metabolic: hypertriglyceridemia, hypercalcemia
- Infection: Hep B, CMV, HIV
- Misc: pregnancy, renal failure
- Trauma: blunt or penetrating abd injury, iatrogennic injury during surgery
MC in women: gallstones
MC in men: alcohol
Classification of acute pancreatitis
Mild acute pancreatitis: absent organ failure and local complications
Moderately severe acute pancreatitis: transient organ failure which resolves within 48hrs, or local and systemic complications w/o organ failure.
Severe Acute pancreatitis: persistent organ failure, can evolve into 1 more organ failure. (kidneys, liver)
Acute Pancreatitis:
- clinical manifestations
- PE findings
Manifestations:
- quick onset of 10-20min
- persistent, severe epigastric pain
- RUQ pain may be steady or colicky
- N/V
- Band like radiation of pain to the back. May get relief with bending forward or sitting up.
- dyspnea
- shock/coma
PE:
- fever, tachycardia (if hypotension severe)
- epigastric/RUQ tenderness
- pain with deep breaths; shallow respirations
- epigastric mass if pseudocyst or tumor
- 3% of pts will have cullens sign (umbillicus) or Grey-Turners Sign (flank)
Pancreatitis:
- lab tests
- imaging
Labs:
-serum amylase:
- serum lipase: high sensitivity; if 3-4x the normal think pancreatitis.
- C-reactive protein: used to differentiate severe from mild dz
Imaging:
-Abd plain film: helps exclude other causes of abd pain.
- CXR:
- elevation of hemidiaphragm
- pleural effusions
- pulm infiltrates
- will only see these if severe.
US: enlarged, hypoechoic pancreas, if gas in bowel it may obscure your image. MC used to look at bile duct stones.
CT:*** most important test for dz of acute pancreatitis, done with BOTH oral and IV contrast
MRI:
-higher sensitivity for dz of acute pancreatitis than CT, but CT is test of choice.
aka MRCP = magnetic resonance cholangiopancreatogram
What is pancreatic pseudocyst?
collection of pancreatic fluid (inactivated pancreatic enzymes) enclosed in a layer of inflammation; a wall of fibrous tissue or granulation.
Tx acute pancreatitis:
admit to hospital; most likely ICU.
NPO
IV hydration w/ crystalloids (lactated ringers except in hypercalcemia)
pain control (morphine, fentanyl, ketorolac(toradol)) **use meperidine MC b/c morphine causes too much spasm in the pancreatic sphincter.
Zofran (ondansetron) or Promethazine (phenergan) PRN
+/- abz, +/- surgery
*most recover in 3-5 days if mild acute pancreatitis.
Risk factors for disease severity? (basically, what makes them high risk for SEVERE dz)
- greater than 55YO
- obesity BMI greater than 30
- organ failure at admission
- pleural effusion or pulmonary infiltrate
- elevated CRP
Chronic Pancreatitis:
- what is this?
- etiologies
What: progressive inflammatory changes resulting in permanent structural damage to the pancreas, leading to impairment of exocrine and endocrine function.
etiologies:
- alcohol abuse (75%)
- genetic: CF, hereditary pancreatitis
- ductal obstruction; trauma, pseudocysts, stones, tumors
- Systemic: SLE, hypertriglyceridemia
- idiopathic
Acute vs Chronic Pancreatitis
- how are the serum amylase and lipase concentrations affected?
- which one is painful?
Serum amylase and lipase concentrations tend to be normal in chronic.
Chronic may be asymptomatic over long periods of time.
*Recurrent episodes of acute lead to chronic over time.
Chronic Pancreatitis:
-clinical manifestations
-dx
-
Manifestations:
- chronic abd pain**
- pancreatic insufficiency (exocrine dysfunction, wt loss)
- fat malabsorption(steatorrhea)
- pancreatic DM; seen with calcifying dz*
(Calcifying dz: pathopneumonic for chronic pancreatitis)
Dx:
-labs: amylase, lipase usually normal b/c pancreas fibrotic resulting in decreased abundance of these enzymes.
-steatorrhea: 72hr quantitative fecal fat determination is gold standard** excretion greater than 10g/day, normal is 7g fat/day
- imaging:
- -calcifications on plain films
- -CT/MRI/US
- -ERCP (endoscopic retrograde choliangiopancreatography)
Tx Chronic Pancreatitis
- pain management and control N/V: NSAIDS, low does amitriptyline, opiates
- Diet: cessation of alcohol and smoking, small low fat meals, H2 or PPI
- Surgery: resection of main pancreatic duct/pseudocyst (this is done as last resort)
Pancreatic Cancer
- risk factors
- MC type
- clinical manifestations
- PE
Risk:
- chronic pancreatitis
- smoking
- obesity
- male gender
MC type is Ductal
adenocarcinoma
Clinical Manifestations:
- +/- pain, weight loss, jaundice. PAINLESS jaundice w/ Wt loss*
- tumor in body or tail present with pain and weight loss
- tumors of the head present with weight loss, steatorrhea, & jaundice.
- majority of tumors are in head*
PE:
- abd mass/ascites
- L supraclavicular node (Virchows node)
- Periumbilical mass (Sister Mary Josephs Node)
- PANCE*
Pancreatic Cancer:
- work up
- dx
Work up:
- US/CT; shows pancreatic mass, dilated bile ducts, liver mets
- LFT show elevated bilirubin, alk phos, aminotransferases normal or slightly elevated
- Serum tumor marker: CA 19-9; closely related to tumor size.
Dx:
- bx; FNA via ERCP or during surgery
- surgery** preferred tx
- -+/- radiation or chemo
- -unresectable if invovles vasculature
- -endoscopic stent insertion or palliative surgery
Prognosis of Pancreatic Cancer:
- what stages are resectable? unresectable?
- survival rate in resectable/unresectable?
Resectable: Stage I and II, survial is 15-20mos.
* 15-20% of pancreatic cancer is resectable.
Unresectable: stage III, chemo and radiation have modest improvement in survival.
*30% of pancreatic cancer is unresectable.
Mets: Stage IV: 50% have limited survival of 3-6mo.
