Pancreatic Disorders Flashcards
In a patient with ARDS, what will the chest Xray look like?
- bilateral diffuse fluffy infiltrates
- normal cardiac size
- Tracheostomy tub
- Left subclavian central line going insdie the right atrium
- ECG wires
Definition of Acute pancreatitis
Cellular injury from:
- activation of protein kinases
- inflammatory mediator
- activation of digestive enzymes in pancreas
- trypsinogen to trypsin results in autodigestion of pancreas and peri-pancreatic tissues
What 2 things were at the top of the Etiology list for pancreatitis?
- gallstones <5mm
- Heavy alcohol use
What is needed to make the diagnosis of acute pancreatitis?
At least 2 of the 3 things:
- Epigastric pain
- Lipase (and amylase) 3x the ULN
- CT changes consistent with pancreatitis
What was the one bolded lab finding for acute pancreatitis?
increased lipase 3x ULN
What is the thing with soap that happens during acute pancreatitis?
Saponification
-interaction of cations with FFAs released by the action of activated lipase on TGs in fat cells —> low blood calcium
What’s the deal with Amylase? Why are we more concerned with lipase than amylase?
- Amylase may be elevated in other conditions
- Lipase is just more specific it looks like
Risk factors for acute pancreatitis?
- smoking
- high dietary glycemic load
- abdominal adiposity
- high age and obesity: increases changes of more severe course
Protective factors against acute pancreatitis?
- veggies
- maybe the use of statins
What do we do to assess the severity of Pancreatitis?
- Ranson criteria
- APACHE II (>8= higher mortality)
- greater the rise in BUN the greater the mortality
- REvised Atlanta classification
- CT Grade of severity index
What is the Ranson criteria for assessing the severity of acute pancreatitis?
3 or more or the following means severe course:
- age >55
- WBC>16
- Blood glucose >200mg
- LDH >350
- AST >250
If these things happen, it just gets worse
- HCT drop or more than 10%
- BUN rise of >5
- PO2 of <60
- Serum Ca<8
- Base deficit over 4
- estimated fluid sequestration of > 6L
What’s the relationship between the number of Ranson criteria present and the mortality rate?
0-2 means mortality rate of 1%
3-4 is 16%
5-6 is 40%
7-8 is 100%
What is the goofy pneumonic that she gave us for the ranson criteria?
GA-LAW (at admission)
C and HOBBS (48 hrs after admission)
-bring this up if can’t remember, slide 26 of pancreas lecture
What is the revised ATLANTA criteria?
- Mild: no organ failure, no local complications
- Moderate: transient organ failure <48 hrs, local complications
- Severe: persistent organ failure >48 hrs
What is Cullen’s sign?
ecchymosis of umbilicus from retroperitoneum fluid and bleeding
Grey turner sign
Ecchymosis of flank from fluid and blood in the retroperitoneum
Imaging of acute pancreatitis
- sentinel loop
- colon cutoff sign
- rapid-bolud IV contrast enhanced CT
- perfusion CT to figure out if an organ is failing or not
Emphysematous pancreatitis
when there’s infected pancreatic necrosis with secondary gas formation
-from gas forming organisms: C perf, enterobacter aerogenes, enterococcus faecalis
Tx of emphysematous pancreatitis
surgical debridement and abx
What are some complications of severe acute pancreatitis?
Intravascualr volume depletion
- walled-off necrosis
- Pseudocysts (high amylase content)
- ARDS
- Pancreatic ascites
How do you treat SAP (severe acute pancreatitis)?
just treat the cause
- alcoholic: abstinence…
- Gallstone: timely lap choecystectomy
- etc…
Tx. of mild acute pancreatitis?
80% resolve sponateously
Tx of severe actue pancreatitis
within 48 hours of admission, start enteral feedings with nasogastric or nasojejunal tube- reduces risk of multiorgan failure and mortality
Etiology
TIGAR-O
- Toxic Metabolic (alcoholic)
- Idiopathic
- Genetic (CFTR, PSTI, SPINK1, PRSS1)
- Autoimmune (IgG4)
- Recurrent
- Obstructive
What is SAPE?
Sentinel acute pancreatitis event
- hypothesis of pathogenesis of chronic panreatitis
- there’s an initial (sentinel) acute pancreatitis event that initiates an inflammatory process that results in injury and later fibrosis (“necrosis-fibrosis”)
What are some pancreatic funciton tests?
- Trypsinogen: level is low in insuficiency…. causes steatorrhea
- Fecal elastase: low in insufficiency
- stimulation tests: cholecystokinin/secretin
What will imaging show for chronic pancreatitis?
Calcifications
-tumefactive chronic pancreatitis= concern for pancreatic Cancer
What will EUS look like for chronic pancreatitis?
Autoimmune= diffuse enlargement of the pancreas, a peripheral rim of hypoattenuation, and irregular narrowing of the main PD
What does the exocrine pancreas secrete?
Amylase
protease
lipase
What does the endocrine pancreas secrete
insulin
somatostatin
glucagon
How is exocrine pancreatic insufficiency confirmed?
-by response to therapy with pancreatic enzyme supplements
What do most people with endocrine insufficiency develop?
Diabetes mellitus
What is absolutely forbidden in chronic pancreatitis?
alcohol
What is the main cause of death in chronic pancreatitis?
Pancreatic Cancer
-prognosis is better in patients with etiology from a remediable condition or autoimmune hepatitis
Which MEN syndrome is associated with hypoglycemia
MEN1
-there’s a hypersecretion of insulin
Where is a Gastrinoma most commonly found?
duodenum
-2nd most common spot is the pancreas
What does MEN1 have?
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumors
what does MEN2A?
Parathyroid hyperplasia
medullary thyroid carcinoma
Pheochromocytoma
What does MEN2B have?
Mucosal neuromas
Marfanoid body habitus
Medullary thyroid carcinoma
Pheochromocytoma
How do you dx MEN Type 1?
2 or more of the following:
- Parathyroid: hypercalcemia, high intact PTH
- Pancreas: Gastinoma (ZE), Insulinoma- hypoglycemia
- Pituitary: cushing syndrome
MEN 2A
2 or three of the following:
- Thyroid (Medullary Thyroid Ca): elevated calcitonin
- Adrenal (Pheochromocytoma): elevated catcholamines
- Parathyroid: Hypercalcemia, high intact PTH
- 2-5% percent will develop Hirschsprung disease
MEN2B
- Marfanoid body habitus
- Medullary thyroid cancer: elevated calcitonin
- Pheochromocytomas: elevated catecholamines
- Neuromas: occur on lips, tongue, mouth, eyelids, etx.
- Frequently a new gene mutation: no family history
