Pancreatic disorders Flashcards
The pancreas is an endocrine gland producing: 3
- Insulin
- Glucagon
- somatostatin
Also functions as an exocrine gland secreting what?
It secretes approximately ____ liters of enzyme-rich fluid every day for the digestion of fats, starch, and protein.
digestive enzymes via a duct.
1.5
- Secretin- released from the duodenal mucosa in response to what?
- What does it stimulates? 2
- the presence of acid in the duodenum.
- stimulates the release of
- bicarbonate
- water.
- Cholecystokinin (CCK)- released from SI endocrine cells in response to what?
- acts directly and through vagal afferents to stimulate pancreatic acinar cells to release what?
- the entry of fats and proteins into the proximal intestine.
- digestive proenzymes.
Acute pancreatitis is an acute inflammatory process of the pancreas. Etiologies? 5
- Mechanical
- Toxic
- Trauma
- Metabolic
- Infection
Acute Pancreatitis:
- Gallstones are more common in who?
- Alcohol are more common in who?
- Gallstones more common cause in women
- Alcohol more common cause in men
If 2nd attack and not one of main 2 causes then look for the less common causes such as? 6
- hypercalcemia
- hyperlipidemias
- biliary sludge
- drugs
- cancer
- missed stone in duct,
Acute onset clinical manifestations? 5
What can this progress to? 2
- persistent, severe epigastric pain
- or RUQ pain may be steady or colicky
- N/ V
- 50% experience band like radiation of pain to back;
- some may get relief w/ bending forward or sitting up.
- Dyspnea
- Shock/Coma
Acute pancreatitis 5-10% of patients may have painless disease and have what?
Unexplained hypotension
Physical exam of acute pancreatitis? 5
- Fever, tachycardia, (hypotension if severe)
- Epigastric/RUQ tenderness
- Shallow respirations- pain with deep breaths
- Possible dyspnea if pleural effusion
- Epigastric mass if pseudocyst or tumor.
In 3% of pts, ecchymotic discoloration may be observed in the periumbilical region (Cullen’s sign) or along the flank (Grey-Turner’s sign).
- ecchymotic discoloration may be observed in the periumbilical region. What sign is this?
- Along the flank. What sign is this?
- Cullen’s sign
- Grey-Turner’s sign
Lab Tests for Acute Pancreatitis?
3
- Serum Amylase
- Serum Lipase
- C reactive protein
Serum amylase
- Rises how?
- Elevated for how many days?
Serum Lipase
- Describe sensitivity and specificity compare to amylase
- Describe its elevation and how long it lasts?
- If ____x nl think pancreatitis.
Serum amylase:
- rises quickly (6 to 12 hrs)
- elevated for 3-5 days
Serum lipase:
- sensitivity 82-100%, more specific than amylase
- elevations occur earlier and last longer
- If 3-4x nl think pancreatitis.
C reactive protein levels
- Levels at what and how long after presentation can predict a more severe course?
- So what do we use this to differentiate?
C-reactive protein:
- levels above 150 mg/dL at 48 hrs after pt presents can predict more severe course.
- Used to differentiate severe from mild disease
Imaging for Pancreatitis?
5
Abdominal plain film
CXR
US
CT scan
MRI
- What does abdominal plain film help us with on pancreatitis? 2
- What percent of pts with pancreatitis have abnormal findings on CXR?
- What are these? 3
1.
- helps to exclude other causes of abdominal pain
- may have localized ileus 2ndry to inflammation
2. CXR: 1/3 of pts w/ pancreatitis have abnormal findings:
3.
- Elevation of hemidiaphragm
- Pleural effusions
- Pulmonary infiltrates
What is the most important test for diagnosis acute pancreatitis & intraabdominal complications and assessment of severity?
CT scan
Pancreatitis
- What would the US show?
MRI for pancreatitis
- Describe its sensitivty compared to CT?
- Advantages? 3
- Higher sensitivity for the diagnosis of early acute pancreatitis than CT scan.
2.
- Lack of nephrotoxicity
- Ability of MRI to better detect fluid collections, necrosis, hemorrhage and pseudocyst
- MRCP better shows the pancreatic and bile ducts
What does this CT show?
pancreatitis
Treatment of pancreatitis?
7
- Admit to hospital with acute pancreatitis
- NPO
- IV hydration with crystalloids to keep UO>30ml/hr (lactated ringers except in hypercalcemia)
- Pain control (morphine, fentanyl, ketorolac)
- Ondansetron (zofran), or Promethazine (Phenergan) prn nausea
- +/- antibiotics,
- +/- surgery (cholecystectomy, necrosectomy- severe dz)
What labs would we do for Pancreatitis?
6
Labs:
- CBC,
- lipase,
- amylase,
- CMP,
- bilirubin,
- C-reactive protein in 48 hrs,
Severe pancreatitis
- Complications with what can develop? 4
- Treatment? 3
- Complications w/
- pulmonary,
- renal,
- circulatory
- hepatobiliary dysfx can occur
2.
- ICU monitoring and supplemental O2
- Prevent infection w/ broad spectrum antibiotics
- Nutrition preferably enteral- Tube feeding
Risk Factors for Disease Severity
5
- Age > 55 yrs
- Obesity—BMI > 30 kg/m2
- Organ failure at admission
- Pleural effusion or pulmonary infiltrate
- Elevated C-reactive protein
What is Chronic Pancreatitis?
Progressive inflammatory changes result in permanent structural damage to the pancreas, leading to impairment of exocrine & endocrine function
Etiologies of chronic pancreatitis?
5
- Alcohol abuse (75%)
- Genetic: cystic fibrosis, hereditary pancreatitis
- Ductal obstruction: trauma, pseudocysts, stones, tumors
- Systemic: SLE, hypertriglyceridemia
- idiopathic
Acute vs. Chronic
- Acute is usually _________?
- Reccurrent acute leads to what?
- Symtpoms of chronic?
- Serum Amylase and Lipase in Chronic?
- Acute is usually nonprogressive
- Recurrent episodes of acute lead to chronic over time
- Chronic may be asymptomatic over long periods of time
- Serum amylase and lipase concentrations tend to be normal in chronic
- Cardinal feature of Chronic pancreatitis?
- Other clinical manifestations of chronic pancreatitis? 3
- Chronic abdominal pain—cardinal feature although 20% may have little to no pain
2.
- Pancreatic insufficiency
- Fat malabsorption
- Pancreatic diabetes
Describe why the following happen:
- Pancreatic insufficiency?
- Fat malabsorption?
- Pancreatic diabetes?
- Pancreatic insufficiency—exocrine dysfunction cannot digest complex foods or absorb digestive breakdown products, wt. loss: 90% of pancreatic function has to be lost for this to occur
- Fat malabsorption (steatorrhea)–lipolytic activity decreases faster then proteolysis: malabsorption of fat sol-uble vitamins (A, D, E, K)
- Pancreatic diabetes —DM late in course of disease, seen pts w/ calcifying disease.
Chronic Pancreatitis
- Why are amylase and lipase usually normal?
- What is the diagnostic gold standard test?
- What test is performed at specialized centers?
- amylase and lipase usually normal because pancreas fibrotic resulting in decreased abundance of these enzymes within the pancreas
- Steatorrhea: 72-hour quantitative fecal fat determination is the gold standard, excretion > 7g fat day; pts w/ steatorrhea usually > 10g q day
- Direct pancreatic function tests: performed via specialized centers
Chronic Pancreatitis Imaging?
3
- Calcifications on plain films
- CT/MRI/US
- ERCP
Chronic Pancreatitis
- CT/MRI/US may show what? 3
- ERCP can reveal what?
- CT/MRI/US
may show
- ductal dilatation,
- enlargement of pancreas,
- pseudocysts
2. ERCP - can reveal changes in the ducts
What does this CT show?
3
- Inflammatory mass at head of pancreas
- Calcifications
- Low attenuation areas of necrosis
Treatment of Chronic Pancreatitis
4
- Establish Dx
- Pain management and control N/V
- Diet
- Surgery
Whats on our differential for chronic pancreatitis?
4
- PUD,
- biliary obstruction,
- pancreatic cancer,
- pancreatic duct strictures or stones
How would we manage pain management and control N/V?
3
- NSAIDs,
- low dose amitriptyline,
- opiates
Diet changes for chronic pancreatitis?
4
- cessation of alcohol and smoking;
- small low fat meals
- with pancreatic enzyme supplements and
- acid suppression (H2 blockers or PPIs) to reduce inactivation of enzymes from gastric acid
- Who is surgery for in pts with pancreatitis?
- What kinds? 3
- for those who fail medical therapy, for pain relief—
2.
- decompression of main pancreatic duct/psuedocyst,
- resection of part of the pancreas,
- denervation procedures
- Why does pancreatic cancer have a poor diagnosis?
- Risk factors? 4
- 85% of all pancreatic cancers are what?
- Poor prognosis because of late presentation
- Risk factors:
- chronic pancreatitis
- smoking
- obesity
- male gender - Ductal adenocarcinoma
85% of all pancreatic cancers
Clinical features of pancreatic cancer? 3
(most common?***)
- +/- pain,
- weight loss,
- jaundice.
Painless jaundice w/ wt. loss***
Tumors in body or tail present w/ what? 2
Tumors of the head present w/ what? 3
- Pain and weight loss
- weight loss, steatorrhea, jaundice
PE of pancreatic cancer will show what?
3
- abdominal mass/ascites 20% pts,
- L supraclavicular node (Virchow’s node)
- palpable periumbilical mass (Sister Mary Joseph’s node)
Workup for chronic pancreatitis:
- Imaging? What would it show? 3
- Labs? What would they show? 3
- Serum tumor marker? 1
- Imaging: US/CT shows pancreatic mass, dilated bile ducts, liver mets
Labs: LFT’s show elevated bilirubin, alk phos, aminotransferases normal or slightly elevated
Serum tumor maker:
CA 19-9 closely related to tumor size
- CA 19-9 can be elevated also in who?
- Serial monitoring can assess what?
- Can be elevated in pts w/ benign pancreaticobiliary disorders
- Serial monitoring can assess the response to treatment
Diagnosis of Pancreatic cancer?
FNA, via ERCP, or during surgery
Treatment of Pancreatic Cancer
5
- surgical resection is preferred tx****
- +/- radiation therapy or chemotherapy
- Usually unresectable if involves vascular structures
- endoscopic stent insertion or palliative surgery
- Pain control and pancreatic enzyme replacement
- Treatment of stage I and II pancreatic cancer? and Prognosis?
- Treatment for stage III? and prognoiss?
- Stage IV prognosis?
- Resectable disease (stage I, II): 15-20% of pts have resectable disease at time of dx, median survival rate 15-20 mos, 5-year survival rate is 20%.
- Unresectable locally advanced (stage III): 30% present in stage III, chemotherapy with or w/o radiation gives modest improvement in survival and palliation.
- Mets (stage IV): 50% have limited survival of 3-6 months.
