Pancreatic Disorders - McGowan Flashcards
what are the two most common cause of acute pancreatitis?
- Biliary tract gallstones
- Heavy alcohol use
Others includes:
- Hypertriglyceridemia
- Trauma
- Meds
- ERCP
- autoimmune (celiac disease, vasculitits)
- Infection
- dialysis
- CP bypass
- CFTR
- Scorpion tring (tityus trinitatis)
- Idiopathic
what 2 out of 3 things are needed to make a diagnosis of acute pancreatitis?
- Epigastric pain
- Lipase (and amylase)) 3 x the ULN
- CT changes consistent with pancreatitis
what lab findings are consistent with acute pancreatitis?
- Increase lipase 3x ULN (more accurate)
- Increaesd amylase 3x ULN
- Hypocalcemia (due to saponification)
- Whole bunch of other shit
what are some risk factors for acute pancreatitis?
- smoking
- high dietary glycemic load
- abd adiposity
- age and obesity
Severity of acute pancreatitis is based on which criteria?
- Ranson criteria
- Sequential organ failure assessment (SOFA)
- Modified Marshall scoring system
- APACHE II (>8 higher mortality)
- Bedside index for severity in acute pancreatitis (BISAP)
- presence of SIRS and elevated BUN on admission with a rise in BUN w/in 24 hrs of hospitalization
- Revised atlanta classificaiton
- CT grade of severity index of acute pancreatitis
On the Ranson criteria for acute pancreatitis, what are some predictors of severe course
- age >55
- WBC > 16k
- glucose >200
- LDH > 350
- AST >250
In Ranson criteria for acute pancreatitis, developing of what within first 48 hrs indicates a worsening prognosis
- HCT drop by 10%
- BUN rise by > 5
- arterial Po2 < 60
- Ca <8
- estimated fluid sequestration of > 6L
a score of what indicates 100% mortality according to Ranson criteria?
7-8
according to ATLANTA criteria for acute pancreatitis, what’s considered a moderate case?
- transient organ failure <48 hrs and with or without local complications
On xray, sentinel loop represents what
segment of air-filled small intestine (most commonly in the LUQ)
On xray, colon cutoff sign represents what
gas filled segment of transverse colon abruptly ending at area of pancreatic inflammation
OR
focal linear atelectasis of the lower lobe of lung
CT with contrast should be avoided when Cr level is greater than
1.5
what imaging modality is best for specially focusing on an organ and it’s perfusion and look for areas of ischemia
Perfusion CT (PCT)
Perfusion CT looking for ischemia, and CT-guided need aspiration of necrotizing pancreatitis are done on which day after onset of acute pancreatitis?
Day 3
Which imaging modality is also therapeutic in that it can in draining a pancreatic pseudocyst?
Endoscopic ultrasound
Treatment for infected pancreatic necrosis with secondary gas formation (emphysematous pancreatitis)
Surgical debridement and Abx (imepenem or meropenem)
possible complication of severe acute pancreatitis (SAP)
- intravascular volume depletion–> 3rd spacing; Ileus; pre-renal azotemia or ATN
- Pleural effusion
- Necrosis, wall-off necrosis (encapsulated)
- Pseudocysts (encapsulated fluid collection with a high amylase content)
- ARDS (within 3-7 days of onset)
- Pancreatic ascites
How is mild acute pancreatitis treated?
- 80% resolves w/o complications
- Pancreas rest (NPO, Bed rest, NG suction for ileus)
- Fluid resuscitation (LOTS)
- Pain control
- resume oral intake once pain free and has bowel sounds
what CT grade for acute pancreatitis indicates two or more acute peripancreatic fluid collection or retroperitoneal air?
Grade E: 4 points with > 50% necrosis, severity index of 10 with >17% mortality rate
In which CT grade for acute pancreatitis are there no pancreatic necrosis
Grade A and B. Grade A is normal pancreas, Grade B is just an enlarged pancreas
If pt presents with painless jaundice and pancreatic calcification on plain film and CT shows tumefactive chronic pancreatis, think
Pancreatic cancer
Multiple episode of acute pancreatitis, PRSS1 defect of trypsinogen gene on chromosome 7 –> chronic pancreatitis, which enzyme would be deficient?
fecal elastase
what are the etiologies of Chronic pancreatitis?
Mneumonic: TIGAR-O
- Toxic-metabolic (alcoholic 45-80% of cases)
- Idiopathic (early onset age 23 or late 62 yr)
- Genetic (<30) (CFTR, PSTI, SPINK1, PRSS1)
- Autoimmune (diagnosed via HISORt Crtieria); Hypergammaglobuinemia (IgG4)
- Recurrent acute pancreatitis
- Obstructive
what labs are altered in chronic pancreatitis?
- Acute attack: increased amylase and lipase
- elevated alk phos and total bili
- glycosuria
- excess fecal fat
- low B12
- Genetic pancreatitis (low trypsinogen)
- Autoimmune (elevated IgG4, ANA, ab to lactoferrin and carbonic anhydrase II
list the types of pancreatic function tests
- Trypsinogen (low level -> steatorrhea)
- Fecal elastase (low in insufficiency)
- Pancreatic malabsorption
- Stimulation tests (CCK/secretin)
what are you likely to see on plain xray in chronic pancreatitis?
Calcification (pancreaticolithiasis)
What are you likely to see on CT of chronic pancreatitis?
- may show calcification that wasn’t seen in xray
- ductal dilation
- tumefactive chronic pancreatitis = concern for pancreatic cancer
what is the most sensitive imaging study for chronic pancreatitis?
ERCP, shows dilated ducts, intraductal stones, strictures, pseudocysts
On endoscopic ultrasound what findings would indicate chronic autoimmune pancreatitis?
- diffuse enlargement of pancreas, peripheral rim of hypoattenuation, irregular narrowing of main duct
what complications are associated with chronic pancreatitis
- brittle diabetes
- pseudocyts or abscess
- cholestatic liver enzymes
- bile duct stricture
- Pancreatic insufficiency
- osteoporosis
- peptic ulcer
- pancreatic CA
Pancreatic insufficiency due to exocrine glands malfunction can be confirmed by
response to therapy with pancreatic enzyme supplements
- secretin stimulation, - detection of decreased fecal chymotrypsin
- decreased pancreatic fecal elastase
- B12 malabsorption
Treatments for chronic pancreatitis
- low fat diet
- avoid alcohol
- avoid opioids
- pancreatic supplements for steatorrhea
- H2 blocker, PPI, Na bicarb
- CF pts: high dose pancreatic enzymes therapy
- Treat DM
- Autoimmune: corticosteroids
- Endoscopic or surgical therapy (stent, dilation, lithtripsy, drainage)
the main cause of death of chronic pancreatitis
pancreatic cancer
Hypersecretion of insulin as seen in the pancreatic neuroendocrine tumor insulinoma is associated with which endocrine neoplasia?
MEN1
nonbeta islet cell tumors associated with MEN1 and can lead to multiple peptic ulcers, and is commonly found in the duodenum
Gastrinoma
which neoplasm are associated with MEN1
- Pituitary adenoma
- Parathyroid hyperplasia
- Pancreatic tumors
Which neoplasm are associated with MEN2A
- parathyroid hyperplasia
- medullary thyroid carcinoma
- Pheochromocytoma
Which neoplasm are associated with MEN2B
- mucosal neuromas
- marfanoid body habitis
- Medullary thryoid carcinoma
- Pheochromocytoma
Pt has hypercalcemia, elevated PTH, acromegaly, or cushings.. which MEN type?
MEN1 : parathyroid –> hypercalcemia, elevated PTH; Pancreas –> gastrinoma aka ZE, insulinoma - hypoglycemia; Pituitary –> acromegaly, cushings
Pt has elevated calcitonin and/or elevated catecholamines; and/or hypercalcemia, elevated PTH, which MEN type?
MEN 2A
Pt with marfanoid body habitus, elevated calcitonin and/or elevated catecholamines, which men type
MEN 2B
