Pancreatitis

Question 1

During the first two weeks of pantreatitis, what issues do we see?

What about after two weeks?

Answer 1

 First two weeks: (SIRS), organ failure
–>SIRS: two or more abnormalities in the temperature, heart rate, respiration, or white bloodcell count not related to infection
 After two weeks: sepsis and its complications

Question 2

Causes of ACUTE panreatitis

Answer 2

Gall stones, alcohol, scorpion venom, Hyperlipidemia, cholesterol, viruses, trauma, pancres divisum, CFTR, or other genetics

Question 3

ACUTE PANCREATITIS:
GALLSTONES
3-7% of patients with gallstones develop acute pancreatitis (AP), responsible for _____ of cases of acute pancreatitis

Answer 3

35-40%

Question 4

Alcohol use and Acute pancreatits

Answer 4

• Alcohol
 10% of alcoholics develop AP
 30% of cases of AP in the United States
 Usually after many years of alcohol abuse

Question 5

TG and acute pancreatitis

Answer 5

Hypertriglyceridemia
 > 1000 mg/dL
 1-4% of AP cases

Question 6

What is pancreas divisum?

Answer 6

Embryologic defect, pancrease forms ring aound the small intestine and blocks passage of food

The main and small duct dont fuse together

Question 6

Genetic cause of Acute Pancreatitis

Answer 6

Serine protease 1 (PRSS1)
• Hereditary pancreatitis, recurrent AP in childhood/early adolescence
• Present in up to 80 % of with hereditary pancreatitisunrelated to CF

Question 7

• Primary defense against pancreatitis is to control trypsin
activity, either by prevention of premature activation of
trypsinogen to trypsin, or by the destruction, inhibition,
or elimination of trypsin from the pancreas
 Mutation impairs above step

Answer 7

Serine protease 1 (PRSS1)

Question 8

• Cystic fibrosis transmembrane conductance regulator (CFTR) defect can lead to Acute Pancreatits
 Mutation may result in production of :
 Leads to ductal obstruction or _______ function

Answer 8

more concentrated or acidic pancreatic juice

altered acinar cell

Question 9

Genetic cause of acute pancreatitis

 Encodes a pancreatic secretory trypsin inhibitor
 Binds and inhibits about 20 % of trypsin activity

Answer 9

Serine protease inhibitor Kazal type 1 (SPINK1)

Question 10

• Inflammation of the pancreas; different etiologies but all same after?

Answer 10

after inciting event or pancreatitis begins
• Inciting event (varies) => early acute changes (similar) => systemic response
(similar)

Question 11

Early acute changes in acute pancreatitis:
•______ activation of proteolytic enzymes

Answer 11

Intraacinar

Question 12

IN acute pancreatitis:

We get Intraacinar activation of proteolytic enzymes: this leads to
• Generation of large amounts of active______ within pancreas

Answer 12

trypsin

Question 13

What causes pancreatic autodigestion

Answer 13

• Vacuoles containing active trypsin rupture
 Leads to activation of further trypsin, chymotrypsin, elastase
• Pancreatic autodigestion from intrapancreatic release of active enzymes

Question 14

Key pathogeneis is acute pancreatitis

Answer 14

MIcrocirculatory injury

Inflammatory cytokines produced

Leukocyte chemoattraction (PMN)

increased vascular permeability and injury (leads to hemorrhage and necrosis)

–> overwhelms normal protective mechanisms

Question 15

What happens from the systemic response in acute pahtogenesis?

Answer 15

• (SIRS)
• ARDS: phospholipase A digests lecithin, a major component of surfactant
• Myocardial depression due to vasoactive peptides
• Renal failure due to hypovolemia and hypotension
• Bacterial translocation from gut due to compromised gut barrier

Question 16

How do gallstones cause acute pancreatitis?

Answer 16

reflux of bile to pancreatic duct d/t ampulla obstruction (stones)

edema occurs from passage of stone

Question 17

How does alcohol cause acute pancreatits?

Answer 17

Increases effect of CCK on transcripton factors and induce premature activation of zymogens

generate more toxic metabolites

Question 18

What ways can acinar cells be damaged and lead to acute pancreatitis?

Answer 18

Chemical injury: TGs release FFA that damage acinar cells and parncreatic capillary endothelium

INfectious injury to acinar cells: CMV or mumps

Mechanical injury to acinar cells: seat belt trauma or posterior penetration of duodenal ulcer

Question 20

Pt comes in with perisitant, severe EPIgastric pain radiating to the back

She has been nauseous and vomitting. What could be the issue?

Answer 20

Acute Pancreatitis: pain radiates to back 50% of tim and 90% pt feel nauseus and vomit

Question 21

Cullens sign and Grey-Turner sign are both severe echymossis can be caused by:

Answer 21

acute pancreatitis

Question 22

What lab findings are there in acute pancreatitis?

Answer 22

Amylase: elevated w/in 6-12 hrs with short 1/2 life

LIpse: elevated 4-8 hours and pesaks at 24 and back to normal 8-14 days

Question 23

What must be present to diagnose acute pancreatitis?

Answer 23

Presence of at least two of the following:
• Constant epigastric or right upper quadrant
abdominal pain with radiation to the back, chest, or flanks
• Serum amylase and/or lipase > 3 times the upper range of normal
• Characteristic abdominal imaging findings

Question 24

What complications can we have with acute pancreatisis

w/in first 4 weeks

over 4 weeks

Answer 24

 Acute peripancreatic fluid collection (< 4weeks)

 pseudocysts (> 4 weeks)
 Acute necrotic collection; Infection

Question 25

Pancreatic pseudocyst present after 4 weeks and what is concerning about this complication of acute pancreatitis?

Answer 25

potential space for bacterial to grow and we can’t access this space with antibiotics

Question 26

What do we do for treatement of Acute Pancreatitis

Answer 26

• Pain control
• Aggressive intravenous fluids; pt losing lots of fluids
• Antibiotics if evidence of infection
• Nutrition* helps a ton
• Address underlying cause
 If stone: endoscopic removal or surgery

Question 27

Causes of chornic pancreatitis

Answer 27

• Alcohol abuse
• Cigarette smoking
• Ductal obstruction
 Pancreas divisum
• Ampullary obstruction
• Autoimmune pancreatitis
• Genetic pancreatitis

Question 28

Pathogenesis of chronic pancreatitis

Answer 28

Progressive fibro-inflammatory process
resulting in permanent structural damage

Question 29

What are three differences between Acute and Chronic Pancreatitis?

Answer 29

 AP is usually painful, CP can be asymptomatic in 20-45%
 Serum amylase and lipase may be normal or only mildly elevated in CP
 CP is patchy, AP is more diffuse

Question 30

How can chornic pancreatits result in duct scarring and obstruction?

Answer 30

Proteinaceous ductal plugs:
• Increased pancreatic protein secretion =>
plugs within ducts => nidus for calcification =>
stones within the ducts => duct scarring and obstruction

Question 31

How do you diagnose chronic pancreatitis

Answer 31

imaging; pancreatic calcification, ductal dilation, enlargement of pancreas, fluid collection

Question 32

How does chornic pancreatic insufficiency present?

Answer 32

• Pancreatic insufficiency
 Fat malabsorption: > 90% of pancreatic function lost
 Diabetes mellitus: late in the disease
• Pain from pseudocysts (ductal disruption)

Question 33

What are long term complications of chronic pancretitis

Answer 33

Bile duct/duodenal compression or infections from pseudocyst
• Increased risk of pancreatic adenocarcinoma

Question 34

Treatement for Chronic pancreatits

Answer 34

• Alcohol and smoking abstinence
• Analgesics
• Diabetes treatment
• Pancreatic enzyme supplementation
• May decrease pain
• Addresses steatorrhea
• Decompression of dilated pancreatic duct

Question 35

What do we look for if we suspect autoimmune pancreatits?

Answer 35

• One form of IgG4-related disease
 IgG4-positive plasma cells in tissue
 Elevated serum IgG4 levels in some patients
 Can affect multiple organs

Question 36

What do you treat autoimmune pancreatitis with?

Answer 36

Treat with corticosteroids

Question 37

• Pancreatic mass that can mimic cancer
• Mild abdominal pain +/- attacks of AP and CP
• Pancreatic duct strictures

Answer 37

AUTOIMMUNE PANCREATITIS