Pathophys of exocrine pancreas

Question 1

Understand the pathophysiology of acute pancreatitis

Answer 1

Trypsinogen and other pro-enzymes are prematurely activated within the pancreas
Auto-digestion of gland
Leakage of enzymes around pancreas may lead to other complications
Inflammatory cascade may result in organ failure or death when severe and systemic

Most common causes are alcohol abuse or obstruction of duct from gallstone
Alcohol
—>premature release and activation of zymogens
—>proteinacious plugs within pancreas duct
—>Abrupt ductal obstruction (stone, trauma, etc)
—>bile reflux or retention of enzymes

Question 2

Understand the presentation of acute pancreatitis

Answer 2

epigastric pain, N/V, Tachycardia, low grade fever, abdominal guarding, loss of bowel sounds, jaundice

Question 3

Understand the basic management of acute pancreatitis

Answer 3

Admit to hospital (usually)
NPO, then slow advancement in diet
Intravenous narcotics for pain
Surgery consultation if gallstones are present
Consider ERCP for bile duct stone removal
Severe disease → feeding tube, IV nutrition, pancreatic debridement, pseudocyst drainage, etc..

Question 4

Understand the pathophysiology of chronic pancreatitis

Answer 4

Permanent destruction of pancreatic parenchyma with replacement by fibrosis (scar tissue)
May lead to ductal strictures, ductal or parenchmal calcifications (stones), or pseudocysts
May be associated with prior episodes of acute pancreatitis

Ductal strictures/stones → pain, exocrine failure
Pancreatic pseudocysts → pain, nausea/vomiting (depending on what’s compressed)
Acinar destruction → exocrine failure
Diabetes → endocrine failure (late)

Question 5

presentation of chronic pancreatitis

Answer 5

usually cause by alcohol
-Abdominal pain-Chronic epigastric pain, radiates to back
Worse after meals
-Steatorrhea-Oily stools
Large-volume, light- colored, foul-smelling
-Hypo- or hyperglycemia- Brittle diabetes from loss of islets

Weight loss Fat

Steatorrhea Fat

Bleeding problems Vitamin K

Anemia Vitamin B12

[Weakness, edema] [Protein]

[Watery diarrhea] (CHO, protein]

Question 6

basic management of chronic pancreatitis

Answer 6

ETOH avoidance!
Pancreas enzyme replacement (pills) for steatorrhea
Treatment of duct obstruction - dilation, stent placement, or stone removal
Celiac nerve block for pain
Surgical resection if refractory and severe
Pancreatectomy with islet cell transplant
Young patients, refractory disease

Question 7

Understand the tests used to diagnose acute pancreatitis

Answer 7

amylase, lipase
Ultrasound
CT/CTA

Question 8

tests used to dx chronic pancreatitis

Answer 8

History, physical exam

Plain x-ray → calcifications in pancreas
CT → dilated duct, atrophy, calcifications, pseudocysts

Secretin test, ERCP, or endoscopic ultrasound → more accurate, but invasive

Question 9

Recognize the presentation of pancreatic cancer

Answer 9

Jaundice, dark urine, pruritus 
Bile duct obstruction (tumors in head)
Abdominal or back pain - late
Capsular distension or nerve invasion
Weight loss
Nausea/vomiting (late) – 
Duodenal or gastric obstruction
Hormonal excess (neuroendocrine)
insulin, glucagon, gastrin, VIP

Question 10

prognosis of pancreatic cancer

Answer 10

4th leading cause of cancer death in U.S.
Adenocarcinoma most common
5-year survival = 5% (# diagnoses ~ # deaths)

Question 11

management of pancreatic cancer

Answer 11

Diagnosis and initial staging
CT or MRI of abdomen
Biopsy and pre-op/definitive staging
Endoscopic ultrasound (EUS) 
Treatment
Surgical resection - select few that are diagnosed early
ERCP with stent for palliation of cholestasis
Celiac nerve block for pain

Question 12

what can masquerade as pancreatic cancer?

Answer 12

autoimmune pancreatitis