Pathophys of Exocrine Pancreas Flashcards
Pancreas Physiological fxn: Exocrine (2)
1) Synthesize enzymes needed for digestion; fats, carbs, proteins
2) Neutralize gastric acid and chyme
Pancreas Physiological fxn: Endocrine (1)
1) Synthesize and secrete insulin, glucagon that regulates glucose and lipid metabolism.
LO1: Classify acute pancreatitis (4)
1) Acute inflamm
2) Acute abd pn
3) Elevated pancreatic enzymes in serum
4) Self-limited
LO1: Classify chronic pancreatitis (4)
1) Chronic inflamm
2) Ductal obstruction
3) Chronic pn or malabsorption
4) Permanent loss of pancreatic fxn
LO1: Acute Pancreatitis specifics (4)
1) trypsinogen and other pro-enzymes prematurely activated
2) Auto-digestion of gland
3) Enzyme leak around pancreas -> complications
4) Inflamm cascade-> organ failure or death
LO1: Acute pancreatitis Causes (2)
1) ETOH - a)Premature release and activation of zymogens
b) Proteinaceous plugs w/in pancreas
2) Abrupt ductal obstruction (stone, trauma)
a) bile reflux or enzyme retention
Gallstone Pancreatitis and Clues (4)
#1 cause in America Clues: 1) Risk factors 2) Seen on imaging (in gallbladder or bile duct) 3) Elevated liver chemistries 4) Dilated bile duct
LO1: Acute pancreatitis Presenting Features
7
1) Abd pn
2) N/V
3) Tachycardia
4) Low grade fever
5) abd guarding
6) loss of BS
7) Jaundice
LO5: Acute pancreatitis Dx tests (4)
1) Serum amylase, lipase - >3x NL
2) US-best for gallbladder stones
3) CT-detects edema, calcifications, fluid collections
4) CT w/ IV contrast -detect necrosis
Acute Pancreatitis Complications (3); Severe dz (5)
1) Ileus
2) Intr-abd hemorrhage
3) pseudocyst formation
Severe dz:
1) pancreatic necrosis
2) bowel obstruction
3) shock
4) Resp or renal failure
5) death
Pancreatic pseudocyst General info (3)
1) Collection of pancreatic fluid, debris surrounded by wall of granulation tissue - no epithelial lining
2) Results from ductal disruption, necrosis, or both
3) Majority (60-70%) resolve w/ time
Pancreatic Pseudocyst Tx (2)
1) Cyst-gastrostomy
2) stent placement
ARDS- General and Dx (5)
1) Occurs in severe pancreatitis
2) Delayed onset
3) Associated w/ hyperlipidemia
4) Dx: Hypoxemia w/ Nl wedge pressure
5) Potentially reversible
ARDS Cont. w/ tx (3)
1) Associated w/ pancreatic necrosis
2) Commonly leads to resp failure
3) Tx =support
LO6: Acute Pancreatitis Management
(6), Severe dz
1) Hospital admit
2) NPO
3) IV fluids
4)IV narcotics
5) Surgery consult if gallstones
6) Consider ERCP for bile duct stone removal
Severe dz -
1) feeding tube,
2) IV nutrition,
3) pancreatic debridement,
4) pseudocyst drainage
LO1: Chronic Pancreatitis General Info (3)
1) Permanent destruction of pancreatic parenchyma w/ fibrosis
2) May lead to ductal strictures, ductal or parenchymal calcifications, or pseudocysts
3) May be associated w/ prior acute pancreatitis
LO1: Chronic Pancreatitis Pathophys
4
1) Ductal strictures/stones ->pn, exocrine failure
2) Pancreatic pseudocysts - pn, n/v
3) Acinar destructiom - exocrine failure
4) Diabetes - endocrine failure (late)
LO1: Chronic Pancreatitis Causes (5)
1) ETOH
2) Idiopathic
3) CF
4) Hereditary pancreatitis
5) Hyperlipidemia
LO1: Chronic Pancreatitis - Clinical Spectrum (8)
1) abd pn
2) Steatorrhea
3) Hypo or hyper-glycemia
4) chronic epigastric pn radiating to back
5) worse after meals
6) oily stools
7) Large volume, light colored, foul smelling
8) Brittle diabetes from loss of islets
Pancreatic Insufficiency: Symptom - Nutrient (6)
1) wt loss - fat malabsorption
2) Steatorrhea - fat malabsorption
3) Bleeding - Vit K
4) Anemia - B12
5) weakness, edema -protein
6) watery diarrhea - CHO, protein
Steatorrhea mechanisms (2)
1) Decreased lipase
2) decreased duodenal pH
a) inactivate pancreas enzymes
b) Bile acid precipitation
LO1: Chronic Pancreatitis Dx
4
1) Hx and PE
2) Plain X-ray - Pancreas calcifications
3) CT - dilated duct, atrophy, calcifications, pseudocysts
4) Secretin Test, ERCP, or endoscopic US - more accurate, but invasive
ERCP -what is it?
Endoscopic retrograde cholangiopancreatography
Secretin Test-General Info
1) Evaluate pancreas fxn
2) Given IV
3) HCO3 increase <80 mEq/L suggests pancreatic obstruction or failure
LO1: Chronic Pancreatitis Tx (5)
1) ETOH avoidance
2) Pancreas enzyme replacement for steatorrhea
3) Tx duct obstructionw/ dilation, stone, placement, or stone removal
4) Surgical resection if refractory and severe
5) Pancreatectomy w/ islet cell transplant - young pts w/ refractory dz
LO3: Pancreatic CA
4
1) 4th leading cause of CA death
2) Adenocarcinoma most common
3) Most die. Median survival 8 months. 5-yr survival 5%
4) Dx late
LO3 Pancreatic CA Presentation
5
1) Jaundice, dark urine, pruritis - bile duct obstruction
2) Abd or back pn (late)
3) Wt loss
4) N/v (late) -duodenal or gastric obstruction
5) Hormonal excess (neuroendocrine) -insulin, glucagon, gastrin, VIP
LO7: Pancreatic CA DX and staging
1) Dx and stage- CT or MRI of Abd
2) Biopsy and pre-op/definitive staging - Endoscopic US
LO7: Pancreatic Tx (3)
1) Surgical resection -if dx early
2) ERCP w/ stent for palliation of cholestasis
3) Celiac nerve block for pn
LO2L Pancreatic NET
6
1) slow growing
2) Favorable prognosis
3) Islet cell origin
4) May present w/ sx of hormone excess
5) Dx and Tx same as adenoCA
6) Octreotide scan can detect lesions not seen by CT or EUS
LO3: Autoimmune Pancreatitis General
5
1) Diffuse or focal enlargement of pancreatic parenchyma
2) IgG-4+ plasma cell and lymphocyte infiltration
3) Males, 40-70 y/o
4) Association: RA, Sjogren’s, IBD, SLE
5) May look like pancreatic CA
LO3: AIP Sx
1) Abd pn
2) jaundice
3) wt loss
4) rarely pancreatitis
LO3: AIP Imaging
Diffuse or focal enlargement of pancreas w. narrowing of CBD +/- PD
LO3: AIP Dx
1) CT/MRI
2) Serum IgG-4
3) Endoscopic US (EUS)
4) ERCP
5) FNA/biopsy
LO3: AIP Tx
1) PO corticosteroids x 6 weeks
2) biliary stenting for sx relief
