Pathophys of Exocrine Pancreas

Question 1

Pancreas Physiological fxn: Exocrine (2)

Answer 1

1) Synthesize enzymes needed for digestion; fats, carbs, proteins
2) Neutralize gastric acid and chyme

Question 2

Pancreas Physiological fxn: Endocrine (1)

Answer 2

1) Synthesize and secrete insulin, glucagon that regulates glucose and lipid metabolism.

Question 3

LO1: Classify acute pancreatitis (4)

Answer 3

1) Acute inflamm
2) Acute abd pn
3) Elevated pancreatic enzymes in serum
4) Self-limited

Question 4

LO1: Classify chronic pancreatitis (4)

Answer 4

1) Chronic inflamm
2) Ductal obstruction
3) Chronic pn or malabsorption
4) Permanent loss of pancreatic fxn

Question 5

LO1: Acute Pancreatitis specifics (4)

Answer 5

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

Question 6

LO1: Acute pancreatitis Causes (2)

Answer 6

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

Question 7

Gallstone Pancreatitis and Clues (4)

Answer 7

#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

Question 8

LO1: Acute pancreatitis Presenting Features

7

Answer 8

1) Abd pn
2) N/V
3) Tachycardia
4) Low grade fever
5) abd guarding
6) loss of BS
7) Jaundice

Question 9

LO5: Acute pancreatitis Dx tests (4)

Answer 9

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

Question 10

Acute Pancreatitis Complications (3); Severe dz (5)

Answer 10

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

Question 11

Pancreatic pseudocyst General info (3)

Answer 11

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

Question 12

Pancreatic Pseudocyst Tx (2)

Answer 12

1) Cyst-gastrostomy

2) stent placement

Question 13

ARDS- General and Dx (5)

Answer 13

1) Occurs in severe pancreatitis
2) Delayed onset
3) Associated w/ hyperlipidemia
4) Dx: Hypoxemia w/ Nl wedge pressure
5) Potentially reversible

Question 14

ARDS Cont. w/ tx (3)

Answer 14

1) Associated w/ pancreatic necrosis
2) Commonly leads to resp failure
3) Tx =support

Question 15

LO6: Acute Pancreatitis Management

(6), Severe dz

Answer 15

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

Question 16

LO1: Chronic Pancreatitis General Info (3)

Answer 16

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

Question 17

LO1: Chronic Pancreatitis Pathophys

4

Answer 17

1) Ductal strictures/stones ->pn, exocrine failure
2) Pancreatic pseudocysts - pn, n/v
3) Acinar destructiom - exocrine failure
4) Diabetes - endocrine failure (late)

Question 18

LO1: Chronic Pancreatitis Causes (5)

Answer 18

1) ETOH
2) Idiopathic
3) CF
4) Hereditary pancreatitis
5) Hyperlipidemia

Question 19

LO1: Chronic Pancreatitis - Clinical Spectrum (8)

Answer 19

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

Question 20

Pancreatic Insufficiency: Symptom - Nutrient (6)

Answer 20

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

Question 21

Steatorrhea mechanisms
(2)

Answer 21

1) Decreased lipase
2) decreased duodenal pH
a) inactivate pancreas enzymes
b) Bile acid precipitation

Question 22

LO1: Chronic Pancreatitis Dx

4

Answer 22

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

Question 23

ERCP -what is it?

Answer 23

Endoscopic retrograde cholangiopancreatography

Question 24

Secretin Test-General Info

Answer 24

1) Evaluate pancreas fxn
2) Given IV
3) HCO3 increase <80 mEq/L suggests pancreatic obstruction or failure

Question 25

LO1: Chronic Pancreatitis Tx (5)

Answer 25

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

Question 26

LO3: Pancreatic CA

4

Answer 26

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

Question 27

LO3 Pancreatic CA Presentation

5

Answer 27

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

Question 28

LO7: Pancreatic CA DX and staging

Answer 28

1) Dx and stage- CT or MRI of Abd

2) Biopsy and pre-op/definitive staging - Endoscopic US

Question 29

LO7: Pancreatic Tx (3)

Answer 29

1) Surgical resection -if dx early
2) ERCP w/ stent for palliation of cholestasis
3) Celiac nerve block for pn

Question 30

LO2L Pancreatic NET

6

Answer 30

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

Question 31

LO3: Autoimmune Pancreatitis General

5

Answer 31

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

Question 32

LO3: AIP Sx

Answer 32

1) Abd pn
2) jaundice
3) wt loss
4) rarely pancreatitis

Question 33

LO3: AIP Imaging

Answer 33

Diffuse or focal enlargement of pancreas w. narrowing of CBD +/- PD

Question 34

LO3: AIP Dx

Answer 34

1) CT/MRI
2) Serum IgG-4
3) Endoscopic US (EUS)
4) ERCP
5) FNA/biopsy

Question 35

LO3: AIP Tx

Answer 35

1) PO corticosteroids x 6 weeks

2) biliary stenting for sx relief