Pathophysiology of exocrine pancreas

Question 1

the pancrease responds to what 2 molecules?

Answer 1

secretin -> stimulates bicarb sectrion

cholecystokinin -> pancreatic enzymes

Question 2

describe zymogen activation

Answer 2

zymogens are secreted into duodenum from pancreas -> trypsinogen is converted to trypsin by brush border enzyme enterokinase -> trypsin proteolytically cleaves zymogens, converting them to their active forms.

Question 3

classify acute pancreatitis

Answer 3

Acute inflammation
Acute abdominal pain
Elevated pancreatic enzymes in serum
Self-limited

Question 4

classify chronic pancreatitis

Answer 4

Chronic inflammation
Chronic pain or malabsorption
Fibrosis and ductal obstruction
Permanent loss of pancreatic function

Question 5

how does alcohol cause acute pancreatitis

Answer 5

Causes Premature release and activation of zymogens.

Causes Proteinacious plugs within pancreas duct

Question 6

what is the #1 cause of acute pancreatitis in America

Answer 6

Gallstone (biliary) pancreatitis

Question 7

what are Clues to diagnosis of gallstone (biliary) pancreatitis)

Answer 7

1) Risk factors for gallstones (age, female,
hypercholestremia)
2) Gallstones seen on imaging (in gallbladder or bile duct)
3) Elevated liver chemistries
4) Dilated bile duct
5) Absence of other risk factors

Question 8

what are complications of acute pancreatitis

Answer 8

Ileus (paralysis of gut)
Intra-abdom hemorrhage
Pseudocyst formation

Question 9

what is a pancreatic pseudocyst

Answer 9

Collection of pancreatic fluid, debris surrounded by wall of granulation tissue - lacks epithelial lining

Question 10

pancreatic pseudocyst can result from _______

Answer 10

ductal disruption, necrosis, or both

Question 11

what syndrome is Associated with pancreatic necrosis

Answer 11

Adult respiratory distress syndrome (ARDS)

Question 12

describe acute pancreatitis managment

Answer 12

Admit to hospital (usually)
Aggressive IV fluids
NPO, slow advancement in diet p 2-3 days
Intravenous narcotics for pain
Surgery consultation if gallstones present
Consider ERCP for bile duct stone removal

Question 13

what is the management for severe acute pancreatitis

Answer 13

feeding tube,
IV nutrition (TPN), 
surgical or endoscopic necrosectomy, 
pseudocyst drainage, etc

Question 14

what is the defining characteristic in chronic pancreatitis

Answer 14

Permanent destruction of pancreatic parenchyma with replacement by fibrosis (scar tissue)

Question 15

what are the causes of chronic pancreatitis

Answer 15

Alcohol (60-70%)
Idiopathic (20%)
other (20%)
      cystic fibrosis
      hereditary pancreatitis
      hyperlipidemia

Question 16

Describe the clinical presentation of Chronic pancreatitis

Answer 16

1)Abdominal pain
Chronic epigastric pain, radiates to back
Worse after meals
2)Steatorrhea
Oily stools
Large-volume, light- colored, foul-smelling
Gas, bloating
3)hypo- or hyperglycemia
Brittle diabetes from loss of islets

Question 17

what are the 2 mechanisms for steatorrhea

Answer 17

Decreased lipase and colipase in duodenum

Decreased duodenal pH
Inactivation of pancreas enzymes
Bile acid precipitation

Question 18

in Chronic pancreatitis what can be seen on plain x-ray and CT?

Answer 18

Plain x-ray → calcifications in pancreas

CT → dilated duct, atrophy, calcifications, pseudocysts

Question 19

what is considered a positive secretin test

Answer 19

Secretin 0.2mcg given IV, if Duodenal [HCO3] increase of less than 80 mEq/l suggests pancreatic obstruction or failure

Question 20

Pancreatic neurendocrine tumor (NET) are _____ growing, the Prognosis is ________ and are of ____
cell origin

Answer 20

slow,
favorable,
Islet

Question 21

what is autoimmune pancreatitis?

Answer 21

Diffuse or focal enlargement of pancreatic parenchyma,

Infiltration of pancreas/ampulla by IgG-4 + plasma cells and lymphocytes

Question 22

what population typically gets autoimmune pancreatitis

Answer 22

Males, typically ages 50-70

Question 23

what other autoimmune diseases is autoimmune pancreatitis associated with?

Answer 23

RA, Sjogren’s, IBD, SLE

Question 24

what symptoms can be seen in autoimmune pancreatitis

Answer 24

abdominal pain,
jaundice,
weight loss,
(rarely) acute pancreatitis

Question 25

What tests can diagnose autoimmune pancreatitis

Answer 25

CT/MRI,
serum IgG-4,
EUS,
ERCP

Question 26

what is the treatment for Autoimmune pacreatitis

Answer 26

PO corticosteroids x 6 weeks

Biliary stenting for symptom relief