SM_160b: Clinical Features of Pancreatic Disorders Flashcards
___ is inflammation of the pancreas that occurs when enzymes of the pancreas auto-digest the pancreas
Pancreatitis is inflammation of the pancreas that occurs when enzymes of the pancreas auto-digest the pancreas
- Acute pancreatitis: occurs suddenly, short-term, can resovle
- Chronic pancreatitis: irreversible changes of the pancreas
Describe diagnosis of acute pancreatitis
Acute pancreatitis: need 2 of 3, avoid imaging unless diagnosis is in question
- Symptoms: classically with severe epigastric pain radiation to back
- Labs: amylase or lipase > 3x upper limit of normal
- Radiology suggestive of pancreatitis
____ and ____ are enzymes mainly but not exclusively produced by the pancreas and released into the small intestine via the pancreas duct
Lipase and amylase are enzymes mainly but not exclusively produced by the pancreas and released into the small intestine via the pancreas duct
- There are normal circulating levels
____ is an enzyme that helps break down fats in the diet
Lipase is an enzyme that helps break down fats in the diet
____ is an enzyme that helps break down carbohydrates
Amylase is an enzyme that helps break down carbohydrates
Describe definitions of acute pancreatitis
Acute pancreatitis
- Interstitial edematous pancreatitis: inflammation of the pancreatic parenchyma and peripancreatic tissues w/o necrosis
- Necrotizing pancreatitis: inflammation associated with parenchymal or periparenchyma necrosis (death of cells)
- Mild: absence of organ failure or local / systemic complications
- Moderately severe: transient organ failure and/or local system complications (< 48 hours)
- Severe: persistent organ failure of ≥ 1 organs
Diagnosis of pancreatitis should be AVOIDED with ____
Diagnosis of pancreatitis should be AVOIDED with nonspecific elevations of amylase or lipase
Describe diagnosis of chronic pancreatitis
Chronic pancreatitis diagnosis
- Radiology and endoscopic tests
- Clinical symptoms (specifically pain and malabsorption)
- Diagnostic testing (to measure pancreas function)
Chronic pancreatitis has ____ in presentation
Chronic pancreatitis has marked heterogeneity in presentation
- Incidental symptomatic severe chronic pancreatitis
- Symptomatic severe chronic pancreatitis
- After ≥ 1 prior episodes of acute pancreatitis
- Subtle signs (fat malabsorption)
Acute pancreatitis etiology is commonly ____ or ____
Acute pancreatitis etiology is commonly alcohol or biliary
- Alcohol: dose-dependent risk for pancreatitis
- Biliary: gallstones, sludge, microlithiasis
Acute pancreatitis genes include ____, ____, and ____
Acute pancreatitis genes include PRSS1, CFTR, and SPINK1
- PRSS1 gene encodes cationic trypsinogen: mutations result in autosomal dominant inheritance of hereditary pancreatitis
- CFTR mutations: transmitted in autosomal recessive fashion
- SPINK1 mutations: generally disease modifying, autosomal recessive
Autoimmune pancreatitis is most likely ____ mediated, diagnosed by ____, and presents as ____
Autoimmune pancreatitis is most likely IgG4 mediated, diagnosed by elevated serum IgG4, and presents as painless mass
- Treated with prolonged steroids
Pancreatitis may occur after ____ due to papillary swelling or contrast injection
Pancreatitis may occur after endoscopic retrograde cholangiopancreatography (ECRP) due to papillary swelling or contrast injection
- Magnetic resonance cholangiopancreatography has replaced ECRP
- Placement of a small pancreatic stent in at-risk patients reduces the risk of post-ERCP pancreatitis
- Indomethacin reduces risk of post-ERCP pancreatitis
- Aggressive IC hydration after ERCP may reduce post-ERCP pancreatitis
Describe diagnosis of acute pancreatitis
Acute pancreatitis diagnosis
- All patients should be ruled out for biliary causes regardless of alcohol history: ALT elevation is most sensitive
- RUQ ultrasound is necessary
- CT should be avoided when diagnosis is known
- MRCP cam be useful but not needed at first episode to evaluate for other causes
Describe diagnosis of recurrent acute pancreatitis
Recurrent acute pancreatitis diagnosis
- Patients with normal liver tests on hospital day #1 and no sludge in gallbladder points away from a biliary source
- Pancreas divisum should be considered
- MRI/MRCP should be considered to evaluate for pancreas divisum, US can be used to evaluate for divisum
- Consider med history, autoimmune pancreatitis, genetic testing
Describe acute pancreatitis management
Acute pancreatitis management
- IV hydration
- Nutrition: avoidance of oral nutrition, but parenteral nutrition has drawbacks, nasojejundal feedings superior to parenteral nutrition
- No advantage to early feeding
Early complications of acute pancreatitis include ____ or ____
Early complications of acute pancreatitis include acute pancreatic fluid collections or acute necrosis collections
- Acute pancreatic fluid collections: due to inflammation and/or pancreas duct disruption leading to accumulation of pancreatic juice, most resolve on their own
- Acute necrosis collections: aspiraation can be performed, avoid surgery early in necrosis
Acute pancreatitis complications after 4 weeks include ____ or ____
Acute pancreatitis complications after 4 weeks include pseudocyst or walled off pancreatic necrosis
- Pseudocysts: mature collections of pancreas juice possibly associated with persistent disruption of pancreatic duct, drain larger pseudocysts
- Walled off pancreatic necrosis: treat if infected or symptomatic, debridement and drainage
____ is a risk factor for chronic pancreatitis
Tobacco is a risk factor for chronic pancreatitis
___ significantly increases the risk of developing pancreatic cancer
Smoking significantly increases the risk of developing pancreatic cancer
Chronic pancreatitis presents as asymptomatic or with ____, ____, ____, as ____
Chronic pancreatitis presents as asymptomatic or with exocrine insufficiency (malabsorption), endocrine insufficiency (diabetes mellitus), pancreatic pain, and neuropathic pain
Describe treatment of chronic pancreatitis
Chronic pancreatitis treatment
- Pancreas enzyme replacement therapy used to treat exocrine function: dosage measured in units of lipase
- Opiates should be avoided
Solid exocrine pancreas neoplasm is ____
Solid exocrine pancreas neoplasm is ductal adenocarcinoma
Solid endocrine pancreas neoplasm is ____
Solid endocrine pancreas neoplasm is iselt cell neoplasms
Benign cystic pancreas neoplasms are ____, ____, and ____
Benign cystic pancreas neoplasms are retention cyst, pseudocyst, and serous cystadenoma
Malignant potential cystic pancreas neoplasms are ____, ____, and ____
Malignant potential cystic pancreas neoplasms are mucinous cystadenoma, intraductal papillary mucinous neoplasm, and solid pseudopapillary neoplasm
____ is the third leading cause of cancer death
Pancreatic adenocarcinoma is the third leading cause of cancer death
- Risk factors: male gender, family history, cigarette smoking, cancer syndromes, non-O blood type, chronic pancreatitis, and obesity / decreased physicla activity
- Genetic syndromes: Peutz-Jeghers (STK11), familial atypical multiple melanoma (FAMM, CDKN2A), BRCA1, BRCA2, and Lynch syndrome
Describe pancreatic cancer presentation
Pancreatic cancder presentation
- Tumors in pancreas head block the bile duct earlier and cause jaundice
- Tumors in the body and tail generally present with advanced disease
____ is the only chance of cure for pancreatic adenocarcinoma but overall survival is low
Surgical resection is the only chance of cure for pancreatic adenocarcinoma but overall survival is low
Pancreatic endocrine tumors are named after ____
Pancreatic endocrine tumors are named after the hormone they secrete
- Insulinomas
- Gastrinomas
- Nonfunctioning
- Glucagonomas
- Somatistatinomas
- VIPomas
Pancreatic neuroendocrine tumors may be classified as ____ or ____
Pancreatic neuroendocrine tumors may be classified as functional or nonfunctional
- Functional: found at earlier stage due to symptoms
- Nonfunctioning: often incidentally found on CT performed for other reasons
Insulinomas are characterized by ____ and diagnosed by ____
Insulinomas are characterized by fasting hypoglycemia and diagnosed by high insulin and c-peptide levels after a prolonged fast (i.e. 72 hour fast)
Gastrinomas most commonly arise in the ____ and have signs due to ____
Gastrinomas most commonly arise in the duodenum and have signs due to elevated gastrin levels
- Remainder found in pancreas or peri-pancreatic lymph nodes
- Signs: abdominal pain, diarrhea, enlarged gastric folds, peptic ulcer disease
- Diagnosis: fastin serum gastrin level (requires acidic gastric pH), secretin stimulation test (gastrin levels rise > 200 after secretin administration)
Mucinous cystic neoplasms occur almost exclusively in ____ around age ____
Mucinous cystic neoplasms occur almost exclusively in women around age 40 (mother)
- Generally behave more aggressively than other pancreas cysts and resection is recommended
____ indicates the presence of a mucinous cyst neoplasm
Ovarian-like stroma indicates the presence of a mucinous cyst neoplasm
- Generally macrocystic and located in body and tail
- Lesiosn do not communicate with the pancreatic duct
- Generally asymptomatic
Intraductal papillary mucinous neooplasms are more common in ____ and typically occur in ____
Intraductal papillary mucinous neooplasms are more common in men and typically occur in elderly (grandparent)
- Malignant potential is less than mucinous cystic neoplasms
____ is pathognomonic for intraductal papillary mucinous neoplasms
Mucin extruding through major papilla is pathognomonic for intraductal papillary mucinous neoplasms
- Mucin-producing cells arranged in a papillary pattern
- Communicates with pancreatid cut: main, side-branch, or both
Serous cystadenomas are more common in ____, present in ____, and are often found ____
Serous cystadenomas are more common in women, present in middle age to elderly, and are often found asymptomatically
- Very low malignant potential
- Resection recommended for symptomatic cysts, cysts which cannot be differentiated from mucinous cystic neoplasms, rapidly growing cysts
