The Pancreas Flashcards
Where is the pancreas located in relation to the duodenum?
the duodenum is situated anteriorly and medially
it curves around the head of the pancrease in a “C”
Where does the pancreas lie in relation to the stomach?
the stomach lies anteriorly and superiorly to the pancreas
Where is the pancreas located in relation to the spleen?
the spleen lies posteriorly and laterally to the pancreas
Where is the vasculature for the pancreas located?
the aorta and IVC pass posteriorly to the head of the pancreas
What is the arterial supply of the pancreas?
the coeliac trunk
What is BV provides venous drainage to the pancreas?
the hepatic portal vein
-carries blood to the liver
Parasympathetic innervation of the pancreas is performed by what cranial nerve?
vagus nerve
CNX
The pancreatic duct joins the common bile duct before draining into the 2nd part of the duodenum. What is the second part of the duodenum called?
Ampulla of vater
What do the exocrine contents of the pancreas contain?
Pancreatic fluid
-enzyme rich (proenzyme, pepsinogen)
Pancreatic fluid has an alkaline pH of 8. Why is this?
this is because it contains bicarbonate
this stabilised enzymes contained in pancreatic fluid
remember a change in pH (acidic) will disrupt enzyme function
What is the exocrine function of the pancreas?
aids digestion
breaks food down so that by the time they reach the jejunum and ileum it can be absorbed
B12 absorption occurs in the ileum
Folate and iron are absorbed in the jejunum
What is the rapid action of insulin (seconds)?
transport glucose into muscle and fat cells
What is the intermediate action of insulin (minutes)?
increases protein synthesis in muscle and liver
decreases gluconeogenesis
increases glycogen synthesis
What is the delayed action of insulin?
increase lipid synthesis in the liver and adipose tissue
Somatostatin is released by delta cells in the pancreas. What is its function?
inhibits insulin, glucagon and pancreatic polypeptides
stops many hormones
What is the function of pancreatic polypeptide?
inhibits exocrine secretion and reduces appetite
stops many enzymes contained in pancreatic fluid
What are the cells of the islets of langerhans?
Alpha cells - glucagon
Beta cells- insulin
Delta cells- somatostatin (inhibition of hormones)
F cells- pancreatic peptide (inhibition of enzymes)
What is the function of acinar cells in the pancreas?
constitute 80% of pancreatic tissue
they are clustered around ducts and are responsible for the synthesis, secretion and storage of digestive enzymes
What is pancreatitis?
- disorder of the exocrine function of the pancrease- affects the digestive functions
- can be acute or chronic
- refers to acinar cell injury (synthesis, secretion and storage of digestive enzymes impacted)
- due to a local or systemic inflammatory respinse
What are the main causes of acute pancreatitis?
G- gallstones
E-ethanol (alcohol)
T-trauma
What is the pathophysiology of acute pancreatitis?
-premature enzyme activation (enzymes are activated where they shouldn’t be); proenzymes produced by the acinar cells are activated and begin to destroy the pancreas
-known as auto-digestion
- acinar cell injury
- leakage of pro-enzymes into pancreatic tissue
- disorderd enzyme cascade leads to activation of pro-enzymes
- inflammatory cascade triggered- neutrophils, macrophages, cytokines
- increased vascular permeability- haemorrhage oedema and pancreatic and peripancreatic fat necrosis
- fat saponifiation will lead to hypocalcemia
- systemic leakage of SIRs products
- hypotension- > shock (Not enough blood flow/oxygen reaching tissues)
- multiorgan failure
- death
What are the causes of acute pancreatitis ?
- Idiopathic
- gall stones
- ethanol
- trauma
- steroids
- mumps
- autoimmune
- scorpion venom
- hyperlipidaemia, hypercalcaemia, parathyroidism
- ERCP (access to ampulla of vater- 2nd part of duodenum)
- drugs
Pneumonic: I GET SMASHED
What is the consequence of gall stones in the gall bladder?
- blocks bile contents from entering the blood; deconjugation and metabolism of bilirubin prevented and bilirubin becomes a component in gallstones which causes jaundice
- pancreatitis
- cholecystitis
- biliary colic (right upper quandrant crampy pain, after meals)
colic- contraction and relaxation- in an attempt to remove the obstruct
What are gallstones made of?
- cholesterol
- bilirubin
- cholesterol and bilrubin
What are the risk factors of gallstones?
- obesity
- female
- fat
- fertile
- forty
- fair
What is the presentation of pancreatitis?
- nausea
- vomiting
- anorexia
- epigastric pain radiating to the back
- pain improves leading forward
- tachycardia
- chovsteks sign
- cardiovascular collape
Cullens sign
Grey turners sign
What is chovsteks sign? How does it present?
- sign that depicts an indication of hypocalcaemia
- tap facial nerve; there is a urgent twitch in the case of hypocalcaemia
hypocalcaemia is due to saponification of pancreatic tissues; calcium used up
Hypocalcaemia causes tetany like symptoms
What investigations can be carried out for the diagnosis of pancreatitis?
- bloods: lipase, amylase, WCC, CRP, haematocrit, calcium
- ABG: hypoxaemia, acid base disturbance
- ultrasound- gall stones
- abdominal CT: very sepcific and sensitive
A glasgow prognostic score >2 is indicative of …
severe pancreatitis
What is required for a clinical diagnosis of pancreatitis?
- P- PaO2 <8kPa
- A- age >55
- N-neutrophils (WCC >15)
- C-calcium <2mmol/L
- Renal (urea)>16mmol/L
- Enzymes (LDH- lactate dehydrogenase in liver >600 units/L)
- A-albumin <32g/L
- S-sugar (glucose>10mmol/L)
Outline the management of pancreatitis
- ABCDE resuscitation- lots of IV fluid
- intensive care management
- analgesia
- antiemetic (nausea and vomiting)
- nutritional support
- calcium replacement
- insulin replacement
- gall stones- ERCP or cholecystectomy
- alcogol- withdrawal regime
- infected necrotic pancreatitis- necrosectomy
What are the risk factors for chronic pancreatitis?
alcohol
smoking
family history
What is the pathphysiology of chronic pancreatitis?
primary insults to ducts and not acinar cells
(unlike acute pancreatitis which is caused by acinar injury)
What are the consequences of chronic pancreatitis?
- reduced exocrine function
- malabsorption (no enzymatic digestion of food so cannot be absorbed in jejunum and ileum)
- diabetes
- calcifications
List potential causes of chronic pancreatitis
oxidative stress (chronic inflammatory state)
ductal obstruction
necrosis-fibrosis
What is the presentation of chronic pancreatitis?
- abdominal pain
- steatorrhoea (present of fat in stool)
- weight loss
- malnutrition
What are the complications of chronic pancreatitis?
- pancreatic cancer
- pseudocyst
- GI bleed
- diabetes
- impaired digestion
What is the management of chronic pancreatitis?
- alcohol and smoking cessation
- enzyme replacement
- PPI (proton pump inhibitors (Block gastric secretions; parietal cells release HCl)
- cyst decompression
chief cells of stomach secrete pepsinogen
What part of the pancreas do majority of pancreatic cancers originate from?
the head of the pancreas
invasive ductal adenocarcinoma
What is the presentation of pancreatic cancers?
- jaundice
- weight loss
- abdominal pain
- courvoisiers sign (jaundice with a gallbladder that is enlarged but not painful)
- endocrine disturbance
What are the risk factors for pancreatic cancer?
smoking
family history
What investigations can be carried out for the diagnosis of pancreatic cancer?
LFTs (Liver function test)
ultrasound
CT
ERCP and biopsy
CA19-9
clotting
What is the management of resectable pancreatic cancer?
surgery
enzyme replacement
biliary stent
radio/chemotherapy
stent to relieve obstruciton
What is the management of unresectable pancreatic cancer?
stent
radio/chemotherapy
What is the management of metastatic pancreatic cancer?
stent
chemotherapy
analgesia
What dental consideration should be made for acute pancreatitis?
LA for emergency treatment only
What dental consideration should be made for chronic pancreatitis?
consider underlying cause
bleeding risk
oral ulceration
What dental consideration should be made for pancreatic cancer?
avoid GA
diabetic complications (healing)
