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Flashcards in Nichols + ??? 2 Deck (91)
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1

Acinar Cell: Protective Mechanisms

1. Inactive proenzymes
2. Membrane enclosed
3. Separate pathways
4. Trypsin inhibitor

2

Acinar Cell: Acute Pancreatitis, mechanisms of injury

1. Blockage of Secretion
2. Co-localization of ZG and lysosomes
-premature zymogen activation
-autodigestion from within acinar cell

3

Cytokines and Acute Pancreatitis

-Proteases activate complement
-C3a and C5a recruit PMNs and macrophages
-Inflammatory cells release cytokines (TNF-alpha, IL-1, PAF, NO)
-Vascular injury and inflammatory responses

4

Local Effets

-autodigestion of the pancreas
-pancreatic swelling (edema)
-fat necrosis and hemorrhage

***pain, nausea, vomiting***

5

Systemic Containment Response

-circulation alpha1-antitrypsin (inactivates circulating proteases)
-Circulating alpha-macroglobulin
-binds to circulating trypsin
-facilitates monocyte clearance of macroglobulin-tyrpsin complexes

6

Severe Pancreatitis: Inflammatory

Cause: TNF-alpha, IL-6
-fever, malaise, confusion

7

Severe Pancreatitis: Vascular

Cause: kallikrein - hypotension
thrombin activation - DIC, hemorrhage
elastase - hemorrhage
chymotrypsin - hemorrhage

8

Severe Pancreatitis: Respiratory

Cause: Phospholipase A2 - hypoxemia

9

Severe Pancreatitis: Metabolic

Cause: Fat Saponification - hypocalcemia

10

Acute Pancreatitis: Causes

gallstones & alcohol

11

Acute Pancreatitis: Symptoms

abdominal pain, nausea, vomiting

12

Acute Pancreatitis: Diagnosis

-elevated serum amylase and lipase
-inflamed pancreas on CT scan

13

Acute Pancreatitis: Management

IV fluids, pain meds, remove stone (if causative)

14

Acute Pancreatitis: Etiologies

-miscellaneous
-autoimmune, hyperlipidemia, hypercalcemia, drugs, infection, iatrogenic, trauma, shock, genetic, scorpion bite
40% alcohol
40% gallstones

15

Hereditary Pancreatitis

tyrpsinogen mutation (arg to his) where degradation of trypsin cleavage is

16

Acute Pancreatitis: Diagnostic Criteria

2 of the 3

1. abdominal pain, nausea/vomiting
2. elevated serum amylase & lipase more than 3x upper limit of normal
3. CT imaging showing pancreatic inflammation

17

Factors suggesting Pancreatitis is from Gallstone

1. age >50
2. female
3. amylase > 4000 IU/L
4. AST > 100 U/L
5. alk. phos. >300 IU/L

18

Acute Pancreatitis: Supportive Management

-close observation (hospital)
-NPO
-very aggressive IV fluid replacement
-relief of pain
-nutritional support (if prolonged)
-antibiotics (if biliary pancreatitis)

19

Acute Pancreatitis: Predictors of Poor Outcome

-admission hematocrit >44% with failure to decrease after 24hrs of IV fluids
-admission BUN>25mg/dl with an increase after 24 hrs of IV fluids

20

Acute Pancreatitis: Clinical Prognosis CT

1. Interstitial Pancreatitis (85%)
-multi-organ failure rate < 10%
-infection rate <1%
-mortality ~3%
2. Necrotizing Pancreatitis (15%)
-multi-organ failure rate 50%
-infection rate 15-20%
-mortality 17%

21

Complications of Acute Pancreatitis

-fluid collections
-pseudocysts
-fistulas (ascites, pleural effusions)
-splenic vein thrombosis

22

Chronic Pancreatitis: Pathophysiology

-recurrent injury with tissue destruction and fibrosis

23

Chronic Pancreatitis: Cause

chronic alcohol

24

Chronic Pancreatitis: Symptoms

chronic abdominal pain
diabetes
steatorrhea

25

Chronic Pancreatitis: Diagnosis

imaging studies

26

Chronic Pancreatitis: Management

pain medications
insulin
enzyme supplements

27

Chronic Pancreatitis: Etiologies

80% alcohol
miscellaneous: cystic fibrosis, hereditary, tropical, autoimmune

28

Chronic Pancreatitis: Pathophysiology

-chronic alcohol ingestion goes to recurrent bouts of pancreatitis and injury, and abnormal secretion (protein plugs and ductal obstruction - calcification)
-the injury: stellate cell activation, fibrosis, pain & cell death, malabsorption diabetes

29

Chronic Pancreatitis: Pathology

-little dark blue dots (lymphocytes), acini are gone, ducts still present (empty)
-residual necrotic debris
-early fibrosis

30

Chronic Pancreatitis: Clinical Presentation

-chronic abdominal pain ~80%
-malabsorption (steatorrhea) ~35%
-diabetes ~35%