Pancreas 1: Acute and Chronic Pancreatitis Flashcards Preview

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Flashcards in Pancreas 1: Acute and Chronic Pancreatitis Deck (47):
1

Protective mechanisms to prevent self digestion:

--production of enzyme in inactive form
--enclosed within membrane to protect against low levels of activated enzyme
--activated enzyme not co-localized with pro-enzyme

2

What stimulates release of zymogen from acinar cell?

VIP (neural, cAMP)
secretin (intestines, cAMP)
ACh (vagus, Ca++)
CCK (intestines, Ca++)

3

earliest event in the pathogenesis of acute pancreatitis

conversion of pancreatic zymogens to their active forms within the acinar cell

4

Mechanisms of pancreatic injury?

1. blockage of secretions

2. co-localization of ZG + lysosomes, which leads to premature ZG activation and autodigestion

5

How do cytokines cause acute pancreatitis?

1. Proteases activate complement
2. C3a and C5a recruit PMNs and macrophages
3. Inflammatory cells release cytokines (TNF-a, IL-1, PAF, and nitric oxide)

=Vascular injury and inflammatory responses

6

Local effects of acute pancreatic injurt

1. Autodigestion of the pancreas
2. Pancreatic swelling (edema)
3. Fat necrosis and hemorrhage

7

Clinical manifestations of acute pancreatitis?

abd pain (radiating to back)

NV

8

Histopath of acute pancreatitis?

coagulative necrosis (with ghost cells) + hemorrhage + degenerating polys

fat necrosis between lobules

9

Gross pathology of acute pancreatitis?

fat necrosis between lobules

Severe acute hemorrhage

10

What is the function of circulating a1-antitrypsin?

inactivates circulating proteases

11

What is the function of circulating a-macroglobulin?

binds to circulating trypsin

facilitates monocyte clearance of macroglobulin-trypsin complexes

12

Severe Pancreatitis:
Fat saponification causes what clinical correlate?

hypocalcemia

13

Severe Pancreatitis:
phospholipase A2 causes what clinical correlate?

hypoxemia

14

Severe Pancreatitis:
kallikrein activation causes what clinical correlate?

hypotension

15

Severe Pancreatitis:
thrombin activation causes what clinical correlate?

DIC, hemorrhage

16

Severe Pancreatitis:
elastase + chymotrypsin cause what clinical correlate?

hemorrhage

17

Severe Pancreatitis:
TNF-alpha and IL-6 activation cause what clinical correlate?

fever
malaise
confusion

18

Acute Pancreatitis:
Main causes?

Gallstones and alcohol

19

Acute Pancreatitis:
Main symptoms?

abd pain, NV

20

Acute Pancreatitis:
Diagnosis?

elevated serum amylase and lipase
inflamed pancreas on CT

21

Acute Pancreatitis:
Trx?

VERY AGGRESIVE IV fluids

pain meds

remove stones if causitive

abx if biliary

NPO

22

What causes hereditary pancreatitis?

Trypsinogen Mutation, which prevents its degradation

23

Diagnostic criteria for acute pancreatitis?

Two of the following Three:
1. abdominal pain, nausea/vomiting
2. elevated serum amylase and lipase more than 3x upper limit of normal
3. CT imaging showing pancreatic inflammation

24

Factors Suggesting Gallstone Etiology?

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

25

Pancreatitis:
Predictors of Poor Outcome?

Admission hct >44% with failure to decr after 24h of IV fluids.

Admission BUN > 25 mg/dl with an incr after 24h of IV fluids.

(hct incr due to loss of plasma w/ retention of RBC)

26

Which has a better prognosis: Interstitial Pancreatitis or Necrotizing Pancreatitis?

interstitial!

Necrotizing Pancreatitis has a multi-organ failure rate of 50%, infection rate 15-20%, mortality 17%

27

Complications of Acute Pancreatitis

Fluid collections
Pseudocysts
Fistulas (ascites, pleural effusions)
Splenic vein thrombosis

28

Chronic Pancreatitis:
Pathophysiology?

recurrent injury with tissue destruction and fibrosis

29

Chronic Pancreatitis:
Cause?

chronic alcohol (80%)

30

Chronic Pancreatitis:
Symptoms?

chronic abdominal pain, diabetes, steatorrhea

31

Chronic Pancreatitis:Dx?

Imaging studies

32

Chronic Pancreatitis:
Management?

Pain medications, insulin, enzyme supplements

33

Chronic Pancreatitis: Pathophysiology, chr ETOH Ingestion

--> abn secretion --> protein plugs and ductal obst --> calcification, pain

--> recurrent bouts of pancreatitis --> stellate cell activation --> fibrosis --> pain + cell death (which causes malabs DM)

34

Chronic Pancreatitis: Pathophysiology, Genetic Abn

--> recurrent bouts of pancreatitis --> stellate cell activation --> fibrosis --> pain + cell death (which causes malabs DM)

35

Chronic Pancreatitis:
Histopath?

lymphocytes
acini = gone
ducts still present (empty)
residual necrotic debris
early fibrosis
prolif/dysplasia of epith around duct

36

Chronic pancreatitis: end-stage
Histopath?

replacement of exocrine acini and ducts by fibroadipose tissue, but with preservation of islets of Langerhans (because they don't autodigest)

37

Chronic Pancreatitis:
Clinical Presentation

Chronic abdominal pain
Malabsorption (steatorrhea)
Diabetes

**Malabsorption + DM = advanced stages

38

Causes of Pain in Chronic Pancreatitis:

--Increased pressure from fibrosis
--Pseudocysts trying to expand against fibrotic area
--Neural Inflammation

39

Pain Management in CP:
Any cause?

Narcotics

40

Pain Management in CP:
Acute exacerbations?

abstinence
enzymes

41

Pain Management in CP:
Neural inflammation?

nerve block splanchniectomy

42

Pain Management in CP:
Ductal hypertension?

drainage (stent or surgery)

43

Pain Management in CP:
Pseudocyst pressure?

drainage (stent or surgery)

44

Steatorrhea in CP:
Cause?

lipase deficiency = fat malabsorption

45

Steatorrhea in CP:
Trx?

1. reduce dietary fat intake
2. oral enzyme supplementation
3. acid suppression therapy (for effectiveness of oral enzymes)

46

Diabetes in CP:
Cause?

Only seen in severe disease with 80% destruction of pancreas:
Loss of both insulin and glucagon

47

Diabetes in CP:
Is this easy to manage?

no--Loss of both insulin and glucagon = brittle

but low insulin requirements, and DKA is rare