Pancreas

Question 1

work up and management for acute pancreatitis?

etiologies?

Answer 1

• Dx screen w/ ↑lipase, confirm w/ CT scan
• Tx NPO/IVF/pain meds

Etiology:
I GET SMASHED
Idiopathic

gallstones (#1),
EtOH (#2)
trauma

steroids
mumps,
autoimmune
scorpion sting,
hypertriglyceridemia (#3),
hypercalcemia
ERCP
drugs

Question 2

presents as MSOF, ARDS, hemodynamic instability, signs of
ecchymoses (Grey-Turner, Fox, Cullen signs)

dx? tx?

Answer 2

hemorrhagic pancreatitis

CT

admit to ICU for close monitoring

Question 3

What are the
Grey-Turner sign
Cullen sign:
Fox sign:

Answer 3

Grey-Turner sign: flank ecchymoses
Cullen sign: periumbilical ecchymoses
Fox sign: ecchymoses of inguinal ligament

Question 4

presents as abd pain and early satiety 2 wks s/p acute pancreatitis

dx and tx

Answer 4

pancreatic abcess

dx with CT scan

tx perc drain + IV abx

Question 5

presents as abd pain and early satiety 5 wks s/p acute pancreatitis

dx and tx

Answer 5

pseudocyst

dx with CT

tx observation (5 cm)

Question 6

chronic epigastric pain,
steatorrhea, diabetes mellitus

how to make dx? tx?
MC etiologies?

Answer 6

chronic pancreatitis

Dx stool elastase test

Tx insulin + pancreatic enzyme replacement, IVF/NPO/pain meds for acute attacks

alcoholism (MCC adults), cystic fibrosis (MCC kids)

Question 7

dull abd pain + s/sx of obstructive jaundice (dark urine, clay stools, pruritus)

dx? tx? tumor marker?

Answer 7

pancreatic cancer

Dx CT scan
Tx:
> cancer in head → Tx Whipple
> cancer in body or tail → Tx distal pancreatectomy
> mets or local invasion→ palliative care

• • f/u tumor markers CA 19
• 9, CEA

Question 8

what is the trousseau phenomenon?

Answer 8

migratory SVT in 10% of pancreatic cancer pts

Question 9

what is the courvoisier sign?

Answer 9

palpable GB w/o pain in 30% of cancer pts

Question 10

mass in pancreas + ↑insulin → Whipple’s triad (hypoglycemia, worse w/ fasting, better w/ glucose)

how to make dx? tx?

Answer 10

Insulinoma

Dx ↑C-peptide levels or monitored fasting (to see if they’re “faking it”)

Tx resection

Question 11

how to work up suspected gastrinoma?

Answer 11

1. get gastrin levels (500 tumor present)
2. if btwn 200-500 get ecretin stimulation test (secretin releases gastrin from gastrinomas, it inhibits gastrin release from the normal stomach)

Question 12

what is the gastrinoma triangle

Answer 12

neck of pancreas
cystic duct
junction b/t 2nd and 3rd part of duodenum

Question 13

new-onset diabetes + necrolytic migratory erythema

how to work up?

Answer 13

glucagonoma

Dx with glucose challenge test

Question 14

triad of gallstones, diabetes, steatorrhea

Answer 14

somatostatinoma

Question 15

“rice water” diarrhea

Answer 15

VIPoma

Question 16

presentation of MEN1 vs MEN2A and 2B

Answer 16

MEN1: pituitary adenoma, pancreatic endocrinoma (MC gastrinoma), parathyroid hyperplasia

MEN2A: parathyroid hyperplasia,
pheochromocytoma, thyroid
medullary cancer

MEN2B: pheochromocytoma, thyroid medullary cancer, mucosal
neuromas, Marfanoid habitus

Question 17

etiology of MEN2A and 2B

Answer 17

AD ret protooncogene

Question 18

treatment for MEN1, 2A, 2B

Answer 18

MEN1: Tx excise parathyroid first (since hyper calcemia can cause ↑gastrin), then gastrinoma, then pituitary adenoma (w/ cabergoline)

MEN2A and B: excise pheo first (life threatening)

Question 19

what is impaired glucose tolerace?

Answer 19

asx w/ fasting glc 110-126

Question 20

how do T1DM typically present?

treatment for T1DM

Answer 20

in DKA

Tx
insulin, 0.5-1 u/kg (2/3 morning, 1/3 evening)

inpatient → Tx SSI

Question 21

pathophys of T2DM

Answer 21

obesity → ↑FFA release → ↑insulin resistance → ↑glucose → classic sx (polyuria, polydipsia,
polyphagia) + blurry vision, weight loss, recurrent vaginal yeast infx

Question 22

how to dx T2DM

Answer 22

Dx fasting glc >126
random glc >200 w/ sx
HbA1C >6.5%

Question 23

how to manage T2DM

Answer 23

T2DM
fasting glc  240 
  1st treat with insuin 
      (still high) 
  add another PO drug

Question 24

what is monitoring schedule of T2DM as an outpatinet

Answer 24

q day – glucose
q visit – BP, foot chk
q 3 mo – HbA1c
q 6 mo – neuropathy chk
q yr – microalbuminuria, BUN/Cr, lipids, eye chk

Question 25

ideal levels of ...  for T2DM
HbA1c
fasting glc
post-prandial glc 
BP 
LDL

Answer 25

HbA1c <100

Question 26

pathophys of macrovascular disease in DM

Ppx?

Answer 26

nonenzymatic glycosylation → atherosclerosis

PPx reduction of risk factors (BP, lipids, smoking, diet, exercise)

Question 27

Pathophys of diabetic nephropathy?

Ppx? Tx?

Answer 27

non-enzymatic glycosylation of BM → loss of negative charge → microalbuminuria → proteinuria → CKD → ESRD

PPx annual microalbuminuria screening

Tx ACE inhibitors

Question 28

Pathophys of diabetic retinopathy?

ppx? tx?

Answer 28

NEG of retinal vx → either background or proliferative retinopathy

PPx annual ophtho referral

Tx photocoagulation

Question 29

Pathophys of diabetic neuropathy?

tx?

Answer 29

NEG of peripheral nerves → damage → “stocking/glove” burning pain, numbness, tingling

• neuropathy → Tx amitriptyline (1st line), gabapentin or duloxetine (2nd line)
• gastroparesis → Tx metoclopramide

Question 30

pathophys of diabetic foot?

Ppx? Tx?

Answer 30

peripheral neuropathy + PVD (ischemia) → repetitive injuries → ulcers and nonhealing

PPx regular foot check

Tx wound care, amputation (last resort)

Question 31

“T1DM exacerbation” = ?
pathophys + s/s?
how to dx?
tx?

Answer 31

DKA

↓insulin → hyperglycemia + ketosis → osmotic diuresis, dehydration, fruity breath, Kussmaul respiration, etc.

Dx ↑glc, ↑ketones, metabolic acidosis

Tx insulin + IVF (NS) + potassium (paradoxical)

Question 32

“T2DM exacerbation” =

pathophys + s/s?
how to dx?
tx?

Answer 32

T2DM exacerbation

↓insulin → hyperglycemia → hyperosmolarity, osmotic diuresis,
severe dehydration

Dx ↑glc, ↑osmolarity, no acidosis or ketosis

Tx insulin + IVF (NS)

Question 33

get SNS dysfunction w/ blood glc of ___

Answer 33

40-50 (HA, weakness, drowsiness, coma)

Question 34

MCC etiology hypoglycemia

Answer 34

insulin overdose (MCC),
factitious hypoglycemia (low Cpeptide levels), insulinoma, etc

Question 35

how to work up hypoglycemia? Tx?

Answer 35

Dx C-peptide, insulin levels, anti-insulin ab, and sulfonylurea levels (look for underlying cause)

Tx underlying cause + sugary foods or IV D50W