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Flashcards in Pancreas Deck (56):
1

Zymogens

store the enzymes in pancreas

released by pancreatic ductal cells into the pancreatic duct where they are secreted into small intestine

2

trypsinogen

cleaved to trypsin and activates other pancreatic enzymes

3

how does pancreas protects itself from its self-digestion?

Pancreatic enzymes are created as proenzymes/zymogens

Packaged into crystal structures with protease inhibitors

Crystal granules have acidic pH and low calcium levels

4

Acute Pancreatitis
Etiologies:

gallstones (MC),
alcohol,
hypertriglyceridemia (thousands),
medications,
ERCP complication

5

Gallstone Pancreatitis (Choledocholithiasis)

patho

gallstones migrate down into cystic duct --> common bile duct

stones lodge into CBD after pancreatic duct origin
o Cause both obstructive jaundice and acute pancreatitis

6

what size stone MC causes gallstone pancreatitis

small gallstones

7

Alcoholic Pancreatitis patho

EtOH increases synthesis of pancreatic enzymes + over sensitized pancreas to CCK

8

TG pancreatitis patho

>1000 (>500 is increased risk)

milky serum = lipase activation and fat is toxic

common in uncontrolled DM, hereditary lipid disorder, pregnancy

9

Medication pancreatitis mechanisms

Immunologic reaction

Direct toxic effects or accumulation of toxic metabolite

Pancreatic ischemia

Increased viscosity of pancreatic juice

10

Hypercalcemia patho

activation of trypsinogen or by calcium deposition into ducts, MC with acute increase in [Ca

11

pancreas divisum

anatomic variant where dorsal and ventral pancreas fail to form causing separate pancreatic ducts

12

general patho pancreatitis (6)

1.Impaired secretion of duodenum and premature activation of pancreatic enzymes in duct

2. Generalized auto digestion of pancreas and peripancreatic fat

3. Local inflammation causes pancreatic ischemia, vascular leak, edema of pancreas

4. Local inflammation causes extravasation of proteinaceous fluid and large amount of fluid leaks into peritoneal space

5. Leukocytes flood area and inflammatory cytokines are produced

6. Inflammatory mediators spill into bloodstream and result in SIRS

13

pancreatitis Complications:

ARDS
myocardial depression
renal failure
shock
metabolic complications
bacterial translocation

14

metabolic complications of pancreatitis

hypocalcemia, hyperlipidemia, hypoglycemia

15

bacterial translocation pancreatitis

bacteria from gut are able to move into lymphatic system and cause systemic infection

16

pain of acute pancreatitis

epigastrium and LUQ

bores thru abdomen into back


Aggravated when lying down, relieved when sitting up and bending forward

17

clinical presentation of pancreatitis

pain in LUQ, mild guarding and distention

n/v

tachycardia

fever

18

Grey's Turners sign

flank ecchymosis

19

indicators of hemorrhagic pancreatitis

Grey’s Turner’s Sign or Cullen’s sign

20

Cullen’s sign

(periumbilical ecchymosis)

21

labs specific for pancreatitis

lipase and amylase

22

lipase

MORE specific than amylase but non-specific for pancreatitis

gasteroenteritis, vomiting, chronic pancreatitis all elevate

levels don't = severity

23

pancreatitis must have 2 of 3:

Elevated lipase

Radiologic evidence of pancreatic inflammation

Clinical picture of acute pancreatitis present

24

evaluation of pancreatitis (imaging + 5)

Abdominal CT scan + search for cause
1. Tox Screen (look for EtOH and drug use)

2. RUQ U/S to look for gallstones if pt has elevated ALT/ST, MRCP to look for CBD stones

3. Medication list review

4. Lipid panel for hypertriglyceridemia

5. No cause found = biliary microlithiasis

25

pancreatitis tx (5)

1. Pancreatic rest
2. Parenteral pain meds
3. High volume IV fluid replacement
o Determined by vitals and lytes
4. +/- insulin replacement
5. NPO, enteral feeding (prevents bacterial translocation)

Prophylactic ABX are NOT routinely used

26

tx Gallstone Pancreatitis:

moderate – severe = urgent ERCP with sphincterotomy followed by lap chole in few days

27

tx Alcoholic Pancreatitis:

absolutely need to avoid alcohol completely, monitor withdrawal (Benzos)

28

tx Med Pancreatitis:

discontinue medication, general care

29

tx HyperTG Pancreatitis:

1. insulin infusion +/- 5% dextrose,

2. Gemfibrozil bid,

3. therapeutic plasmapheresis

30

systems infected by Autoimmune Pancreatitis

Pancreatic symptoms
Biliary symptoms
systemic features

31

Autoimmune pancreatitis
Pancreatic features:

mass enlargement and pancreatic duct strictures

32

Autoimmune pancreatitis
Biliary features:

obstructive jaundice,
biliary strictures,
transaminase elevation in cholestatic pattern,
mimic pancreatic CA or CCC

33

autoimmune pancreatitis
Systemic features

Sjogren’s syndrome,
lung nodules,
autoimmune thyroiditis,
nephritis

34

autoimmune pancreatitis Characteristic appearance on imaging

CT or MRI show diffuse enlargement of pancreas with featureless borders

Tissue biopsy

35

autoimmune pancreatitis treatment

glucocorticoids

36

Complications

infection of pancreas and peri pancreatic tissue

fluid collection = pseudocyst

37

bacteria that often cause pancreatic infection

E. coli,
Pseudomonas,
Staphylococcus,
Klebsiellosis,
Streptococcus,
Enterobacter,
anaerobes

38

abscesses

Formed by necrotic pancreatic tissue and gut flora, req. drainage or debridement

Distinguished from pseudocysts bc it has WBC in needle drainage and on CT will have lots of debris, not uniform

39

Pancreatic Pseudocysts

collection of fluid >4 weeks

result of pancreatitis that has pancreatic juice with high concentrations of digestive enzymes encased in granulation tissue

40

pancreatic pseudocyst
Tx:

watchful waiting (4-6 weeks) then surgical, percutaneous, or endoscopic drainage
Mc in cysts > 7 cm

41

pancreatic pseudocyst
complications

Complications:

Expansion = abdominal pain or obstruction

Secondarily infected = abscess

Pancreatic ascites and pleural effusions

Erosion thru blood vessel = bleeding or pseudoaneurysm (esp. splenic vein)

42

severe pancreatitis
graded by

ranson criteria

43

ranson criteria how to

score patient at 0hrs of presentation and 48hrs after

not used due to need to wait 48 hrs

44

severe pancreatitis tx

ICU, monitor for complication, anticipator and supportive

pancreas is necrotic = debridement

45

chronic pancreatitis

Progressive inflammatory changes cause patchy fibrosis and diminished pancreatic function

Can result from any etiology that causes acute pancreatitis

Increases risk of developing pancreatic cancer

46

chronic pancreatitis
Presentation:

persistent pain that wax and wanes in intensity, constant but less severe than AP

47

chronic pancreatitis S/S:

Pancreatic insufficiency:

Fat malabsorption:


Diabetes (brittle)

48

manifestations of pancreatic insufficiency in chronic pancreatitis

inability to digest complex foods or absorb partially digested products

49

manifestations of Fat malabsorption in chronic pancreatitis

steatorrhea and fat soluble vitamin deficiency (A,D,E,K, B-12)

50

chronic pancreatitis workup

fecal fat test

pancreatic calcification on imaging

diabetes

51

tx of chronic pancreatic

pain control

avoidance of overstimulation

pancreatic enzyme supplementation

52

pain meds steps in chronic pancreatitis

1. NSAIDs
2. TCAs
3. Gabapentin
4. Opiates

53

pancreatic enzyme supplementation

Lipase/protease/amylase

Creon,
zenpep,
pancreaze,
ultresa,
pertzye

54

Distinguishing between Acute and Chronic

Lack of severe pain (chronic)

Normal levels of pancreatic enzymes bc chronic pancreatitis is a PATCHY process

55

medications associated w/ pancreatitis

DPP-IV
Valproate
Tetracyclines
Corticosteroids
Estrogen
GLP - 1
Lasix
Sulfa drugs

56

drugs associated with pancreatitis

Chlorothorazidine
Cimetidine/Tangament
HCTZ
Flagyl
Macrobid