Pancreas

Question 1

Zymogens

Answer 1

store the enzymes in pancreas

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

Question 2

trypsinogen

Answer 2

cleaved to trypsin and activates other pancreatic enzymes

Question 3

how does pancreas protects itself from its self-digestion?

Answer 3

Pancreatic enzymes are created as proenzymes/zymogens

Packaged into crystal structures with protease inhibitors

Crystal granules have acidic pH and low calcium levels

Question 4

Acute Pancreatitis

Etiologies:

Answer 4

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

Question 5

Gallstone Pancreatitis (Choledocholithiasis)

patho

Answer 5

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

Question 6

what size stone MC causes gallstone pancreatitis

Answer 6

small gallstones

Question 7

Alcoholic Pancreatitis patho

Answer 7

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

Question 8

TG pancreatitis patho

Answer 8

> 1000 (>500 is increased risk)

milky serum = lipase activation and fat is toxic

common in uncontrolled DM, hereditary lipid disorder, pregnancy

Question 9

Medication pancreatitis mechanisms

Answer 9

Immunologic reaction

Direct toxic effects or accumulation of toxic metabolite

Pancreatic ischemia

Increased viscosity of pancreatic juice

Question 10

Hypercalcemia patho

Answer 10

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

Question 11

pancreas divisum

Answer 11

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

Question 12

general patho pancreatitis (6)

Answer 12

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

Question 13

pancreatitis Complications:

Answer 13

ARDS
myocardial depression
renal failure
shock
metabolic complications
bacterial translocation

Question 14

metabolic complications of pancreatitis

Answer 14

hypocalcemia, hyperlipidemia, hypoglycemia

Question 15

bacterial translocation pancreatitis

Answer 15

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

Question 16

pain of acute pancreatitis

Answer 16

epigastrium and LUQ

bores thru abdomen into back

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

Question 17

clinical presentation of pancreatitis

Answer 17

pain in LUQ, mild guarding and distention

n/v

tachycardia

fever

Question 18

Grey’s Turners sign

Answer 18

flank ecchymosis

Question 19

indicators of hemorrhagic pancreatitis

Answer 19

Grey’s Turner’s Sign or Cullen’s sign

Question 20

Cullen’s sign

Answer 20

(periumbilical ecchymosis)

Question 21

labs specific for pancreatitis

Answer 21

lipase and amylase

Question 22

lipase

Answer 22

MORE specific than amylase but non-specific for pancreatitis

gasteroenteritis, vomiting, chronic pancreatitis all elevate

levels don’t = severity

Question 23

pancreatitis must have 2 of 3:

Answer 23

Elevated lipase

Radiologic evidence of pancreatic inflammation

Clinical picture of acute pancreatitis present

Question 24

evaluation of pancreatitis (imaging + 5)

Answer 24

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

Question 25

pancreatitis tx (5)

Answer 25

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

Question 26

tx Gallstone Pancreatitis:

Answer 26

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

Question 27

tx Alcoholic Pancreatitis:

Answer 27

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

Question 28

tx Med Pancreatitis:

Answer 28

discontinue medication, general care

Question 29

tx HyperTG Pancreatitis:

Answer 29

1. insulin infusion +/- 5% dextrose, 2. Gemfibrozil bid, 3. therapeutic plasmapheresis

Question 30

systems infected by Autoimmune Pancreatitis

Answer 30

Pancreatic symptoms Biliary symptoms systemic features

Question 31

Autoimmune pancreatitis | Pancreatic features:

Answer 31

mass enlargement and pancreatic duct strictures

Question 32

Autoimmune pancreatitis | Biliary features:

Answer 32

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

Question 33

autoimmune pancreatitis | Systemic features

Answer 33

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

Question 34

autoimmune pancreatitis Characteristic appearance on imaging

Answer 34

CT or MRI show diffuse enlargement of pancreas with featureless borders Tissue biopsy

Question 35

autoimmune pancreatitis treatment

Answer 35

glucocorticoids

Question 36

Complications

Answer 36

infection of pancreas and peri pancreatic tissue fluid collection = pseudocyst

Question 37

bacteria that often cause pancreatic infection

Answer 37

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

Question 38

abscesses

Answer 38

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

Question 39

Pancreatic Pseudocysts

Answer 39

collection of fluid >4 weeks result of pancreatitis that has pancreatic juice with high concentrations of digestive enzymes encased in granulation tissue

Question 40

pancreatic pseudocyst | Tx:

Answer 40

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

Question 41

pancreatic pseudocyst | complications

Answer 41

Complications: Expansion = abdominal pain or obstruction Secondarily infected = abscess Pancreatic ascites and pleural effusions Erosion thru blood vessel = bleeding or pseudoaneurysm (esp. splenic vein)

Question 42

severe pancreatitis | graded by

Answer 42

ranson criteria

Question 43

ranson criteria how to

Answer 43

score patient at 0hrs of presentation and 48hrs after not used due to need to wait 48 hrs

Question 44

severe pancreatitis tx

Answer 44

ICU, monitor for complication, anticipator and supportive pancreas is necrotic = debridement

Question 45

chronic pancreatitis

Answer 45

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

Question 46

chronic pancreatitis | Presentation:

Answer 46

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

Question 47

chronic pancreatitis S/S:

Answer 47

Pancreatic insufficiency: Fat malabsorption: Diabetes (brittle)

Question 48

manifestations of pancreatic insufficiency in chronic pancreatitis

Answer 48

inability to digest complex foods or absorb partially digested products

Question 49

manifestations of Fat malabsorption in chronic pancreatitis

Answer 49

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

Question 50

chronic pancreatitis workup

Answer 50

fecal fat test pancreatic calcification on imaging diabetes

Question 51

tx of chronic pancreatic

Answer 51

pain control avoidance of overstimulation pancreatic enzyme supplementation

Question 52

pain meds steps in chronic pancreatitis

Answer 52

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

Question 53

pancreatic enzyme supplementation

Answer 53

Lipase/protease/amylase ``` Creon, zenpep, pancreaze, ultresa, pertzye ```

Question 54

Distinguishing between Acute and Chronic

Answer 54

Lack of severe pain (chronic) Normal levels of pancreatic enzymes bc chronic pancreatitis is a PATCHY process

Question 55

medications associated w/ pancreatitis

Answer 55

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

Question 56

drugs associated with pancreatitis

Answer 56

``` Chlorothorazidine Cimetidine/Tangament HCTZ Flagyl Macrobid ```