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Summer FDTN Exam 5 > Pancreas > Flashcards

Pancreas Flashcards

(61 cards)

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1
Q

What vascularity supplies the pancreas

A

Celiac axis and SMA

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2
Q

What innervates the pancreas

A

ANS

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3
Q

What are the pancreas’s Exocrine functions

A

Amylase: breakdown starch
Lipase: breakdown fat
Protease: breakdown proteins

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4
Q

What stimulates the pancreas to release it’s juices

A

Gastric acid
CCK
Vagal stimulation

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5
Q

What is in pancreatic “juice”

A

Electrolytes, bicarbonate, digestive enzymes

It neutralizes gastric acid and provides basic environment for pancreatic enzymes

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6
Q

What is the pancreas’s Endocrine function

A

Insulin released in response to increased blood glucose (increases permeability of cell membranes to glucose= lower blood glucose)
Glucagon released in response to low blood sugar (causes conversion of glycogen to glucose in the liver= increase blood sugar)

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7
Q

Where is amylase found

A

secreted from pancreatic *acinar cells, into duodenum to digest starch
Also in saliva, ovaries, skeletal muscle, and gallbladder (sensitive but not specific to pancreatic disease)

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8
Q

How do amylase levels change

A

Normal: 60-120
Abnormal levels w/in 12 hours of pancreatic injury
Return to normal in 48-72 hours

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9
Q

What causes amylase to leak into circulation

A

Damage to acinar cells (pancreatitis) or obstruction of pancreatic flow (CA or CBD stones)

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10
Q

What happens to amylase in chronic pancreatitis

A

Usually not increased in circulation because with chronic, acinar cells are destroyed- so there is no amylase even made!

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11
Q

Where is Lipase found

A

Secreted by pancreas into duodenum to breakdown TG into fatty acids
More specific but can also be found in renal failure or intestinal infarct

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12
Q

How do Lipase levels change

A

Normal: 0-160
non-pancreatic elevation: <3 of upper limit normal
Acute pancreatitis: Rise 24-48 hrs post injury
Return to normal in 5-7 days

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13
Q

What is acute pancreatitis

A

Inflammatory disease w/ autodigestion of pancreas by proteolytic enzymes prematurely activated in pancreas

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14
Q

What causes acute pancreatitis

A 
MC: alcohol and gallstones*** 
Also blunt trauma, ERCP
Hypertriglyceridemia**, hypercalcemia 
Ischemia, vasculitis 
mumps, CMV, EBV, HIV, varicella
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15
Q

What toxins can cause acute pancreatitis

A

Alcohol*

Thiazide diuretics , Estrogen, sulfonamides, Salicylates, Valproic acid, 6-MP, anti-HIV meds, Scorpion venom

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16
Q

How does acute pancreatitis present (oldcarts)

A 
O: acute, after eating meal 
L: midepigastric radiating to back 
D: constant 
C: steady, boring 
A: lying supine worsens Sx 
R: sitting and leaning forward makes it better 
Sx: anorexia, n/v, abdominal distention
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17
Q

Clinically how does acute pancreatitis present

A 
fever, tachy/tachy, +/- hypotension 
Jaundice 2/2 biliary obstruction 
Hypoactive/absent bowel sounds 
Significant midepigastric ttp w/ or w/o guarding/rebound 
Cullen's sign: periumbilical ecchymosis 
Grey-turner sign: flank ecchymosis
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18
Q

Lab workup for acute abdominal pain should always include

A

Amylase and Lipase!!

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19
Q

Diagnostics for acute pancreatitis will show

A

Elevated: amylase, lipase, WBC, HCT, Creatinine, Glucose (mild), LFT (transient)
Decreased: Calcium, O2 (on ABG)

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20
Q

What LFT’s strongly suggest acute pancreatitis

A

ALT >150 gallstone pancreatitis

High bilirubin: gallstone pancreatitis

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21
Q

What radiographs get you get to find acute pancreatitis

A

XR: normal vs ileus
CT: pancreatic edema, calcifications, pseudocysts, necrosis, abscess
MRCP
*Endoscopic US: best test, highest sensitivity

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22
Q

What are XR beneficial for in acute pancreatitis

A

CXR: R/o pulmonary infiltrates or pleural effusions!

Abd XR is likely to r/o obstruction (stones), ileus (sentinel loop), or perforation

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23
Q

CT abdomen is used for

A

Diagnosis, showing enlargement of pancreas, blurring of fat planes/fat stranding
ID severity of disease
ID complications (necrosis, pseudocysts, abscess, hemorrhage)

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24
Q

Why are MRI/MRCP better than CT

A

Lower risk nephrotoxicity
Increased characterization of fluid collections, necrosis, abscess, and pseudocysts
Better view of biliary and pancreatic ducts (good if you can’t see CBD stone on CT/US and you expect biliary pancreatitis)

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25
What are indications for an ERCP
Visualize biliary and pancreatic duct anatomy Obtain cytology or biopsy Therapeutic (stone removal, stent insertion, sphincterotomy)
26
On ERCP you may visualize
CBD stricture w/ dilation of hepatic ducts | Extrahepatic biliary obstruction
27
What are MCC of extrahepatic biliary obstruction
Gallstones Pancreatitis Pancreatic cancer
28
How do you manage acute pancreatitis
Admit Tx underlying cause NPO (may provide enteral or parenteral depending on length of NPO)- advance diet when no longer need IV narcotics IVF** Meperidine for pain control (demerol) If infected necrosis is a concern, give Abx (Imipenem*)
29
Sx of early complications are
Decreased UO, rising creatinine Respiratory failure Worsening pain, fever or leukocytosis (so monitor labs closely!!)
30
Local complications of acute pancreatitis are
Pseudocyst: fluid/debris collection w/ fibrotic wall- no epithelial lining Abscess: Infected pseudocyst/necrotic area (fever, highWBC, Sx worsening) Necrosis: non-viable tissue Hemorrhage Ascites (from leaking duct or pseudocyst)
31
What are Sx of pancreatic pseudocyst
Abdominal pain early satiety N/V
32
What can happen to a pseudocyst and how do you treat
Can spontaneously resolve or rupture Can be complicated by rupture, hemorrhage, or infection Surgery vs drainage to Tx, bases on Sx or infection
33
What are systemic complications of acute pancreatitis
``` Respiratory failure/ARDS pulmonary edema pleural effusions atelectasis Renal failure Hypotension/shock Ileus Hyperglycemia hypocalcemia ```
34
What is Ranson's criteria
Method used to predict mortality from acute pancreatitis, not diagnose 0-2: <1% mortality 3-4: 15% mortality 5-6: 40% mortality 7-8: 100% mortality Overall mortality is 10-15% for acute pancreatitis
35
Initial signs on Ranson's criteria are
``` 55+ y/o WBC >16K Glucose >200 AST >250 LDH >350 ```
36
Delayed signs on Ranson's criteria are
``` HCT drop >10% BUN increase >5mg Calcium <8mg pO2 <60 Sr Albumin <3.2 Fluid sequestration 4-5L ```
37
How can you prevent acute pancreatitis recurrence
Do ERCP if there is a CBD stone elective cholecystectomy is biliary pancreatitis Alcoholic pancreatitis: no alcohol high TG: diet modify and lipid lowering meds Drug induced: remove offending drug
38
What is chronic pancreatitis
repeat episodes of acute inflammation leading to permanent structural damage and ductal obstruction Gradual loss= Exo and Endocrine insufficiency
39
What causes chronic pancreatitis
``` MC: Alcohol** Repeat episodes of acute pancreatitis Cystic fibrosis Hereditary Idiopathic ```
40
What are Sx of chronic pancreatitis
*Epigastric pain Early: similar to acute pancreatitis Late: becomes continuous Aggravators: alcohol, largely fatty meals
41
What does Exocrine insufficiency lead to
malabsorption; Steatorrhea (greasy, foul smelling stool 2/2 high excretion of fecal fat Weight loss: fear of eating and malabsorption
42
What does endocrine insufficiency lead to
Diabetes; Polyuria, phagia, etc. Insulin dependence Brittle DM (alpha and beta cells affected)
43
What is the chronic pancreatitis Classic Triad*
Diabetes (late) Steatorrhea Pancreatic calcifications
44
Diagnostics for chronic pancreatitis show
Slightly increased (or normal): amylase/Lipase Mild elevation: Bilirubin and Alk Phos High glucose
45
What tests can you run for chronic pancreatitis
Secretin stimulation test (abn if 60% of exocrine Fxn lost)- expensive, not really used Fecal fat test (72 hour quantitative fecal fat)
46
Plain films for chronic may show
Scattered calcifications
47
CT for chronic pancreatitis may show
Calcifications Ductal dilation Pseudocysts
48
MCRP for chronic may show
Pancreatic and biliary ducts | Used more and more for evaluating and diagnosing
49
ERCP for chronic may show
Chain of lakes It is the gold standard but very invasive Can use the esophageal US for similar results and less risk of pancreatitis
50
How do you manage chronic pancreatitis
Behavior modify: No alcohol or high fat foods Early ID of complications is key Manage diabetes Treat malabsorption w/ pancreatic enzyme supplements
51
Pain relief for chronic pancreatitis can be achieved by
Pancreatic enzyme supplements (try 1st) Amitriptyline or SSRI Narcotics (long acting preferred- Contin or Fentanyl patch) Endoscopic procedure (ductal dilation, stenting) Nerve block (celiac plexus w/ ethanol or steroids) Lithotripsy (not good evidence) Surgical resection (if CA suspected or when other Tx fail)
52
What is the pathology of pancreatic carcinoma
Most are adenocarcinoma* 15% of cysts are neoplasms Refer ALL patients w/ a pancreatic lesion to GI surgery
53
RF for pancreatic carcinoma are
Male African American Age >45 Smoking, Alcohol, Chronic pancreatitis, diabetes, obesity, FHx
54
How does pancreatic carcinoma present
``` Vague, non-specific Bloating Abdominal pain (MC Sx) Gnawing epigastric pain radiating to back early satiety weight loss Painless jaundice** Pruritis, alcoholic stools (pale), dark urine Acute pancreatitis Steatorrhea ```
55
THIS is pancreatic cancer until proven otherwise
Painless jaundice
56
PE findings for pancreatic cancer are
Cachectic Jaundice Icterus (eyes) Virchow's node (left supraclavicular LAD) Ascites Courvoisier's sign (palpable non-ttp gallbladder)
57
Lab studies for pancreatic cancer are
Elevated bilirubin and Alk Phos (esp. obstructive jaundice) Mild increase in amylase and lipase Mild anemia Glucose intolerance CA 19-9 (tumor marker, will be elevated relative to tumor size)
58
How do you diagnose pancreatic cancer
US: dilated CBD, pancreatic head mass CT/helical CT: test of choice for staging disease and to ID eligibility for resection MRCP: as sensitive as ERCP but w/o complication risk. Can't get tissue sample ERCP: double duct sign (stricture of CBD and pancreatic ducts), can get tissue Bx Endo US: eval local tumor/vascular involvement, beft for FNA biopsy
59
How do you treat pancreatic carcinoma
Whipple! resection is the only potential cure
60
Palliation of Sx of pancreatic carcinoma are
``` Biliary obstruction (pruritis and biliary stent) Weight loss (cachexia, exocrine insufficiency) Pain (narcotics, chemo vs radiation ```
61
What is the prognosis of pancreatic cancer
Poor- 5% five year survival Better if lesion is resectable (will need chemo and radiation) Unresectable lesion: 8-12 months if locally invasive, 3-6 months if metastatic

Summer FDTN Exam 5 (12 decks)

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