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Pancreas Dz Flashcards

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1
Q

This is the acute inflammatory process of the pancrease with variable involvement of regional tissues or remote organ systems.

A

Pancreatitis

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2
Q

This is the acute inflammatory process of the pancrease with variable involvement of regional tissues or remote organ systems.

A

Pancreatitis

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3
Q

What is diagnostic criteria for Pancreatitis?

A
  1. Symptoms like epigastric pain consistent with the dz
  2. Serum Amylase or lipase greater than 3x the upper limit of normal
  3. Imaging: CT or MRI

**Need two of the three to dx

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4
Q

This type of pancreatitis involved no organ failure.

A

Mild Pancreatitis

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5
Q

This type of pancreatitis involves persistent organ failure. (Shock, Pulm insufficiency, Renal Failure, GI bleed)

A

Severe Pancreatitis

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6
Q

This type of pancreatitis involved transient organ failure or local complications.

A

Moderate Pancreatitis

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7
Q

What are local complications of pancreatitis?

A
  1. Necrosis
  2. Abscess
  3. Pseudocyst
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8
Q

This stage of pancreatitis involves a protracted course related to necrosis (organ failure infected necrosis and/or complications from surgery.

A

Stage 2

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9
Q

This stage of pancreatitis involved inflammatory cascade lasting a week. Severeity related to extra-pancreatic organ failure related to SIS infection is uncommon.

This can lead to resolution, fluid collection, ischemia (and therefore necrosis)

A

Stage 1

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10
Q

What is the most important enzyme/molecule involved in pancreatitis?

A

Trypsin

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11
Q

What can cause pancreatic injury?

A
  1. Alcohol
  2. Gallstones
  3. Release of Active Enzymes
  4. Other
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12
Q

Pancreatic Injury can cause Multiple Organ Failure by what methods?

A
  1. Granulocyte and Macrophage Activation
  2. Degradative Enzymes
  3. Activation of Proteotype Cascades in Blood
  4. Endothelial Damage
  5. Circulatory Effects

***Important to note that it’s pretty circular, when one thing happens it can cause other things to happen which will worsen the pancreas and other organs.

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13
Q

What are some predisposing factors for Pancreatitis?

A
  1. Obstruction (gall stones, tumors, diverticula, annular pancreas, choledochocele)
  2. Alcohol/Toxins/Drugs
  3. Metabolic: hypercalcemia or triglycerides
  4. Trauma
  5. Infections
  6. Vascular
  7. Post ERCP
  8. Pancreaticobiliary tract dz
  9. Familial Pancreatitis
  10. Idiopathic
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14
Q

Important drugs to know that can cause Pancreatitis!

A
  1. Azathioprine/6-MP
  2. Vaproic Acid
  3. Pentamidine/Didanosine
  4. Estrogen
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15
Q

What is the big difference between the anatomy of a normal pancreas and pancreas divisum?

A

The dorsal and ventral duct in the normal pancrease fork off of a main vessel, whereas the pancreas divisum’s ventral duct is not clearly demarcated/connected

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16
Q

What are the clinical features of Pancreatitis?

A
  1. Abdominal pain, nausea, vomiting
  2. SIRS
  3. Tenderness, guarding, occasionally rigidity
  4. Palpable mass eg pseudocyst
  5. Cullens, Grey Turner sign
  6. Signs of other organ failure
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17
Q

How do you evaluate a patient with suspected pancreatitis?

A
  1. Take a careful history
  2. Physical Exam
  3. Labs: Chemistries, CBC, BMP, TG
  4. Imaging: XRay, US, CT/MRI
  5. Endoscopic US: Preferably after a month or so
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18
Q

In a patient with pancreatitis, what levels of amylase and lipase should we see in the serum?

A

Elevated!!!

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19
Q

Evaluation of Acute Pancreatitis

A

Factor Scoring Systems:

  1. Ranson
  2. Glasgow
  3. APACHE II
  4. BISAP (BUN, Impaired MS, SIRS, Age, Pleural Effusion)
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20
Q

How do you treat Acute Pancreatitis?

A
  1. Put pancreas at rest
  2. Aggressive Fluid Resuscitation (Cr, HCT, BUN)
  3. Relieve Pain
  4. Abx – Not initially
  5. Nutrition (not they may not be able to eat, so you will want to do an enteral or IV feed ASAP)
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21
Q

What factors would indicate a bad prognosis for acute pancreatitis?

A
  1. Hypotension
  2. Respiratory Failure
  3. Hypocalcemia
  4. Need for massive fluid and colloid replacement
  5. Elevated serum LDH or CRP
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22
Q

When is an Endoscopic Retrograde Cholangiopancreatography definitely beneficial?

A
  1. Cholangitis

2. Visualized Stone in the CBD

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23
Q

When is an Endoscopic Retrograde Cholangiopancreatography not beneficial?

A
  1. Mild Dz
  2. Resolved
  3. Routine pre CCY (Cholecystectomy)
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24
Q

When is an Endoscopic Retrograde Cholangiopancreatography possibly beneficial?

A

Severe pancreatitis, high suspicious of stone

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25
T/F: ERCP can induce acute pancreatitis
True! 5-8%
26
What is the role of imaging in a patient with suspected acute pancreatitis?
1. Confirm dx 2. Grade severity 3. Exclude other intraabdominal process 4. Dx local complications such as necrosis, abscess, or pseudocyst
27
4 types of fluid collections in the pancreas
1. Acute Fluid Collections 2. Pseudocysts 3. Pancreatic Necrosis 4. Pancreatic Abscess
28
What is the most common cause of Chronic Pancreatitis?
Alcohol
29
What are other factors that can cause chronic pancreatitis?
1. Calcific Pancreatitis of the tropics 2. Hereditary 3. Hyperparathyroidism 4. CF 5. Pancrease Divisum 6. Misc.
30
What are two ways to classify chronic pancreatitis?
1. Big Duct | 2. Small Duct
31
Big Duct chronic pancreatitis is most generalize by:
EtOH etiology Common in males Common Exocrine or Endocrine Insuffiency
32
Small Duct chronic pancreatitis is most generalize by:
Idiopathic etiology Common in Females Rare Exocrine or Endocrine Insuffiency
33
Which classification of chronic pancreatitis is more easily diagnosed?
Big Duct
34
What imaging tests can we use to diagnose chronic pancreatitis?
Endoscopic US, ERCP, CT, MRI/MRCP, US, and/or KUB
35
What functional tests can be done to diagnose chronic pancreatitis?
1. Secretin/CCK Test 2. Fecal Elastase 3. Fecal Chymotrypsin 4. Serum trypsin 5. Fecal Fat 6. Serum Glucose
36
What does the secretin test test for? What would these levels look like for a patient with Chronic Pancreatitis?
Measures bicarb secretion by the pancreas. Chronic Pancreatitis: Low Bicarb concentration Carcinoma: High Bicarb concentration
37
How do you treat the pain in chronic pancreatitis?
1. Abstinence 2. Analgesics 3. Medical Therapy -- enzymes, octeotide, antioxidants 4. Endoscopic Therapy 5. Neurolysis 6. Sx (Drainage or resection)
38
_____% of patients with painful small duct chronic pancreatitis (44%) had concomitant gastroparesis.
44
39
What is diagnostic criteria for Pancreatitis?
1. Symptoms like epigastric pain consistent with the dz 2. Serum Amylase or lipase greater than 3x the upper limit of normal 3. Imaging: CT or MRI **Need two of the three to dx
40
This type of pancreatitis involved no organ failure.
Mild Pancreatitis
41
This type of pancreatitis involves persistent organ failure. (Shock, Pulm insufficiency, Renal Failure, GI bleed)
Severe Pancreatitis
42
This type of pancreatitis involved transient organ failure or local complications.
Moderate Pancreatitis
43
What are local complications of pancreatitis?
1. Necrosis 2. Abscess 3. Pseudocyst
44
This stage of pancreatitis involves a protracted course related to necrosis (organ failure infected necrosis and/or complications from surgery.
Stage 2
45
This stage of pancreatitis involved inflammatory cascade lasting a week. Severeity related to extra-pancreatic organ failure related to SIS infection is uncommon. This can lead to resolution, fluid collection, ischemia (and therefore necrosis)
Stage 1
46
What is the most important enzyme/molecule involved in pancreatitis?
Trypsin
47
What can cause pancreatic injury?
1. Alcohol 2. Gallstones 3. Release of Active Enzymes 4. Other
48
Pancreatic Injury can cause Multiple Organ Failure by what methods?
1. Granulocyte and Macrophage Activation 2. Degradative Enzymes 3. Activation of Proteotype Cascades in Blood 4. Endothelial Damage 5. Circulatory Effects ***Important to note that it's pretty circular, when one thing happens it can cause other things to happen which will worsen the pancreas and other organs.
49
What are some predisposing factors for Pancreatitis?
1. Obstruction (gall stones, tumors, diverticula, annular pancreas, choledochocele) 2. Alcohol/Toxins/Drugs 3. Metabolic: hypercalcemia or triglycerides 4. Trauma 5. Infections 6. Vascular 7. Post ERCP 8. Pancreaticobiliary tract dz 9. Familial Pancreatitis 10. Idiopathic
50
Important drugs to know that can cause Pancreatitis!
1. Azathioprine/6-MP 2. Vaproic Acid 3. Pentamidine/Didanosine 4. Estrogen
51
What is the big difference between the anatomy of a normal pancreas and pancreas divisum?
The dorsal and ventral duct in the normal pancrease fork off of a main vessel, whereas the pancreas divisum's ventral duct is not clearly demarcated/connected
52
What are the clinical features of Pancreatitis?
1. Abdominal pain, nausea, vomiting 2. SIRS 3. Tenderness, guarding, occasionally rigidity 4. Palpable mass eg pseudocyst 5. Cullens, Grey Turner sign 6. Signs of other organ failure
53
How do you evaluate a patient with suspected pancreatitis?
1. Take a careful history 2. Physical Exam 3. Labs: Chemistries, CBC, BMP, TG 4. Imaging: XRay, US, CT/MRI 5. Endoscopic US: Preferably after a month or so
54
In a patient with pancreatitis, what levels of amylase and lipase should we see in the serum?
Elevated!!!
55
Evaluation of Acute Pancreatitis
Factor Scoring Systems: 1. Ranson 2. Glasgow 3. APACHE II 4. BISAP (BUN, Impaired MS, SIRS, Age, Pleural Effusion)
56
How do you treat Acute Pancreatitis?
1. Put pancreas at rest 2. Aggressive Fluid Resuscitation (Cr, HCT, BUN) 3. Relieve Pain 4. Abx -- Not initially 5. Nutrition (not they may not be able to eat, so you will want to do an enteral or IV feed ASAP)
57
What factors would indicate a bad prognosis for acute pancreatitis?
1. Hypotension 2. Respiratory Failure 3. Hypocalcemia 4. Need for massive fluid and colloid replacement 4. Elevated serum LDH or CRP
58
When is an Endoscopic Retrograde Cholangiopancreatography definitely beneficial?
1. Cholangitis | 2. Visualized Stone in the CBD
59
When is an Endoscopic Retrograde Cholangiopancreatography not beneficial?
1. Mild Dz 2. Resolved 3. Routine pre CCY (Cholecystectomy)
60
When is an Endoscopic Retrograde Cholangiopancreatography possibly beneficial?
Severe pancreatitis, high suspicious of stone
61
T/F: ERCP can induce acute pancreatitis
True! 5-8%
62
What is the role of imaging in a patient with suspected acute pancreatitis?
1. Confirm dx 2. Grade severity 3. Exclude other intraabdominal process 4. Dx local complications such as necrosis, abscess, or pseudocyst
63
4 types of fluid collections in the pancreas
1. Acute Fluid Collections 2. Pseudocysts 3. Pancreatic Necrosis 4. Pancreatic Abscess
64
What is the most common cause of Chronic Pancreatitis?
Alcohol
65
What are other factors that can cause chronic pancreatitis?
1. Calcific Pancreatitis of the tropics 2. Hereditary 3. Hyperparathyroidism 4. CF 5. Pancrease Divisum 6. Misc.
66
What are two ways to classify chronic pancreatitis?
1. Big Duct | 2. Small Duct
67
Big Duct chronic pancreatitis is most generalize by:
EtOH etiology Common in males Common Exocrine or Endocrine Insuffiency
68
Small Duct chronic pancreatitis is most generalize by:
Idiopathic etiology Common in Females Rare Exocrine or Endocrine Insuffiency
69
Which classification of chronic pancreatitis is more easily diagnosed?
Big Duct
70
What imaging tests can we use to diagnose chronic pancreatitis?
Endoscopic US, ERCP, CT, MRI/MRCP, US, and/or KUB
71
What functional tests can be done to diagnose chronic pancreatitis?
1. Secretin/CCK Test 2. Fecal Elastase 3. Fecal Chymotrypsin 4. Serum trypsin 5. Fecal Fat 6. Serum Glucose
72
What does the secretin test test for? What would these levels look like for a patient with Chronic Pancreatitis?
Measures bicarb secretion by the pancreas. Chronic Pancreatitis: Low Bicarb concentration Carcinoma: High Bicarb concentration
73
What causes the pain in chronic pancreatitis?
1. Stenosis of the common bile duct 2. Stenosis of the duodenum 3. Acute Inflammation 4. Neural inflammation 5. Increased pressure in the parenchyma, duct, or pseudocyst
74
How do you treat the pain in chronic pancreatitis?
1. Abstinence 2. Analgesics 3. Medical Therapy -- enzymes, octeotide, antioxidants 4. Endoscopic Therapy 5. Neurolysis 6. Sx (Drainage or resection)
75
_____% of patients with painful small duct chronic pancreatitis (44%) had concomitant gastroparesis.
44
76
T/F: Narcotic therapy will make the severe abdominal pain and delayed gastric emptying assc with Chronic Pancreatitis
True!
77
Endoscopic Therapy (stents?) are most effective in treating what?
Pain Relief (60-80%)
78
What are the risks of stent therapy?
1. Stent occlusion or migration 2. Pancreatitis 3. Ductal and parenchymal changes (about 2/3)
79
This procedure bypasses the duct and creates an anastomosis directly with the duodenum.
Lateral Pancreaticojejunostomy
80
95% of all pancreatic cancers are ________.
Exocrine! (Ductal adenocarcinoma, cystic, acinar cell carcinoma, pseudopapillary, colloid, adenosquamous)
81
The rest of the pancreatic tumors are:
1-2% Endocrine 1% Lymphoma Mets (RCC, Breast, Melanoma) Sarcomas
82
85-90% of all pancreas tumors are __________. Yet ductal cells only 10-15% of gland mass.
Pancreatic Adenocarcinoma
83
Risk Factors for Pancreatic Cancer
1. Black >> White (~2:1) 2. Cationic Trypsinogen: 40% have cancer by 70 yo 3. Rare < 45 yo 4. 7% of Pancreatic Ca = Familial 5. High fat, low fruit/veg diet 6. Smokers
84
How would a patient with pancreatic cancer present?
Pain radiating to the back Weight Loss New onset DM Nausea, Vomiting
85
How do you dx pancreatic cancer?
CT (Pancreas Protocol) Endoscopic US - Biopsy, Staging, CPN/CPB US - Biopsy of Liver Mets ERCP - Not required -- cT better *Avoid ERCP is sx would be performed in 7-10 days
86
In a patient with obstructive jaundice and pancreatic cancer, what are the effects of ERCP?
1. Preoperative biliary drainage (may cause more post-op wound infection, prolongs hospital stay and costs, risks of cholangitis/pancreatitis) 2. Good for Cholangitis, Pruritis, Delay in Sx
87
What is a big issue with pancreatic cancer
Develops late in the course of the dz, usually unresectable.
88
How would you treat pancreatic cancer?
1. Endoscopic: SEMS (duodenal/biliary) 2. Sx: Gastrojejunostomy 3. Jejunal Feeding tube with gastric decompression tube
89
Risk Factors for Pancreatic Cancer
General: Age, males, smoking, obesity Ethnicity: Ashkenazi jewish/ AA descent Family history esp FPC (2 or >2 first degree relatives with PC) Genetic syndromes: FAP/HNPCC/hereditary pancreatitis and breast/ovarian, Peutz-jeghers
90
Tests for Pancreatic Cancer:
Genetics: clusters of PC or other cancers (breast, ovarian, melanoma) Biomarkers: CA19-9 Imaging

Gastroenterology (12 decks)

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