Pancreas I: Acute and Chronic

Question 1

What are the four protective mechanisms of acinar cell?

Answer 1

Inactive proenzymes
membrane enclosed
separate pathways
trypsin inhibitor

Question 2

What are the four signals that act on the acinar cell to trigger zymogen release?

Answer 2

VIP, Secretin, Ach, CCK

Question 3

What is the earliest event in the pathogenesis of acute pancreattisis?

Answer 3

the conversoin of pancreatic zymogens to their active forms within the acinar cell

Question 4

What are the mechanisms of injury in acute pancreatitis?

Answer 4

blockage of secretion
co-localization of ZG and lysosomes
- premature zymogen activation
- autodigestion from within acinar cell

Question 5

Explain the relationship of cytokines and acute pancreatitis?

Answer 5

proteases activate complement, C3A AND C5A recruit pmns and macrophages
inflammatory cells release cytokines (TNFa, IL1 PAF AND NO)
vascular injury and inflammatory responses

Question 6

What are the local effect of acute pancreatitis?

Answer 6

autodigestion of pancreas
pancreatic sweeling (edema)
fat necrosis and hemorrhage

this leads to pain, n/v and abdom and radiating back pain (because retroperitoneal)

Question 7

In acute pancreatitis where is the fat necrosis?

Answer 7

between lobules

Question 8

What is the first radiographic sign of acute pancreatitis?

Answer 8

edema

Question 9

How does the body respond to pancreatitis?

Answer 9

Circulating a1-antitrypsin and a-macroglobulin (binds to circulating trypsin and facilitates monocyte clearnace of macroglobulin-trypsin complexes)

Question 10

What happens in inflammatory failure of containment to severe pancreatitis?

Answer 10

TNFa and IL6 leading to malaise fever and confusion

Question 11

What happens in vascular failure of containment to severe pancreatitis?

Answer 11

kallikrein activation, thrombin activation, elastase chymotrypsin, leading to hypotension, dic hemorrhage

Question 12

What happens in respiratory failure of containment to severe pancreatitis?

Answer 12

phospholipase a2 which degrades surfactant

Question 13

What happens in metabolic failure of containment to severe pancreatitis?

Answer 13

fat saponification leading to hypocalcemia (bad for heart)

Question 14

Describe the pathophysiology of acincar cell injury

Answer 14

insult to pancreas (i.e. etoh, obstruction)
intracellular activation of zymogens
cell necrosis and autodigestion

Question 15

describe pathophy of local inflammatory response

Answer 15

cytokines and chemokines released by acinar cells
inflammatory cells recruited
inflammatory mediators released (tnfa il1)
pancreatic and vascular injury

Question 16

describe pathophys of systemic response

Answer 16

circulating inflammatory mediators

sirs

Question 17

What are clinical causes of acute pancreatitis

Answer 17

gallstones and alcohol

Question 18

what are the main symptoms of acute pancreatitis?

Answer 18

abdominal pain, nausea vomiting

Question 19

How can you dx acute pancreatitis

Answer 19

elevated serum amylase and lipase, inflamed pancreas on ct

Question 20

What are the main causes of pancreatitis?

Answer 20

alcohol or gallstones

Question 21

What do you need to dx acute pancreatitis?

Answer 21

two of three:
abdominal pain, n/v
elevated serum amylase and lipase more than 3x upper limit of normal
ct imaging showing pancreatic inflammation

Question 22

What are risk factors for gallstones?

Answer 22

> 50 female with amylase over 4000, ast over 100, alk phosph over 300

Question 23

What are main predictors of poor outcome from acute pancreatitis?

Answer 23

hematocrit over 44% (from dehydration) bun over 25 mg/dl

Question 24

What is more common: interstitial pancreatitis or necrotizing?

Answer 24

interstitial (85%) with inflammation and edema

Question 25

37 yo wf with etoh prob and abdominal pain with increased amylase and ast and alt. Dilated cbd with no gallstones on CT. Dx?

Answer 25

gallstone pancreatitis because alcohol will not dilate the CBD

Question 26

Chronic Pancreatitis pathophys?

Answer 26

recurrent injury with tissue destruction and fibrosis. ie chronic alcohol ingestion
leads to abnormal secretion then protein plugs and ductal obstruction then to calcifications

Question 27

What are symptoms of chronic pancreatitis?

Answer 27

chronic abdominal pain, diabetes, steatorrhea

Question 28

Chronic pancreatitis is caused by

Answer 28

alcohol!!!!!!!!!!!!!!!80% gallstones don’t cause chronic pancreatitis

Question 29

What happens to stellate cells?

Answer 29

after recurrent bouts of pancreatitis and injury, stellate cells (which normally store vit. d.) become collagen producing cells.

Question 30

What do you see on histology in chronic pancreatitis?

Answer 30

little dark blue dots everywhere (lymphocytes), ducts are present but empty

Question 31

What does the pancreas become after chronic pancreatitsi?

Answer 31

fibroadipose tissue with preservation of islets of langherans

Question 32

why are islets of lagerhans preserved in chronic pancreatitis?

Answer 32

they don’t autodigest because they are endocrine. with severe pancreatitis though, they may be casualties.

Question 33

What are causes of pain in chronic pancreatitis?

Answer 33

increased pressure
biliary strictures and acute focal pancreatitis
and neural inflammation

Question 34

At what point do you see steatorrhea and diabetes in chronic pancre?

Answer 34

end-stage

Question 35

Why does steatorrhea occur in cp?

Answer 35

lipase deficiency

Question 36

Does lipase and proteinase deficiency occur first in cp?

Answer 36

lipase

Question 37

57 yo male adb pain diarrhea and weight loss. CT shows pan calcific and cystic stritures. increased amylase and glucose. next step?

Answer 37

address issues of alcohol ingestion