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Clin Med III, Exam 2 (ASL) > Pancreatic Disease (Lauren 🌭) > Flashcards

Pancreatic Disease (Lauren 🌭) Flashcards

1
Q

What is the difference between the endocrine and exocrine parts of the pancreas?

A

Endocrine- islet of langerhans making glucagon and insulin

Exocrine- Acinar and ductal cells making digestive enzymes

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2
Q

What usually causes acute pancreatitis in men vs women?

A

Men: alcohol

Women: gallstone

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3
Q

What are the TWO MAIN causes of acute pancreatitis?

A

Gallstones (35-40%)

Chronic Alcohol Abuse (25-35%)

Idiopathic

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4
Q

What are all the things that can cause acute pancreatitis that you can remember with the helpful mnemonic “I get smashed?”

A 
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion/snake bites
Hyperlipidemia/Hyeprcalcemia 
ERCP
Drugs

I don’t think she will test on this she just wanted to tell us a stupid mnemonic

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5
Q

What is the pathophysiology of acute pancreatitis?

A
  1. High pancreatic levels of activated trypsin
  2. Pancreatic auto-digestion, injury and inflammation
  3. Inflammation leads to organ injury, organ failure, death, etc
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6
Q

Describe the pain of acute pancreatitis

**

A

Mid epigastric

Radiates to back

Constant

BORING

Gets better with leaning forward, knees flexed and sitting

Gets worse with lying down, food, alcohol
****

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7
Q

Other than abdominal pain, what else may a patient with acute pancreatitis complain of?

A

Nausea/Vomiting

Anorexia

SOB if pleural effusions

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8
Q

What will you find on physical exam of acute pancreatitis?

A

Tachycardia

Tachypnea

Fever

Hypotension

Distentenion/hypoactive bowels if ileus is present

Scleral icterus if choledocholithiasis or edema of pancreatic head

Hepatomegaly if alcohol abuse

Xanthomas if hyperlipidemia

Parotid swelling if mumps

Sometimes Jaundice, pallor, or diaphoresis

(I don’t know if this is important or not I’m so sorry!)

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9
Q

What will you see on physical exam if your patient has Severe Necrotizing Pancreatitis?

A

Cullen’s sign

Grey-turner’s sign

Panniculitis

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10
Q

What is Cullen’s sign?

A

Ecchymosis around the belly button

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11
Q

What is Grey Turners sign?

A

Ecchymosis on the flanks

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12
Q

What is panniculitis?

A

Erythematous nodules in the subcutaneous fat

**

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13
Q

What labs will you order for acute pancreatitis, and what would you find?

A

CBC-elevated WBC

CMP- hypercalcemia, elevated bilirubin

Amylase and Lipase**

CRP will be over 150 @ 48hrs if severe pancreatitis

ALT will be over 150 @ 48hrs if gallstone pancreatitis

Urine trypsinogen-2 dipstick test

Don’t know how important this is

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14
Q

Which is more specific for pancreatic injury: Amylase or Lipase

A

Lipase

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15
Q

In acute pancreatitis, Amylase rises in _______ hrs, peaks in ____ hrs and normalizes in _________days

A

Rises in 6-12 hrs

Peaks in 48 hrs

Normalizes in 3-5 days

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16
Q

In acute pancreatitis, Lipase rises in ______ hrs, peaks at _____ hrs, and normalizes in _________ days

A

Rises in 4-8 hours

Peaks at 24 hours

Normalizes in 8-14 days

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17
Q

When would you do genetic testing for pancreatitis?

A

If there is a strong family history of pancreatitis

Under age 35 at onset

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18
Q

All patients having genetic testing should have __________ ________ before and after!

A

Genetic counseling

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19
Q

What will you see on X-ray if your patient has acute pancreatitis?

A

Sentinel Loop (small bowel inflammation and air from an ileus?)

Gallstones
**THIS SLIDE HAD A STAR ON IT**

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20
Q

If you suspect pancreatitis, what imaging should you do?

A

Ultrasound

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21
Q

If your patient has unexplained acute pancreatitis, and there is a risk for malignancy, what imaging should you do?

A

Abdominal CT w IV Contrast-“pancreas protocol”

MRI with MRCP

Endoscopic Ultrasound

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22
Q

What imaging should be done for recurrent pancreatitis?

A

Consider endoscopic ultrasound

And/or

ERCP

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23
Q

What imaging would you use to identify the severity of pancreatitis, as well as any complications like necrosis, psuedocysts, abscess, and hemorrhage?

A

Abdominal CT

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24
Q

For patient who tick all the boxes for acute pancreatitis on exam and labs, what kind of imaging should you NOT DO early on?

A

CT!!!

Why: CT is to look for complications of acute pancreatitis, which don’t even show up for 3 days. Besides, most cases are uncomplicated anyways. Also IV contrast might worsen their condition.

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25
Q

What does MRCP stand for?

A

Magnetic Resonance Cholangiopancreatography

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26
Q

What are the advantages of MRCP over CT?

A

Not as bad for kidneys

Easier to see fluid collections, necrosis, abscesses, and pseudocysts

Better view of biliary and pancreatic ducts

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27
Q

What structures can you visualize with ERCP?

A

Biliary ducts

Pancreatic ducts

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28
Q

Other than visualization, what else can ERCP do?

A

Biopsies

Stone removal

Stent insertion

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29
Q

If you do an endoscopic ultrasound, and it is abnormal, what should you do next?

A

“Consider ERCP”

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30
Q

What are the DIagnoitic Criteria for acute pancreatitis?

****

A

Requires 2 of the following:

  1. ) acute persistent, severe, epigastric pain that often radiates to back
  2. ) Elevated serum lipase or amylase to 3x normal
  3. ) Consistent imaging findings on CT w contrast, MRI, or US (don’t need imaging if first 2 criteria are met)
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31
Q

Almost all acute pancreatitis are treated (inpatient/outpatient)

A

Inpatient

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32
Q

How do you treat acute pancreatitis?

A

Aggressive hydration

NPO- just until pain and N/V is controlled

Pain control-opioids

Antiemetic

Antibiotics if you think its infective necrosis (Imipenim has good pancreas penetration)

Early identification of complications

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33
Q

What are some possible complications of acute pancreatitis?

A

Peripancreatic fluid collection

Pancreatic pseudocyst

Necrosis

Gastric Outlet dysfunction

Splenic and portal vein thrombosis

SIRS (systemic inflammatory response syndrome)

Organ failure (heart, lungs kidney)

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34
Q

What is a pancreatic pseudocyst?

A

A collection of fluid walled off by inflammatory cells that presents as a palpable mass in the mid-epigastric area.
Happens to 10% of patients with acute pancreatitis.
May spontaneously resolve or continue to enlarge.
If it becomes symptomatic or infected, you need to drain it or do surgery.

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35
Q

What are the two classifications of acute pancreatitis?

A

Interstitial edematous acute pancreatitis (inflammation without necrosis)

Necrotizing acute pancreatitis

36
Q

What are some of the scoring systems used to predict the severity of acute pancreatitis?

A

Ranson Criteria

APACHE Score

37
Q

What are some things that might be present within 72 hours of acute pancreatitis onset that would make you suspect that there are complications going on, and you should do a CT?

A

Persistent or recurrent abdominal pain

Increase in pancreatic enzyme level after initial decrease

New or worsening organ dysfunction

Sepsis

(IDK WTF is going on on slide 49, but this is my best interpretation of it)

38
Q

What things must be present for your acute pancreatitis to be classified as “Severe”

A

1 local complication

1 systemic complication (SIRS)

39
Q

What finding at initial assessment of acute pancreatitis are associated with severe disease?

A

> 55 yrs of age

Obesity

Aletered mental status

NUB>20 or rising

Hematocrit >44% or rising

X ray: extrapancreatic fluid collections, pleural effusions, pulmonary infiltrates

I have no idea if this is important or not

40
Q

What usually kills people with acute pancreatitis in the FIRST 2 weeks?

A

SIRS/organ failure

41
Q

What usually kills people with acute pancreatitis AFTER 2 weeks?

A

Sepsis

42
Q

How do you prevent recurrence of acute pancreatitis?

A

Treat whatever caused it 😑

Gallstone pancreatitis: ERCP or cholecystectomy

Alcoholic pancreatitis: stop drinking

Hypertriglyerides: diet and lipid meds

Drug induced: discontinue offending med lol

43
Q

You have a 40 yr old female who presents with severe, persistent, boring, epigastric pain that radiates to her back. It started after eating pizza. She feels better when sitting leaning forward. She has had N/V and is running a fever.
What would we expect to find when reviewing her lipase?

A

Over 3x normal.

Acute pancreatitis

44
Q

You have a 40 yr old female who presents with severe, persistent, boring, epigastric pain that radiates to her back. It started after eating pizza. She feels better when sitting leaning forward. She has had N/V and is running a fever. Her lipase is 3x normal.
Do we need to do an abdominal CT to diagnose her with acute pancreatitis?

A

No

*****

45
Q

What is this:

Progressive, fibrotic, inflammatory changes that cause long term structural damage to the pancreas

A

Chronic pancreatitis

46
Q

What causes Chronic pancreatitis?

A

Repeated episodes of acute inflammation

47
Q

Which has higher mortality: acute pancreatitis or Chronic pancreatitis

A

Acute

48
Q

What happens to the functions of the pancreas with Chronic pancreatitis?

A

Exocrine insufficiency

Endocrine insufficiency

49
Q

What are the results of exocrine insufficiency caused by Chronic pancreatitis?

A

Steatorrhea

Weight loss (fear of eating and malabsorption)

50
Q

What is steatorrhea?

A

Fatty, greasy, foul smelling turds

51
Q

What are the results of endocrine insufficiency as a result of Chronic pancreatitis?

A

DIABETES

usually insulin dependent

52
Q

What is the most common cause of Chronic pancreatitis?

A

Alcohol induced

🍺🍺🍻🍷🥂🥂🍾🍹🍸🍺🍻🥂🥃🥃

53
Q

What is the CLASSIC TRIAD of Chronic pancreatitis?

A

Diabetes

Steatorrhea

Calcifications

54
Q

What two things aggravate Chronic pancreatitis?

A

Alcohol 🍺

High Fat Meals 🍕

55
Q

What are the 3 possible tests you could do if you suspect your patient has Chronic pancreatitis?

A

Secretin stimulation test (Not used often)

Fecal Fat testing (72hr collection- GOLD STANDARD)

Fecal elastase (Single sample- TEST OF CHOICE)

56
Q

What is the test of choice for steatorrhea/Chronic pancreatitis?

A

Fecal Elastase

(Test of choice becasue it only requires 1 piece of poop.

Fecal Fat testing is the Gold Standard but it requires 72hrs of poop collection)

57
Q

What Chronic pancreatitis can you see on abdominal x ray?

A

Scattered calcifications

***

58
Q

What will you see on Abdominal CT of Chronic pancreatitis?

A

Calcifications

Ductal dilation

Pseudocysts
*******

59
Q

What is the ~Pathognomic~ finding on ERCP of Chronic pancreatitis?

A

Chain-Of-Lakes
***

🗾

60
Q

How do you treat Chronic pancreatitis?

A

Behavior mods- alcohol, low fat meals, stop smoking

Manage diabetes

Pancreatic enzyme supplements for malabsorption

Pain relief- amitriptyline, SSRI, pain management referral

Endoscopic dilation/stunting

Resection

61
Q

Acute, severe, boring, epigastric pain that radiates to the back

A

Acute pancreatitis

62
Q

Pain is worse in supine position and better sitting, leaning forward

A

Acute pancreatitis

63
Q

3 diagnostic criteria for acute pancreatitis, patient only needs to meet 2/3

A

Clinical presentation

Amylase or Lipase 3x normal

Radiographic findings

64
Q

Diabetes

Steatorrhea

Calcifications

A

Classic Triad of chronic pancreatitis

65
Q

What is “chain of lakes”

A

ERCP finding of chronic pancreatitis. Alternating stenosis and dilation of the pancreatic duct

66
Q

Progressive inflammation with long term structural damage leading to pancreatic insufficiency

A

Chronic pancreatitis

67
Q

What is the most common type of pancreatic cancer?

A

Exocrine- 95%

68
Q

85% of all pancreatic tumors are what type?

A

Ductal adenocarcinoma

*******

69
Q

Do most pancreatic cancers involve the head of the pancreas?

A

Yes, 60-70% do. This is good because it is more likely to be palpated

70
Q

How do most patients with pancreatic cancer present?

A

Locally advanced or metastatic disease

71
Q

What are the major risk factors for pancreatic cancer?

A

Smoking

Obese

Sedentary

Chronic pancreatitis

Pancreatic cysts

EtOH

Old

72
Q

What are the top 3 symptoms of pancreatic cancer?

A

Epigastric pain

Jaundice

Weight loss

73
Q

Will you be able to palpate the gallbladder in pancreatic cancer?

A

YES, and it will NOT HURT THEM

Courvoiser sign**

74
Q

A nontender palpable gallbladder is what sign

A

Courvoisier’s sign

75
Q

Courvoiser sign is positive in which type of cancer

A

Pancreatic

76
Q

Will someone with pancreatic cancer be jaundiced with scleral icterus?

A

Yes

77
Q

Can you diagnose a patient with pancreatic cancer based on symptoms alone

A

NO

78
Q

What Labs do you need to order if a patient shows up with jaundice or epigastric pain?

A

Serum aminotransferases (liver stuff)

Alkaline phosphate

Bilirubin

Serum lipase (if epigastric pain- indicates acute pancreatitis)

CA 19-9- tumor marker for pancreatic cancer*****

79
Q

What is the tumor marker in pancreatic cancer?

A

CA 19-9

80
Q

If a pt presents with Jaundice, what imaging do you need to do?

A

Abdominal ultrasound

MRCP and/or ERCP if you suspec choledocholithiasis

81
Q

What imaging do you need to do if your patient shows up with epigastric pain and weight loss, but is not jaundiced?

A

Triple Phase Thin Sliced Enhanced Helical CT of Abdomen with 3D reconstruction 😑 she actually put that

Ultrasound- lacks sensitivity for small tumors, and can’t ID necrosis

(Looking for pancreatic cancer)

82
Q

What is the test of choice for staging pancreatic cancer and determining eligibility for resection?

A

Contrast Enhanced Helical CT

83
Q

What is the only potential cure for pancreatic cancer?

A

Surgical resection (Whipple procedure)

84
Q

What is the Whipple Procedure?

A

Last ditch effort for pancreatic cancer.

Removal of part of stomach, gallbladder, head of pancreas, and 1st part of duodenum

(Probably not on test)

85
Q

How do you manage a patient with pancreatic cancer?

A

Remove any biliary obstructions

If gastric obstruction, decompress stomach

Narcotics for pain

Chemo/Radiation- shrinks tumor, improves pain

86
Q

What two things do you need for diagnosis of pancreatic cancer?

A

Imaging

Histology

87
Q

What is the prognosis for pancreatic cancer?

A

Very poor

Clin Med III, Exam 2 (ASL) (3 decks)

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