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Flashcards in Pancreatic Disorders Deck (25)
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1

Pancreatic Proteases 

  • Zymogens (inactive) when secreted
  • Normal Activation:
    • enter duodenum
    • enteropeptidase activates Trypsinogen to trypsin
    • Trypsin activates all pancreatic proteases
  • Trypsinogen can auto-activate if it remains in duct

2

Pancreatic Lipases

  • do not require activation 
    • requires CoLipase (zymogen) for activity 
  • Normal:
    • Trypsin activates Co-Lipase in duodenum
  • Lipases and co-lipases digest fat of the omentum
    • if in abdominal cavity=not active

3

Pancreatic Insufficiency 

  • symptoms of poor pancreatic function
  • occurs when 90% of function lost
  • Symptoms:
    • Fat malabsorption=steatorrhea (excess fat in stool)
    •  

4

Acute Pancreatitis

  • poor pancreatic function
  • leads to inadequate supply of pancreatic digestive enzymes and bicarbonate

5

AcutePancreatitis: Symptoms

  • Severe pain (slow or sudden) 
    • pain may get worse with eating.
  • Nausea and Vomiting
  • Fever
  • Weight Loss
  • Greasy or oily stools
  • diarrhea (loose stool)
  • Diabetes
  • Jaundice (rare)

6

Acute Pancreatitis: Incidence

  • 18/100,000 in the US
    • but the numbers are rapidly increasing
  • Highest incidence: African americans
  • More common in males than females

7

Acute Pancreatitis: Cause

  • Bile Duct Obstruction-38%
  • Alcohol use-36%
    • females more susceptible
  • Trauma-5%
  • ERCP-5%
    • to remove gallstones
  • Drugs-2%
  • Minor causes (<1%)

8

Acute Pancreatitis: Clinical Presentation

  • Abdominal pain (epigastric)
  • nausea and vomiting
  • Possibe: Tachycardia, tachypnea, dyspnea, fever, confusion, delirium or coma
  • Obstructive jaundice may be present

9

Acute Pancreatitis: Diagnosis

  • Elevated serum amylase/lipase within hours
    • lipase is more specific than amylase
  • Ultrasound for duct obstruction
  • CT for pancreatic necrosis

10

Acute Pancreatitis: Treatment

  • Supportive therapy-control pain and nausea
  • Fluid replacement of peritoneal/pleural losess
  • endoscopic removal of gallstones if needed
    • gallstones usually clear themselves from the duct
    • gallstones in other parts of the billiary tree should be removed prior to patient discharge
      • may involve cholecystectomy (remove gallbladder)
  • Remove necrotic tissue

11

Acute Pancreatitis: Complications

  • Respiratory distress
    • most common
  • Hypotension/shock, renal failure, hyperglycemia, hypertrilyceridemia, pseudocyst formation GI Bleeding

12

Acute Pancreatitis: Prognosis

  • 80% recover within 48hrs
  • 2% mortality
  • morbidity is higher in obstructive conditions

13

Pancreatic Pseudocysts

  • Complications of acute pancreatitis
    • abdominal trauma in children
    • major cause of pancreatic masses
    • major occur in chronic pancreatitis
  • Walls of granulation tissue
    • not epithelial 
  • Formed by lack of drainage
    • form reservoir of:
      • necrotic tissue
      • hemolyzed blood
      • enzymes
      • infection
  • Dectable by most imaging
  • Tx:
    • surgical removal of cyst (common)
    • endoscopically drain (less common)

14

Chronic Pancreatitis: Incidence

  • (1 in16) 300/100,000 clinically; 5% on autopsy
  • 2x higher in males
  • 3x higher in african americans

15

Chronic Pancreatitis: Etiology/causes

  • Alcoholism-60-70%
  • Idiopathic-30%
  • cystic fibrosis phenotypes
    • cause of pancreatitis or pancreatic insufficiency
  • Tobacco use
  • Other causes:
    • progession of acute pancreatitis
    • Chronic obstructive/congenital malformation/autoimmune
    • ischemia, infeciton other herditary causes

16

Chronic Pancreatitis: Clinical Presentation

  • insidious onset
  • presents with moderate to severe abdominal pain 
    • severe pain=Nausea and Vomiting
  • History may include:
    • diabetes mellitus
    • steatorrhea
    • prior abdominal pain
    • acute pancreatitis

17

Chronic Pancreatits: Prognosis

  • High mortality rate=30%

18

Chronic Pancreatits: Complications

  • Progressive pancreatitc insufficiency (100%)
  • Diabetes mellitus
    • 33%
    • occurs later than other complications
  • Risk of pseudocysts (10%)
  • duodenal or duct obstrction: 5-10%
  • Pancreatic cancer-4%

19

Chronic Pancreatitis: Diagnosis

  • Imaging (CT & ECRP)
    • calcification-most easily detected by CT scan
    • ERCP detailed imaging of duct system
    • MRI-some uses
  • Functional Tests:
    • Pancreatic Function test
      • intubate duodenuma and meausre duodenal flow in response to Secretin or enzymes in response to tCCK
    • Endocrine insufficiency
      • blood glucose
    • Exocrine insufficiency:
      • fecal elastase (common)
      • fecal fat (Steatorrhea)
      • Serum Trypsinogen

20

Chronic Pancreatitis: Treatment

  • Modify high risk behaviors
    • alcoholism consult
    • stop smoking
    • pancrease may heal itself if cause is eliminated
  • Pain management
  • Surgery to correct:
    • Pseudocyst
    • Abscess/fistula 
    • Ascites
    • duct or duodenal obstruction
    • hemorrhages or thrombosis

21

Exocrine Pancreas Insufficiency: prevalence

  • 11-12% of 50-75 y.o.

22

Exocrine Pancreatic Insufficinecy: Etiology

  • Chronic or autoimmune pancreatitis
  • Cystic Fibrosis (CFTR gene mutation)
  • Pancreatic Duct obstructions

23

Exocrine Pancreatic Insufficiency: Prognosis

  • Reversible
    • alcoholic
    • duct obstruction
  • Irreversible
    • Cystic fibrosis
    • autoimmune
    • progress to complete pancreatic insufficiency

24

Pancreatic Insufficiency: Tests

  • Blood tests: 
    • Fat soluble vitamines (A, E, D, K)
    • Trypsinogen or other pancreatic zymogens 
  • Fecal tests
    • 72hr fecal fat absorption (not specific)
    • Fecal elastase (most specific)
  • Serum CCK and Secretin Tests
  • Differential tests for intestinal causes of malabsorption
    • D-xylose
      • small intestinal absorption
    • Hydrogen breath
      • intestinal absorption and enteric enzymes
    • Schilling test
      • B12 absorption

25

Pancreatic Insufficiency: Treatment

  • Exocrine insufficiciency:
    • oral pancreatic enzymes products (PEPs)
  • Endocrine:
    • insulin