The pancreas is an endocrine gland producing: 3
Also functions as an exocrine gland secreting what?
It secretes approximately ____ liters of enzyme-rich fluid every day for the digestion of fats, starch, and protein.
digestive enzymes via a duct.
1. Secretin- released from the duodenal mucosa in response to what?
2. What does it stimulates? 2
1. the presence of acid in the duodenum.
2. stimulates the release of
1. Cholecystokinin (CCK)- released from SI endocrine cells in response to what?
2. acts directly and through vagal afferents to stimulate pancreatic acinar cells to release what?
1. the entry of fats and proteins into the proximal intestine.
2. digestive proenzymes.
Acute pancreatitis is an acute inflammatory process of the pancreas. Etiologies? 5
1. Gallstones are more common in who?
2. Alcohol are more common in who?
1. Gallstones more common cause in women
2. Alcohol more common cause in men
If 2nd attack and not one of main 2 causes then look for the less common causes such as? 6
3. biliary sludge
6. missed stone in duct,
Acute onset clinical manifestations? 5
What can this progress to? 2
1. persistent, severe epigastric pain
2. or RUQ pain may be steady or colicky
3. N/ V
4. 50% experience band like radiation of pain to back;
5. some may get relief w/ bending forward or sitting up.
Acute pancreatitis 5-10% of patients may have painless disease and have what?
Physical exam of acute pancreatitis? 5
1. Fever, tachycardia, (hypotension if severe)
2. Epigastric/RUQ tenderness
3. Shallow respirations- pain with deep breaths
4. Possible dyspnea if pleural effusion
5. Epigastric mass if pseudocyst or tumor.
In 3% of pts, ecchymotic discoloration may be observed in the periumbilical region (Cullen’s sign) or along the flank (Grey-Turner's sign).
1. ecchymotic discoloration may be observed in the periumbilical region. What sign is this?
2. Along the flank. What sign is this?
1. Cullen's sign
2. Grey-Turner's sign
Lab Tests for Acute Pancreatitis?
1. Serum Amylase
2. Serum Lipase
3. C reactive protein
1. Rises how?
2. Elevated for how many days?
1. Describe sensitivity and specificity compare to amylase
2. Describe its elevation and how long it lasts?
3. If ____x nl think pancreatitis.
1. rises quickly (6 to 12 hrs)
2. elevated for 3-5 days
1. sensitivity 82-100%, more specific than amylase
2. elevations occur earlier and last longer
3. If 3-4x nl think pancreatitis.
C reactive protein levels
1. Levels at what and how long after presentation can predict a more severe course?
2. So what do we use this to differentiate?
1. levels above 150 mg/dL at 48 hrs after pt presents can predict more severe course.
2. Used to differentiate severe from mild disease
Imaging for Pancreatitis?
Abdominal plain film
1. What does abdominal plain film help us with on pancreatitis? 2
2. What percent of pts with pancreatitis have abnormal findings on CXR?
3. What are these? 3
-helps to exclude other causes of abdominal pain
-may have localized ileus 2ndry to inflammation
2. CXR: 1/3 of pts w/ pancreatitis have abnormal findings:
-Elevation of hemidiaphragm
What is the most important test for diagnosis acute pancreatitis & intraabdominal complications and assessment of severity?
1. What would the US show?
MRI for pancreatitis
1. Describe its sensitivty compared to CT?
2. Advantages? 3
1. Higher sensitivity for the diagnosis of early acute pancreatitis than CT scan.
-Lack of nephrotoxicity
-Ability of MRI to better detect fluid collections, necrosis, hemorrhage and pseudocyst
-MRCP better shows the pancreatic and bile ducts
What does this CT show?
Treatment of pancreatitis?
1. Admit to hospital with acute pancreatitis
3. IV hydration with crystalloids to keep UO>30ml/hr (lactated ringers except in hypercalcemia)
4. Pain control (morphine, fentanyl, ketorolac)
5. Ondansetron (zofran), or Promethazine (Phenergan) prn nausea
6. +/- antibiotics,
7. +/- surgery (cholecystectomy, necrosectomy- severe dz)
What labs would we do for Pancreatitis?
6. C-reactive protein in 48 hrs,
1. Complications with what can develop? 4
2. Treatment? 3
1. Complications w/
-hepatobiliary dysfx can occur
-ICU monitoring and supplemental O2
-Prevent infection w/ broad spectrum antibiotics
-Nutrition preferably enteral- Tube feeding
Risk Factors for Disease Severity
1. Age > 55 yrs
2. Obesity—BMI > 30 kg/m2
3. Organ failure at admission
4. Pleural effusion or pulmonary infiltrate
5. Elevated C-reactive protein
What is Chronic Pancreatitis?
Progressive inflammatory changes result in permanent structural damage to the pancreas, leading to impairment of exocrine & endocrine function
Etiologies of chronic pancreatitis?
1. Alcohol abuse (75%)
2. Genetic: cystic fibrosis, hereditary pancreatitis
3. Ductal obstruction: trauma, pseudocysts, stones, tumors
4. Systemic: SLE, hypertriglyceridemia
Acute vs. Chronic
1. Acute is usually _________?
2. Reccurrent acute leads to what?
3. Symtpoms of chronic?
4. Serum Amylase and Lipase in Chronic?
1. Acute is usually nonprogressive
2. Recurrent episodes of acute lead to chronic over time
3. Chronic may be asymptomatic over long periods of time
4. Serum amylase and lipase concentrations tend to be normal in chronic
1. Cardinal feature of Chronic pancreatitis?
2. Other clinical manifestations of chronic pancreatitis? 3
1. Chronic abdominal pain—cardinal feature although 20% may have little to no pain
Describe why the following happen:
1. Pancreatic insufficiency?
2. Fat malabsorption?
3. Pancreatic diabetes?
1. Pancreatic insufficiency—exocrine dysfunction cannot digest complex foods or absorb digestive breakdown products, wt. loss: 90% of pancreatic function has to be lost for this to occur
2. Fat malabsorption (steatorrhea)--lipolytic activity decreases faster then proteolysis: malabsorption of fat sol-uble vitamins (A, D, E, K)
3. Pancreatic diabetes —DM late in course of disease, seen pts w/ calcifying disease.
1. Why are amylase and lipase usually normal?
2. What is the diagnostic gold standard test?
3. What test is performed at specialized centers?
1. amylase and lipase usually normal because pancreas fibrotic resulting in decreased abundance of these enzymes within the pancreas
2. Steatorrhea: 72-hour quantitative fecal fat determination is the gold standard, excretion > 7g fat day; pts w/ steatorrhea usually > 10g q day
3. Direct pancreatic function tests: performed via specialized centers
Chronic Pancreatitis Imaging?
1. Calcifications on plain films
1. CT/MRI/US may show what? 3
2. ERCP can reveal what?
-enlargement of pancreas,
-can reveal changes in the ducts
What does this CT show?
1. Inflammatory mass at head of pancreas
3. Low attenuation areas of necrosis
Treatment of Chronic Pancreatitis
1. Establish Dx
2. Pain management and control N/V
Whats on our differential for chronic pancreatitis?
2. biliary obstruction,
3. pancreatic cancer,
4. pancreatic duct strictures or stones
How would we manage pain management and control N/V?
2. low dose amitriptyline,
Diet changes for chronic pancreatitis?
1. cessation of alcohol and smoking;
2. small low fat meals
3. with pancreatic enzyme supplements and
4. acid suppression (H2 blockers or PPIs) to reduce inactivation of enzymes from gastric acid
1. Who is surgery for in pts with pancreatitis?
2. What kinds? 3
1. for those who fail medical therapy, for pain relief—
-decompression of main pancreatic duct/psuedocyst,
-resection of part of the pancreas,
1. Why does pancreatic cancer have a poor diagnosis?
2. Risk factors? 4
3. 85% of all pancreatic cancers are what?
1. Poor prognosis because of late presentation
2. Risk factors:
3. Ductal adenocarcinoma
85% of all pancreatic cancers
Clinical features of pancreatic cancer? 3
1. +/- pain,
2. weight loss,
Painless jaundice w/ wt. loss***
Tumors in body or tail present w/ what? 2
Tumors of the head present w/ what? 3
1. Pain and weight loss
2. weight loss, steatorrhea, jaundice
PE of pancreatic cancer will show what?
1. abdominal mass/ascites 20% pts,
2. L supraclavicular node (Virchow's node)
3. palpable periumbilical mass (Sister Mary Joseph’s node)
Workup for chronic pancreatitis:
1. Imaging? What would it show? 3
2. Labs? What would they show? 3
3. Serum tumor marker? 1
1. Imaging: US/CT shows pancreatic mass, dilated bile ducts, liver mets
Labs: LFT’s show elevated bilirubin, alk phos, aminotransferases normal or slightly elevated
Serum tumor maker:
CA 19-9 closely related to tumor size
1. CA 19-9 can be elevated also in who?
2. Serial monitoring can assess what?
1. Can be elevated in pts w/ benign pancreaticobiliary disorders
2. Serial monitoring can assess the response to treatment
Diagnosis of Pancreatic cancer?
FNA, via ERCP, or during surgery
Treatment of Pancreatic Cancer
1. surgical resection is preferred tx****
2. +/- radiation therapy or chemotherapy
3. Usually unresectable if involves vascular structures
4. endoscopic stent insertion or palliative surgery
5. Pain control and pancreatic enzyme replacement
1. Treatment of stage I and II pancreatic cancer? and Prognosis?
2. Treatment for stage III? and prognoiss?
3. Stage IV prognosis?
1. Resectable disease (stage I, II): 15-20% of pts have resectable disease at time of dx, median survival rate 15-20 mos, 5-year survival rate is 20%.
2. Unresectable locally advanced (stage III): 30% present in stage III, chemotherapy with or w/o radiation gives modest improvement in survival and palliation.
3. Mets (stage IV): 50% have limited survival of 3-6 months.