GI E2- Pancreas

What does the pancreatic duct join the common bile duct to form?

Hepatopancreatic ampulla (of vater)

Where does the hepatopancreatic ampulla of vater empty?

Into duodenum at major duodenal papilla (controlled by sphincter of Oddi)

What cells secrete pancreatic juice?

Acinar cells

What do pancreatic secretions consist of?

Amylase, lipase, deoxyribonuclease & ribonuclease, sodium bicarbonate, & proteases (trypsin, elastase, etc)

What are endocrine functions of the pancreas?

Islets of langerhans which secrete insulin, glucagon, & somatostatin

What are exocrine functions of the pancreas?

Digestive / pro-enzymes (Trypsinogen, chymotrypsinogen) controlled by gastrin, secretin, & CCK

What condition is an acute, reversible pancreatic inflammation with enzymatic release into the parenchyma, which activates enzymes that lead to autodigestion of the pancreas?

Acute pancreatitis

What contributes to injury in acute pancreatitis?

Edema → vascular insufficiency → ischemia

What is the pathogenesis of hereditary pancreatitis?

Genetic mutations create imbalance of proteases & inhibitors → inappropriate activation of pancreatic zymogens → autodigestion & inflammation

What is the “I get smashed” mnemonic for causes of acute pancreatitis?

Idiopathic

Gallstones

Ethanol

Trauma

Steroids

Mumps

Autoimmune

Scorpion sting

Hypercalcemia or Hypertriglyceridemia (serum TG > 1000 mg/dl)

ERCP

Drugs

At what serum TG levels would hypertriglyceridemia associated pancreatitis occur?

≥ 1000 mg/dL

What is the pathogenesis of alcohol induced pancreatitis?

First attack occurs after 8-10 yrs of heavy usage & episodes will continue to occur with continued alcohol abuse

What is the pathogenesis of gallstone induced pancreatitis?

Related to transient or complete obstruction of pancreatic ductal flow or reflux of bile into pancreatic duct (occurs with choledolcolithiasis)

What drugs can cause drug induced pancreatitis?

Cannabis, codeine, enalapril, furosemide, mesalamine, metronidazole, simvastatin, etc

What occurs in 5-7% patients undergoing ERCP?

ERCP induced pancreatitis

The following ssx are associated with what condition?

• Epigastric / LUQ pain that radiates through to the back

  • steady, boring pain, increases in intensity

• often bends forward or pulls knees to chest

• N, V, abd distension, restless

• very tender to palpation

• dec bowel sounds

• +/- fever

Acute pancreatitis

What is Cullen’s sign?

Blue discoloration to umbilicus form retroperitoneal bleeding in pancreatic necrosis

What is Grey Turner’s sign?

Green brown discoloration to flanks seen with severe, necrotizing pancreatitis

The following PE findings can be seen in a patient with what condition?

• anxious, “shocky”, rarely jaundice

• erythematous nodules form fat necrosis

• rales, atelectasis, effusions, diminished/absent bowel sounds

• Cullens sign or grey turners sign (if severe)

Acute pancreatitis

The following labs are likely to be seen in what condition?

• Amylase & lipase elevated >3x upper limit w/in 12 hrs for several days

  • lipase more specific, sensitive, & elevated longer

• hypocalcemia bc necrotic fat binds calcium

• LFTs- ALT > 150 (highly specific for stones)

• possible protein casts in UA

• etc

Acute pancreatitis

What is the preferred lab test for acute pancreatitis because it is most specific, sensitive, & remains elevated the longest?

Lipase

What should you think of with increased ALP & bilirubin?

Biliary disease

What is the gold standard for acute pancreatitis imaging?

CT abd

What is seen on abd flat plate imaging of acute pancreatitis?

Sentinel loop → dilatation of segment of large or small intestine

What criteria aids in predicting the mortality of acute pancreatitis & the severity of pancreatic necrosis, based upon labs at admission and at 48 hrs?

Ranson’s criteria

What is Ranson’s criteria?

Glucose > 200

AST > 250

LDH > 350

Age > 55

WBCs > 16,000

+other factors after 48 hrs; 1 point for each

What is the APACHE II score?

Acute physiology and chronic health evaluation → provides estimate of ICU mortality based on lab values & patient signs beginning w/in first 24 hours of ICU admission

What is replacing Ranson’s & apache score in the evaluation of acute pancreatitis?

Bedside Index of Severity in Acute Pancreatitis (BISAP) → 5 factor scoring system useful w/in first 24 hrs of hospitalization

What is the criteria for BISAP?

Bun > 25 mg/dL

Impaired mental status

SIRS

Age > 60

Pleural effusion

*1 point for each; score of ≥ 3 associated w/ inc mortality & complications

What is the treatment for acute pancreatitis?

NPO, IVF, rest pancreas for 3-7 days, NG tube, analgesics, enteral feeding, pancreatic secretion suppression/enzyme blockage, IV acid blockers, possible ICU admission

What should be started in patients with mild acute pancreatitis once they are off analgesics, has normal bowel sounds, and is hungry?

Clear or full liquid diet

What should patients with gallstone induced pancreatitis undergo during admission to decrease the risk of recurrence?

Laparoscopic cholecystectomy

What causes death in acute pancreatitis?

Resp failure, ARF, intraabdominal abscess, hemorrhage

What complications can be seen with acute pancreatitis?

Pseudocyst, pancreatic ascites, SC fat necrosis

What condition?'

• collection of fluid, tissue & debris within or adjacent to the pancreas (complication of acute pancreatitis)

• frequently opens directly into pancreatic duct

• sx: fever, tachycardia, abd mass, tenderness, infx, rupture, hemorrhage

Pseudocyst

What is the treatment for a pseudocyst caused by acute pancreatitis?

Observation or endoscopic/surgical drainage if sx, rapidly enlarging, or infected

What condition?

• episodes of acute inflammation in already damaged pancreas OR pancreatic damage w/ malabsorption & persistent pain

• destruction of parenchyma leads to fibrosis & calcifications

Chronic pancreatitis

What is the pathogenesis of chronic pancreatitis?

Pancreatic ducts become dilated, irregular or strictured → glandular tissue has irregular areas of patchy replacement of normal acing tissue fibrosis → neuritis & hypertrophy may create associated pain

What are causes of chronic pancreatitis?

Alcohol, idiopathic, genetic, autoimmune (PSC, PBC, T1DM), obstructive / tumors, recurrent (postnecrotic, vascular disorders)

The following sx are seen with what condition?

• Hallmark: abd pain & pancreatic insufficiency

• RUQ, LUQ, epigastric, episodic unrelenting pain that is persistent, deep, & boring to the back

  • worsens w/ alcohol & postprandial

• steatorrhea - indicates fat malabsorption

• metabolic bone disease (low trauma fx)

• DM - late occurence

• wt loss from malabsorption

Chronic pancreatitis

The following diagnostic workup is for what condition?

• plain XRs- calcifications

• abd U/S - low sensitivity

• abd CT & MRI - mainstays

• endoscopic ultrasound (EUS)

• MRCP - chain of lakes (reserved when therapeutic intervention is necessary)

Chronic pancreatitis

What would show on MRCP in a patient with chronic pancreatitis?

Chain of lakes sign - dilatation & tortuosity of the main pancreatic duct

What is the treatment for chronic pancreatitis?

Analgesics, EUS guided celiac plexus block, replace pancreatic enzymes, H2RAs or PPIs (for acid suppression), octreotide, low fat diet, PO hypoglycemics or insulin, cyanocobalamin administration

What complications can occur with chronic pancreatitis?

Pseudocyst, inc risk of pancreatic cancer, obstruction (biliary, ductal, or duodenal), pancreatic ascites, pleural effusion, pancreatic fistulae, narcotic addiction

What is the median age of diagnosis for pancreatic cancer?

60-65 (rare before 45)

Who is pancreatic cancer MC in?

African American males

Pancreatic cancer is linked to a high association with what?

Smoking

What RF are associated with pancreatic cancer?

Smoking, fhx in first degree relative (can be autosomal dominant), long hx of DM & insulin resistance, obesity, high intake of fat and smoked/processed meat, hx of chronic pancreatitis

What are most pancreatic cancers?

ductal adenocarcinomas

What do nearly all pancreatic malignancies develop from?

Exocrine portion of the pancreas

The following sx are seen with what condition?

• insidious vague low intensity & poorly localized epigastric or back pain

  • radiates from epigastrium to back

  • improves w/ bending forward

  • present for several mos prior to dx

• jaundice if tumor is in head of pancreas

  • painless jaundice- obstruction of extra hepatic bile duct

• wt loss, anorexia, weakness

• bloating, constipation, diarrhea

• courvoiseir sign

Pancreatic cancer

What is Courvoisier sign?

Obstructed bile duct is accompanied by a palpable, nontender gallbladder

How would labs appear in pancreatic cancer?

ALP inc 4-5x UNL, mild elevation of LFT, bilirubin inc in late disease, CA19-9 tumor marker

What are diagnostic imaging options for pancreatic cancer?

Transabdominal US, helical CT w/ contrast, endoscopic US, ERCP / MRCP

What is the prognosis of pancreatic cancer?

Poor - most present late in the disease

What is the treatment for pancreatic cancer?

Whipple procedure, chemo & XRT, palliative care