Disorders of the Pancreas

Only the tail of the pancreas is _______, the majority of the pancreas is ______.

tail - intraperitoneal

most pancreas - retroperitoneal

What type of cell releases pancreatic lipase?

Acinar cells

Pancreatitis is often secondary to what 2 causes?

biliary tract disease and alcohol abuse

What are some pancreatic enzymes in body fluids?

lipase and amylase

The function of the ____ is to secrete pancreatic juice - alkaline fluid (pH 8) containing ~20 enzymes)

pancreas

______ is stimulated by acidic chyme; and is released into the blood by duodenal S cells

secretin

____ is stimulated by AAs, peptides, and fatty acids; and is released into the blood by duodenal I-Cells

CCK

The main inhibitor of exocrine secretion is ___

Somatostatin

What are some enzymes secreted by the pancreas?

amylolytic, lipolytic, and proteolytic

What are the 4 factors that prevent autodigestion of the pancreas and loss of any of these functions can lead to:

• Premature enzyme activation

• Autodigestion

• Acute pancreatitis

1. Packaging of pancreatic proteases in proenzyme form

2. Intracellular calcium homeostasis

3. Acid-base balance

4. Synthesis of protective protease inhibitors

Most cases of acute pancreatitis are due to what?

biliary tract disease ( #1 = gallstones) or #2 = heavy EtOH intake

drugs, hypercalcemia, hypertriglyceridemia (3rd MCC), ERCP, dialysis are all other causes of what?

acute pancreatitis

A pt presents with complaints of N/V, fever, pallor, and ABRUPT/severe epigastric abd pain that radiates to the back and gets better when leaning forward. Upon PE there was NO guarding, rigidity or rebound tenderness. There is also absent bowel sounds. Her skin is pale, cool, and clammy. She has a + gray turner sign. Labs show elevated amylase and lipase. ---- what is the likely dx?

acute pancreatitis

What is the sign characterized by a retroperitoneal hemorrhage and is associated with acute pancreatitis?

Gray Turner sign

What is the sign characterized by a intraperitoneal hemorrhage and is associated with acute pancreatitis?

Cullen sign

Amylase or lipase: remains elevated longer and is more accurate for diagnosis?

lipase

ALT >150 suggests what?

biliary pancreatitis

What diagnostic scoring system is used for acute pancreatitis?

Ranson criteria (know at least presentation criteria!)

What two signs will you see on KUB imaging for acute peritonitis?

sentinel loop and colon cut off sign

should you get a CT of the abd with or without for acute pancreatitis?

WITH

What is the diagnostic imaging of choice for acute pancreatits?

CT Abd WITH contrast

What KUB sign when diagnosing acute pancreatitis is defined by a localized ileus (segment of air-filled small intestine) most commonly in the LUQ?

sentinel loop

What KUB sign when diagnosing acute pancreatitis is gas filled segment of transverse colon abruptly ending at the area of pancreatic inflammation?

colon cut off sign

Pancreatic calcifications are sign in what stage of pancreatitis?

chronic pancreatitis

What are some complications acute pancreatitis?

Pre-renal azotemia

ARDS

Pancreatic abscess

Fluid collection/necrosis

Hemorrhage

What is the tx for mild acute pancreatitis?

NPO or clear liquids only, IVF, analgesics (diluadid 1mg q4h IV)

**think NPO, fluids, pain!

**mild dz is more common, subsides in several days

What is the tx for severe acute pancreatitis?

• NPO

• IVF

• ICU monitoring

• Surgical consult

• Hypocalcemia → calcium gluconate

• Coagulopathy or hypoalbuminemia → FFP or serum albumin

• Colloid administration à increased risk of ARDS

• Enteral nutrition vs. parenteral nutrition

• IVF abx

What is the IVF ABX PROPHYLAXIS tx for severe acute pancreatitis?

imipenem or cefuroxime

What is the IVF ABX CONFIRMED INFECTION

tx for severe acute pancreatitis?

imipenem or meropenem

What are the complications of acute pancreatitis and how are you treating them?

• necrotizing pancreatitis → necrosectomy

• abscess → percutaneous or surgical drainage

• pancreatic pseudocyst → monitor or surgical correction

What are the risk factors for chronic pancreatitis?

"TIGAR-O"

Toxic-metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis or obstructive

EtOH

acute vs chronic pancreatitis?

similar to acute, but not as severe and has less hemodynamic issues

A pt presents with complaints of PERSISTENT recurrent episodes of epigastric or LUQ pain, anorexia, N/V/C, WL, and flatulence. She complains of frequent steatorrhea. PE shows tenderness over the pancreas during attacks as well as guarding. ----- what is the likely dx?

chronic pancreatitis

What is a common symptom for chronic pancreatitis?

steatorrhea- bulky, foul, fatty stools may occur late in course (bc they can’t digest fats!)

What are some labs/ diagnostics associated with chronic pancreatitis?

• Amylase and lipase may be elevated during attack however NL values do not exclude diagnosis

• ALP and bilirubin - compression of bile duct

• Glycosuria

• Excess fecal fat

• Secretin stimulation test - pancreatic exocrine insufficiency

• Genetic mutations

• IgG4 levels, ANA

• Pancreatic biopsy

What is the gold standard for dx of chronic pancreatitis IF IMAGING FAILS?

HISTOLOGY

What is the initial dx imaging study of choice for chronic pancreatitis?

CT

What is the most sensitive (but also invasive) imaging study for chronic pancreatitis and what will you see?

ECRP- shows dilated ducts, intraductal stones, strictures, pseudocysts

What will EUS (2nd test) show for suspected chronic pancreatitis?

Hyperechoic foci with shadowing indicative of calculi in the main pancreatic duct and lobularity with honeycombing of the pancreatic parenchyma

What are some chronic pancreatitis complications?

• OPIOID addiction

• Diabetes

• Pancreatic pseudocyst and/or abscess

• Pancreatic exocrine insufficiency

• Malnutrition

• Pancreatic Cancer

What is the treatment for chronic pancreatitis?

• Low fat diet

• ETOH cessation

• Avoid opioids- NSAIDs, APAP, tramadol, TCA

• Pancreatic enzyme replacement

• Surgical intervention

What composes ranson criteria?

three or more of the following predict a severe course complicated by pancreatic necrosis:

age >55yo

WBC count >16,000

Blood glucose >200

Serum Lactic dehydrogenase >350

Aspartate aminotransferase >250

What is another name for direct bilirubin?

A. Conjugated

B. Unconjugated

A!

What is the most common cause of acute liver failure?

A. Augmentin (amoxicillinc-clavulanic acid)

B. Acetaminophen

C. Ketamine

B!

What type of hernia is depicted by A?

A. Indirect inguinal hernia

B. Direct inguinal hernia

C. Femoral hernia

A!

Which of the following is associated with inflammatory bowel disease?

A. Primary biliary cirrhosis

B. Primary sclerosing cholangitis

C. Hemochromatosis

D. Rotor syndrome

B!

Which of the following is not a component of Charcot’s triad?

A. Fever/chills

B. Jaundice

C. AMS (altered metal status)

D. RUQ pain

C!

Which of the following is not commonly seen in hemochromatosis?

A. Kayser–Fleischer rings

B. Arthralgias

C. ED

D. Insulin resistance

A! (wilson’s disease)

What test is available for PSC

A. ANA

B. AMA

C. P-ANCA

D. Lactoferrin

C! (you see PSC w/ UC and P-ANCA is + in UC)

What test is available for PBC

A. ANA

B. AMA

C. P-ANCA

D. ASCA

B! *look up smooth muscle AMA

A 38 yo male with hepatic failure, what should you consider?

A. Wilson’s disease

B. Hemochromatosis

C. PBC

A!

(B is over 50)

Treatment of Wilson’s

A. Penicillamine

B. Phlebotomy

C. Phenobarbital

D. Ursodeoxycholic acid

A!

25 yo female with a history of DVT presents with acute liver failure and ascites. What do you suspect?

A. PSC

B. Budd Chiari

C. Hep C

D. Acute mesenteric ischemia

B!

45 year old female with RUQ pain, jaundice, fever. What do you need to rule out?

A. Cholecystitis

B. Cholangitis

C. PUD

B!

A patient with bleeding presents with elevated PT/INR. IV Vit K fails to improve bleeding time. What could this suggest?

A. Liver failure

B. Malabsorption

C. Protein C deficiency

A!

*improved with Vit. K can indicate malabsoroption

Criteria for acute pancreatitis?

A. Ranson’s

B. Rome

C. PECARN

A!

What can predict necrosis in acute pancreatitis?

A. Triglycerides >1000

B. Creatinine > 1.8 at 48 hours

C. HCT < 30 early in course

B!

What is the most common cause of death in chronic pancreatitis?

A. Cancer

B. ARDS

C. CKD

A!

What is the most common cause of cancer? not type!

Thromboembolic events