Diseases of the Pancreas

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Answer

function of bicarbonate

neutralize gastric acid

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acute pancreatitis definition

Clinical syndrome defined by enzymatic damage to the pancreas resulting in discrete episodes of abdominal pain and elevation in serum amylase and lipase 3 times the upper limit of normal

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key event in pancreatitis

inappropriate activation of trypsinogen to trypsin within the pancreas. Activated trypsin activates other proteases. Cascade of events – autodigestion locally & release of proinflammatory mediators that affect other organs systems distally

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Acute interstitial pancreatitis

mild pancreatitis with pancreatic edema

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Acute Necrotizing pancreatitis

severe pancreatitis with necrosis of parenchyma and blood vessels

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Most common causes of acute pancreatitis

gallstones (35%, more often females), Alcohol (30% of cases, most often males), Obstruction, medications, infections, metabolic, toxins, vascular, abdominal trauma, post - ercp, inherited, idiopathic (20%)

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Metabolic causes of pancreatitis

hypertriglyceridemia (usually >1000), hypercalcemia

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Toxic causes of pancreatitis

alcohol, methylalcohol, scorpion sting

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Vascular causes of pancreatitis

ischemia, vasculitis

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Sx of pancreatitis

constant, epigastric pain radiating to the back. Usually associated with N/V, tachycardia secondary to hypovolemia, fever, systemic toxicity (sepsis), jaundice, decresaed breath sounds, distention, tenderness

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Decreased breath sounds associated with pancreatitis is caused by

effusion

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Ileus causes

decreased bowel sounds

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Flank ecchymosis from retroperitoneal hemorrhage

Gray Turner's Syndrome. Leaking of blood from the pancreas. Acute necrotizing pancreatitis

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Periumbilical ecchymosis

Cullen's sign. Leaking of blood from the pancreas. Acute necrotizing pancreatitis

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Labs in pancreatitis

elevated amylase and lipase (must have clinical signs of pancreatitis)

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Imaging in pancreatitis

Plain films, US, CT, MRCP (MRI that looks at biliary tree and pancreatic ducts), ERCP (endoscopically looks at biliary tree and pancreatic tree; intervention friendly)

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Most commonly used pancreatic criteria

Ranson Criteria

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Apache score >8 indicates

severe pancreatitis. Advantage of APACHE is that you don't have to wait 48 hours to calculate (ranson takes 2 days) and you perform this daily

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Tx for pancreatitis

Pancreatic rest (NPO), IVF (dehydrated due to third-spacing), pain meds, if severe: monitor in ICU, prophylactic abx, jejunal feed after 3 days NPO

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Local Complications of pancreatitis

Fluid collections, pancreatic necrosis (sterile or infected), pancreatic abscess

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Non-local complications of pancreatitis

ARDS, sepsis, renal failure

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Number one cause of chronic pancreatitis

Chronic Alcohol use accounts for 70% of cases

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Causes of Chronic pancreatitis

Chronic alcohol use, chronic obstruction of pancreatic duct, tropical chronic pancreatitis (due to malnutrition), autoimmune (elevated IgG4), Genetics, Idiopathic

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Clinical features of chronic pancreatitis

persistent/recurrent epigastric and LUQ pain, steatorrhea, Diabetes

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Labs in Chronic pancreatitis

Amyslase (lipase usually not elevated b/c it is burned out), fecal fat, fecal elastase, secretin stimulation test

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Radiology in Chronic Pancreatitis

Ab plan film, CT, MRCP, ERCP, EUS

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Classic finding in chronic pancreatitis on imaging

pancreatic calcifications.

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Chain of lakes is seen on which imaging studies in chronic pancreatitis?

MRCP, ERCP

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Pancreatic adenocarcinoma epidemiology

mean age of onset 70's-80's, M:F = 1.3:1, most common location is head of pancreas

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Biggest risk factor of Pancreatic adenocarcinoma

Tobacco Use.

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Painless jaundice may be associated with

pancreatic adenocarcinom of the pancreas head. CBD is compressed.

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Courvoiseir's sign

palpable GB due to head mass compressing CBD

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Best imaging for pancreatic adenocarcinoma

CT.

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If CT or MRI shows no mass, but you are still concerned, order a

endoscopic ultrasound

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What is the risk associated with CT guided biopsy?

Seeding

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Best option for tissue diagnosis in pancreatic adenocarcinoma

Endoscopic Ultrasound with FNA

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Pancreatic adenocarcinoma may be resectable if

there is no vascular invasion, lymphatic involvement or mets

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_____ of pancreatic adenocarcinoma patients present wtih mets at diagnosis

50%. Mean survival is 3-6 months if metastatic

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Which remains elevated longer? Lipase or Amylase?

Serum Lipase, for 3-5 days. May be helpful if patients seek medical attention several days following symptom onset

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Steatorrhea

Due to pancreatic exocrine insufficiency resulting in fat malabsorption. Loose, greasy, malodorous stools. Fat soluble vitamin deficiency (A,D,E,K)

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