Gastroenterology
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| Pancreatic functional units | exocrine: acinus; endo: islet of Langerhans (alpha: glucagon; beta: insulin)
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| Acute pancreatitis: pathophys | Inappropriate downregulation of trypsin inhibitor (acinar injury via toxicity) -> trypsin activates other proteases, in cascade: local autodigestion -> fat necrosis; distal: profound inflammatory response
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| Acute pancreatitis: 2 types | acute interstitial; acute necrotizing
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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 & blood vessels
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| Acute pancreatitis: Classic sx: | Constant, epigastric pain radiating to back; some relief leaning forward; usu assoc w/ N&V
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| Acute pancreatitis: other sx: | tachycardia (2/2 hypovolemia); fever (1-3 days from onset); icterus/jaundice; decreased breath sounds (pleural eff); abd tenderness (rebound); necrotizing: systemic toxicity, sepsis
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| Gray Turner sx | Flank ecchymosis from retroperitoneal hemorrhage; in acute necro panc
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| Cullen sx | Periumbilical ecchymosis; in acute necro panc
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| Acute panc: plain films | Calcified gall stone/panc; sentinel loop air in sm bowel/LUQ; colon cut-off sx (no air distal to splenic flexure). Atelectasis, effusion.
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| Imaging of choice for pancretic parenchyma | CT
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| Acute panc: prognosis based on: | Ranson criteria (on admission & after 48 hr); APACHE II score (immed & daily); Glasgow; CT severity score
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| Acute pancreatitis: Mgmt | Pancreatic rest (NPO); IVF (+/- albumin +/- FFP); NGT if ileus; pain meds; Abx if >30% necrosis; Surgical consult
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| Acute panc: complications | ARDS, sepsis, renal fail; fluid collections (30-50%), panc necrosis (sterile (20% infected), panc abscess, ascites, pleural effusion, pseudocyst, DM
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| Acute panc: most common comp | pseudocyst (10-20%): collection of panc juice encased by granulation tissue; 4-6 wks
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| Chronic panc: causes | Chronic alcohol use (70%); chronic obstruction of pancreatic duct
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| Chronic panc: clinical findings | Persistent/recurrent epigastric & LUQ pain, radiating to left lumbar; Steatorrhea; DM
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| Chronic panc: dx | no lab tests (amy/lipase usu not inc); fecal fat/elastase; secretin stim test
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| Chronic panc: Abd plain film: | Pancreatic calcifications (classic finding)
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| Chronic panc: CT | Pancreatic calcifications, atrophied pancreas
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| Chronic panc: MRCP/ERCP | Chain of lakes (areas of dilation / stenosis along pancreatic duct)
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| Chronic panc: Mgmt | Abstain from EtOH; tx pain (panc enzyme replacement; H2 blocker/PPI)
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| Chronic panc: Surg | Puestow (lateral pancreatojejunostomy) if duct dilated >6 mm; OR subtotal or total pancreatectomy
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| Pancreatic cancer: RFs | tobacco; chronic panc; exposure to dyes; non-IDDM in pt >50; h/o partial gastrectomy or cholescystectomy; genetics
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| Pancreatic cancer clinical features | Painless jaundice. Severe wt loss. Pruritus hands/feet. Courvoisier sx . Trousseau sx
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| Pancreatic cancer: head vs body/tail | Most common location: head; painless jaundice (compresses CBD); body/tail: abd pain d/t retroperitoneal invasion into celiac plexus
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| Courvoisier sx | palpable GB due to head mass compressing CBD
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| Trousseau sx | migratory thrombophlebitis
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| Pancreatic cancer: labs | Alk Phos; Bilirubin, CA 19-9
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| Pancreatic cancer: surg: | in head: Whipple; in body/tail: distal pancreatectomy & splenectomy & 5FU C/RTx
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| Pancreatic cancer: Tx if not resectable | Locally advanced: 5FU Chemoradiation; mets: Gemcitabine; Pain control, palliative stents
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| Pancreatic cancer: prognosis | 15-20% candidates for pancreatectomy; 50% mets at time of dx; if resectable: 15-17 mos (if not: worse)
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| Acute panc: etiologies | GS (40%), EtOH (30%), Drugs, obstructive (eg, Crohn), metab (high TG, high Ca), infxs, autoimmune, ischemia, post-ERCP (35-70% asx elev amylase), post-trauma, CF, familial (auto dom), Trinidad scorpion
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| Acute panc familial etio | Auto dom: PRSS1, CFTR, SPINK1 genes)
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| Acute panc: causative drugs include: | Furosemide, thiazides, ACEI, sulfa, DDI, asparaginase, estrogen, 6-MP/AZA, dapsone, 5-ASA, valp
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| Acute panc DDx | Acute chole, perf viscus (eg, duod ulcer), intestinal obstn, mesenteric ischemia, Inferior MI, AAA leak, distal Ao Dissection, rupture ectopic PG
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| Acute panc: Labs | Amylase (>3x ULN = panc). Lipase >specific > amylase. ALT >3x ULN prob GS panc. Elev WBC (10-30), BUN, glucose. Low Ca. Inc/dec HCT. Alk phos not helpful.
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| Acute panc on abd CT | TOC for dx. Enlarged panc, peripancreatic edema
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| If suspect panc necrosis: | CT w/contrast at day 3
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| Acute panc: MRI/MRCP | to detect necrosis; stones/ductal disruption
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| Pancreatitis: endoscopic u/s | Most sensitive study for structural changes in chronic panc; limited role in acute panc. Useful in occult biliary dz (microlithiasis)
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| Acute panc tx | IVF (to 10L/d if severe), NPO, pain ctrl (demerol/morphine/dilaudid), ppx abx if severe/necrosis. Chole if GS. ERCP + sphincterotomy if severe cholangitis/sepsis
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| Chronic pancreatitis complications | DM, panc abscess, pseudocyst, CBD stricture, steatorrhea, malnutrition, PUD
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| Pancreatic cancer tumor types | Adenocarcinoma (from ductal epithelium; most common). Endocrine tumors. Cystic pancreatic neoplasm.
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| Ranson criteria at admission | Age >55. Glucose >200. WBC >16. LDH >350. AST >250.
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| Ranson criteria at 48 hours | pO2 <60. HCO3 <20. Ca <8.0. BUN increase by 1.8. HCT decrease by 10%. Third spacing >6L
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| Acute pancreatitis Abx (if severe / >30% necrosis by CT) | Imipenem or Ertapenem for up to 14 days
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| Infected necrosis in pancreatitis usually requires: | surgery / debridement
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| Acute pancreatitis systemic complications | Shock, ARDS, ARF, GI bleed, DIC
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| Acute pancreatitis metabolic complications | hypocalcemia, hyperglycemia, elevated TG
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| Acute pancreatitis: other complications | Acute fluid collection (30-50%). Pseudocyst (10-20%) x4-6 weeks. Sterile pancreatic necrosis (20%)
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| Mgmt of infection in acute pancreatitis | Necrosis: ?FNA. For pos cx/gram stain, Abx & perc drainage. Abscess (usually after 4 weeks): Abx + CT guided drainage
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| Mgmt of ascites/pleural effusion in acute pancreatitis | ?ERCP with stent
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| Pancreatic enzymes (8): | Pancreatic amylase (digests starch); proteases (trypsin, chymotrypsin, carboxypeptidase, elastase); pancreatic lipase (digests triglycerides); ribonuclease & deoxyribonuclease
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| Activation of trypsin: MOA | At the brush border near lumen to small intestine, enterokinase splits trypsinogen molecule to form trypsin, which activates precursors of the pancreatic proteases
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| N/V, epigastric abdominal pain, worse supine, caused by alcohol ingestion, or following fatty meals | Acute pancreatitis
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| peri-umbilical or flank ecchymosis | Acute pancreatitis (Cullen & Grey Turner Sign)
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| Acute pancreatitis: most common complication | pseudocyst: collection of panc juice encased by granulation tissue; > 4 wks
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| Pancreatic cancer risk factors | tobacco; chronic panc; exposure to dyes; non-IDDM in pt >50; h/o partial gastrectomy or cholescystectomy; genetics
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| Panc ca: clinical findings | jaundice, wt loss; Courvoisier sx; Trousseau sx
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| Panc cancer most common location: | head; painless jaundice (compresses CBD); body/tail: abd pain d/t retroperitoneal invasion into celiac plexus
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| Panc ca: most common sx | Pain, obstructive jaundice, weight loss; BUT classic hx = painless jaundice
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| Courvoisier sx | palpable GB due to head mass compressing CBD = pancreatic ca
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| Trousseau sign in pancreatic cancer is secondary to: | migratory thrombophlebitis
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| Trousseau sign manifests as: | carpopedal spasm when BP cuff is inflated (related to hypocalcemia)
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