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Pancreatic Disease

Gastroenterology

QuestionAnswer
Pancreatic functional units exocrine: acinus; endo: islet of Langerhans (alpha: glucagon; beta: insulin)
Acute pancreatitis: pathophys Inappropriate activation of trypsinogen to trypsin w/in pancreas (acinar injury via toxicity); trypsin activates other proteases; cascade: local autodigestion -> fat necrosis; distal: release of proinflam mediators -> profound inflam response
Acute pancreatitis: 2 types acute interstitial; acute necrotizing
Acute interstitial pancreatitis: mild pancreatitis with pancreatic edema
Acute necrotizing pancreatitis: severe pancreatitis with necrosis of parenchyma & blood vessels
Acute pancreatitis: Classic sx: Constant, epigastric pain radiating to back; some relief leaning forward; usu assoc w/ N&V
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
Gray Turner sx Flank ecchymosis from retroperitoneal hemorrhage; in acute necro panc
Cullen sx Periumbilical ecchymosis; in acute necro panc
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.
Imaging of choice for pancretic parenchyma CT
Acute panc: prognosis based on: Ranson criteria (on admission & after 48 hr); APACHE II score (immed & daily); Glasgow; CT severity score
Acute pancreatitis: Mgmt Pancreatic rest (NPO); IVF (+/- albumin +/- FFP); NGT if ileus; pain meds; Abx if >30% necrosis; Surgical consult
Acute panc: complications ARDS, sepsis, renal fail; fluid collections (30-50%), panc necrosis (sterile (20% infected), panc abscess, ascites, pleural effusion, pseudocyst, DM
Acute panc: most common comp pseudocyst (10-20%): collection of panc juice encased by granulation tissue; 4-6 wks
Chronic panc: causes Chronic alcohol use (70%); chronic obstruction of pancreatic duct
Chronic panc: clinical findings Persistent/recurrent epigastric & LUQ pain, radiating to left lumbar; Steatorrhea; DM
Chronic panc: dx no lab tests (amy/lipase usu not inc); fecal fat/elastase; secretin stim test
Chronic panc: Abd plain film: Pancreatic calcifications (classic finding)
Chronic panc: CT Pancreatic calcifications, atrophied pancreas
Chronic panc: MRCP/ERCP Chain of lakes (areas of dilation / stenosis along pancreatic duct)
Chronic panc: Mgmt Abstain from EtOH; tx pain (panc enzyme replacement; H2 blocker/PPI)
Chronic panc: Surg Puestow (lateral pancreatojejunostomy) if duct dilated >6 mm; OR subtotal or total pancreatectomy
Pancreatic cancer: RFs tobacco; chronic panc; exposure to dyes; non-IDDM in pt >50; h/o partial gastrectomy or cholescystectomy; genetics
Pancreatic cancer clinical features Painless jaundice. Severe wt loss. Pruritus hands/feet. Courvoisier sx . Trousseau sx
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
Courvoisier sx palpable GB due to head mass compressing CBD
Trousseau sx migratory thrombophlebitis
Pancreatic cancer: labs Alk Phos; Bilirubin, CA 19-9
Pancreatic cancer: surg: in head: Whipple; in body/tail: distal pancreatectomy & splenectomy & 5FU C/RTx
Pancreatic cancer: Tx if not resectable Locally advanced: 5FU Chemoradiation; mets: Gemcitabine; Pain control, palliative stents
Pancreatic cancer: prognosis 15-20% candidates for pancreatectomy; 50% mets at time of dx; if resectable: 15-17 mos (if not: worse)
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
Acute panc familial etio Auto dom: PRSS1, CFTR, SPINK1 genes)
Acute panc: causative drugs include: Furosemide, thiazides, ACEI, sulfa, DDI, asparaginase, estrogen, 6-MP/AZA, dapsone, 5-ASA, valp
Acute panc DDx Acute chole, perf viscus (eg, duod ulcer), intestinal obstn, mesenteric ischemia, Inferior MI, AAA leak, distal Ao Dissection, rupture ectopic PG
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.
Acute panc on abd CT TOC for dx. Enlarged panc, peripancreatic edema
If suspect panc necrosis: CT w/contrast at day 3
Acute panc: MRI/MRCP to detect necrosis; stones/ductal disruption
Pancreatitis: endoscopic u/s Most sensitive study for structural changes in chronic panc; limited role in acute panc. Useful in occult biliary dz (microlithiasis)
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
Chronic pancreatitis complications DM, panc abscess, pseudocyst, CBD stricture, steatorrhea, malnutrition, PUD
Pancreatic cancer tumor types Adenocarcinoma (from ductal epithelium; most common). Endocrine tumors. Cystic pancreatic neoplasm.
Ranson criteria at admission Age >55. Glucose >200. WBC >16. LDH >350. AST >250.
Ranson criteria at 48 hours pO2 <60. HCO3 <20. Ca <8.0. BUN increase by 1.8. HCT decrease by 10%. Third spacing >6L
Acute pancreatitis Abx (if severe / >30% necrosis by CT) Imipenem or Ertapenem for up to 14 days
Infected necrosis in pancreatitis usually requires: surgery / debridement
Acute pancreatitis systemic complications Shock, ARDS, ARF, GI bleed, DIC
Acute pancreatitis metabolic complications hypocalcemia, hyperglycemia, elevated TG
Acute pancreatitis: other complications Acute fluid collection (30-50%). Pseudocyst (10-20%) x4-6 weeks. Sterile pancreatic necrosis (20%)
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
Mgmt of ascites/pleural effusion in acute pancreatitis ?ERCP with stent
Created by: Abarnard