Term
| pancreatic juice secretion has what components and which ones increase w/ secretory rate |
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Definition
HCO3 inc w/ sec rate
Na/K stays constant
Cl- dec w/ sec rate |
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Term
| What mediates the cephalic, gastric, and intestinal phases of panc secretion? |
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Definition
vagus
vagal-cholinergic
Intestinal: AAs/FAs/Ca/H/distention result in CCK/secretin/enteropanc reflexes |
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Term
| T/F: An important part of the cephalic phase is secretion of Cholecystokinin (CCK) |
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Definition
Most important mediator of pancreatic enzyme secretion
Release stimulated by hydrolytic products of digestion (amino acids & fatty acids)
This concept is the basis for using pancreatic enzyme supplements to treat painful chronic pancreatitis |
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Term
| What regulates secretion of Secretin |
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Definition
MOST potent & efficacious stimulant of pancreatic fluid & bicarbonate
Major regulator = duodenal pH
Threshold for release=pH < 4.5
Below pH 4.5, pancreatic bicarb is directly proportional to the total amount of titratable acid presented to duodenum |
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Term
| T/F: the pancreas secretes enterokinase to activate enzymes. |
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Definition
| Enterokinase not made in panc in sep compartment to rpevent activation of trypsinogen and autodigestion |
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Term
| What are the main mechanisms of Acute Panc injury? |
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Definition
| that insults to the pancreas cause activation of zymogens and production of cytokines and chemokines. The mechanisms involved in initiating these two types of events are not well understood yet although ischemia may promote both. The activation of zymogens leads to pancreatic parenchymal injury (i.e. necrosis and apoptosis). The production of cytokines, chemokines, and neurogenic factors (such as substance P) leads to an inflammatory response/parenchymal injury AND a systemic inflamm response! |
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Term
| For a Dx fo Acute Panc what must be there |
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Definition
2/3 of:
Abdominal Pain
Pancreatic Enzymes in Serum
Radiologic Evidence |
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Term
| T/F: it is typical for acute panc injury to last a considerably long time |
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Definition
| F: After an isolated bout of acute pancreatitis, pancreatic function and histology return to normal. However, with severe disease, recovery may take up to a year. |
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Term
| Most common causes of AP? |
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Definition
| varies on geog location – alc is more common at wsu. Biliary more at umms. Most common are alc/biliary!! QUIZ |
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Term
| T/F: If you take out the Gall Bladder it is still possible for you to get a stone in the bile duct. |
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Definition
T: Gallstone Pancreatitis
35-40% of pancreatitis
3-7% pts. w/ gallstones develop
associated alk phos and bilirubin
cholecystectomy risk 10 to 20-fold
Two laps AK and bilirubin = MOST SPEC for panc! If you take out GB you can still have it b/c you can have stone formation in bile duct. |
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Term
| Mechanisms of gallstone pancreatitis proposed by Opie |
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Definition
| Two mechanisms of gallstone pancreatitis have been proposed. In the first, the stone obstructs the common opening of the common bile duct and pancreatic duct and allows reflux of bile into the pancreas. |
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Term
| T/F: the big stones cause more severe and more frequent gallstones |
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Definition
| F: not the big stones it’s the little ones that sneak out, more in number and you get a wider cystic duct size |
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Term
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Definition
| multifold mechs – alc fx blood flow and juice secretion! More proteinaceous. Sensitizes to CCK and direct toxic fx due to zymogen activation and cytokine generation. Sphincter of oddi spasms. CCK/secretin stimulation. |
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Term
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Definition
Altered enzyme activity
Trypsinogen mutations tryps mutations (site inside that is cleaved to inactivate it…that’s where mut is…so you have overactive tryps)
Abnormal ion movement
Cystic fibrosis transmembrane regulator (CFTR) mutations
Metabolic
Familial hypertriglyceridemia |
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Term
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Definition
May be due to direct or indirect injury
MVA
abdominal surgery
Blunt trauma (MVA) disruption of PD in mid-body of pancreas due to crushing against spine
Sx of AP may develop years after injury
Rx=ERCP placed stent or surgery |
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Term
| In utero there is a failure to fuse the panc buds. What is the treatment for this and how to dx? |
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Definition
Pancreatic DivisumFailure of pancreatic bud fusion in utero
incidence = 6-7%
Rx=minor ampullary sphincterotomy
Rx effective in acute recurrent rather than chronic pancreatitis
Must drain jucies through MINOR ampulla – smaller opening.
Little tree branches – DIAGNOSTIC! Tx is to cut ethe smaller opening. Not effective once they’ve developed chronic panc. |
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Term
| What are the markers for Autoimmune Pancreatitis and the diagnostic pattern of ductal disease on ERCP? |
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Definition
Subacute symptoms
Irregular, narrowed duct
Periductal lymphocytic- plasmacytic inflammation and fibrosis
IgG4, IgE, autoimmune markers
Steroid responsive
– dilated alternating patterns DIAGNOSTIC for AI! Order IGG1-4…4 is key for AI!only one that’s tx w/ steroids. |
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Term
| Drug Induced Pancreatitis Sorted by Incidence |
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Definition
Only 6 drugs common that we need to know! asparaginase, Aza/6-mercaptopurine, didanosine, penamidine, valproate
Drug induced pancreatitis sorted by incidence |
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Term
| Clinical Presenting Features in order of most common. |
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Definition
Abdominal pain
Nausea / vomiting
Tachycardia
Low grade fever
Abdominal guarding
Loss of bowel sounds
Jaundice
not all have abd pain! Guarding/bowel…sit forward to get panc off spine and try not to move. |
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Term
| amylase or lipase for dx and which one stays more elevated |
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Definition
| lipase more spec and stays more elev |
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Term
| T/F: Degree of elevation of amylase does not correlate with severity of pancreatitis |
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Definition
T: Peaks & falls early
Degree of elevation does not correlate with severity of pancreatitis
Cleared by renal system
Prolonged elevation should prompt eval for pseudocyst or cancer
Look at your patient first & then the amylase !!! |
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Term
Alternative Sources of Enzyme Elevations
for amylase and amlyase/lipase both |
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Definition
Amylase elevation alone
parotitis
tubulo-ovarian disease (e.g. ectopic pregnancy or pelvic inflammatory disease)
macroamylasemia
Amylase & Lipase elevation
biliary stone impaction
intestinal injury (e.g. small bowel perforation)
renal failure
intestinal ischemia |
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Term
| The finding of ecchymosis in one of either flanks or the periumbilical area (Cullen’s sign) represents extravasation of pancreatic hemorrhage into these areas. Such signs are associated with a poor prognosis. What's the name of this sign @ the flanks? |
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Definition
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Term
| How well do the prognosis systems like bedside assmt, scoring systems, serum markers and CT work? why is imp for us to know severity? |
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Definition
They all have big limitations.
For example, patients with severe disease are more likely to develop pancreatic infections and preventative antibiotic therapy decreases the rate of infection and mortality. Thus, an early prediction of severe disease is important so that preventative antibiotic therapy can be instituted. Furthermore, patients with severe disease are more likely to develop respiratory or other organ complications and should be monitored for these so that appropriate and timely supportive therapy can be instituted. |
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Term
| Early Indicators of Severity |
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Definition
Tachycardia, hypotension
Tachypnea, hypoxemia
Hemoconcentration – cytokines going crazy make 3rd spacing and => leaky!
Oliguria
Encephalopathy
Ileus with a tense abdomen = BAD prognostic sign!!! |
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Term
| Ranson’s early prognostic indicators are only 57% to 85% sensitive and 68% to 85% specific in predicting severe disease outcome. What do they include? |
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Definition
THEY DON'T INCLUDE AMYLASE!
Admission: Age > 55 years
WBC > 16,000 mm3
Glucose > 200 mg/dl
LDH > 350 IU/L
AST > 120 IU/L
After 48 hrs
Hct decrease >10%
BUN increase > 5 mg/dl
Ca2+ < 8 mg/dl
PaO2 < 60 mm Hg
Base deficit > 4 mEq/L
Negative fluid balance > 6L |
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Term
| The majority of patients with severe disease have from 3 to 5 criteria. what's their risk of dying? |
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Definition
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Term
| BISAP what is it? What's risk of mortality? QUIZ!!! |
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Definition
BUN>25
Impaired mental status
SIRS*
Age >60
Pulmonary abnormality
*SIRS=
HR>90
RR>20 or pCO2<38
36° > rectal T >38°
4 > WBC > 12
Scores w/in 24h → mortality
0 -2 → < 1.5%
3 → 7.7%
4 → 20%
5 → 60% |
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Term
Early death due to?
Late death >1wk due to? |
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Definition
| The major causes of death from acute pancreatitis change with time. In the first week, SIRS/multi-organ failure is the most common cause of death. Later, infectious complications/multiorgan failure become important. |
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Term
Fatal Pancreatitis Diagnosed Postmortem
% and why? |
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Definition
22-42% of fatal cases
Reasons: no abd pain, multi-organ failure/coma/resp failure at presentation, and false negative bld tests/imaging. |
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Term
| Which tx is good for fixing the root cause of AP? |
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Definition
there are no specific treatments for attenuating the underlying pathophysiologic mechanisms of acute pancreatitis.
Supportive care
Aggressive fluid and electrolyte replacement
Monitoring
Vital signs
Urine output
O2 saturation
Pain
Analgesia, anti-emetics
Other treatments
Acid suppression
Antibiotics
NG tube
Nutritional support
Urgent ERCP
IV octreotide |
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Term
| Nasogastric suction is effective at altering the course of the disease. T/F? |
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Definition
F NG tube not change course only tx underlying sx.
Nasogastric Suction in Acute Pancreatitis
Nasogastric suction is not needed in the treatment of mild pancreatitis because of demonstrated lack of benefit. Nasogastric suction should be used in patients in patients with intractable nausea or vomiting; or gastric or intestinal ileus. |
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Term
| Nutritional support is recommended when? |
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Definition
when protracted course is likely
3-4 days px not going better, don’t wait for px to start nutritional therapy. Put tube beyond lig of Treitz since don’t want panc stimulation |
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Term
| T/F: The use of Abx for prophylaxis against infection remains controversial |
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Definition
True: but we use it in Infected Necrosis
Surgical drainage frequently required
Pancreatic Abscess
Catheter drainage
Infected Pseudocyst
Endoscopic or percutaneous drainage |
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Term
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Definition
| One indication is diagnosis although this test has only moderate sensitivity for diagnosis, as it is often normal in mild disease. More importantly, CT is used for prognosis as described in the following slides; and to determine complications. The CT is most useful for determination of complications such as fluid collections and other serious complications such as involvement of the GI tract, spleen, liver or kidneys in the process. CT can also be used to guide aspiration of potential sites of infection. |
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Term
| Pancreatic Pseudocysts in AP when to treat and what are they? |
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Definition
most resolve on their own but >6cm need tx
Localized fluid collection, no epithelial lining, exist > 4 weeks. Don’t always cause probs…
Develop in >10% of cases
Complications
hemorrhage, infection, obstruction (GI or biliary)
Treatment ??
size> 6 cm
duration > 6 weeks
endoscopic, transluminal, surgical |
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Term
| What's a good imaging technique to see pseudocysts? |
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Definition
| EUS - localize cyst. How far from lumen and detect vasc strx. Don’t want to stick cath through that => hemorrhage! due to vascular strx |
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Term
| QUIZZZ: What is needed for Cholangitis immediately? |
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Definition
Urgent ERCP <24 hrs for Biliary Pancreatitis
studies indicate that acute ERCP and sphincterotomy might reduce morbidity in patients with severe pancreatitis who also have cholangitis. The use of EUS to detect persistent common duct stones as additional criteria for intervention might increase the benefits of this intervention. |
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Term
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Definition
Chronic
Chronic inflammation w/ LYMPHOCYTES
Chronic abdominal pain
Progressive loss of pancreatic endocrine and exocrine function - there’s not enough working tissue to reelase the enzymes.
Acute
Acute inflammation
Acute abdominal pain
Elevated pancreatic enzymes in serum
Self-limiting – no long-term traces |
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