Term
| histology of chronic pancreatitis |
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Definition
| fibrosis, chronic inflammation, and a calcification within a small pancreatic duct. |
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Term
| Etiologies of chronic pancreatitis |
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Definition
In Western countries, the most common etiology of chronic pancreatitis is alcohol abuse. In a growing number of patients, inherited causes are identified. Inherited conditions that predispose to chronic pancreatitis include mutations in the CFTR gene that cause cystic fibrosis, mutations in the trypsinogen gene that cause hereditary pancreatitis, and familial hypertriglyceridemia.
India - fibrocalculous pancreatitis |
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Term
| Proposed mechanisms of chronic pancreatitis |
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Definition
it’s REPEATED ATTACKS that => panc. Injury necrosis scar tissue repeated over and over!
Intraductal plugging/obstx
direct toxins and toxic metabolites
oxidative stress
necrosis/fibrosis |
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Term
| Pain features and clinical stool features of CP |
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Definition
Intermittent or constant
Moderate to severe
Epigastric with
radiation to back
Associated with food
Steatorrhea |
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Term
| Clinical Manifestations in CP |
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Definition
Abdominal Pain ~80%
Calcification ~30% k to dx
Diarrhea/Steatorrhea ~30%
Diabetes ~30%
Weight loss ~50% |
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Term
| T/F: CP needs to be dx w/ CT to be conclusively CP... |
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Definition
F
QUIZ: if you get this x-ray that’s enough to make DX! Not need CT
Pancreatic calcifications detected using standard radiographs |
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Term
| Where do you see calcifications? |
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Definition
| The calcifications are intraductal and best seen in the pancreatic head or tail because the spinal column obscures their detection in the body. In alcoholic pancreatitis, calcification is observed in 20-50% of patients. Calcification is particularly frequent in hereditary and tropical pancreatitis. |
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Term
| TF: CT detects pancreatic calcification with greater sensitivity than an abdominal x-ray and is often used if the abdominal film is negative. |
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Definition
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Term
| What's a complication of pseudocyst in CP and if we look at it w/ a CT what will we see? |
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Definition
| CT scan demonstrating pseudocyst in chronic pancreatitis. The pseudocyst is anterior to the main pancreatic duct that is filled with stones. The pseudocyst is compressing the duodenum and stomach (filled with contrast) and causing obstruction of the gastric outlet and gastric dilation. |
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Term
| EUS findings in chronic pancreatitis |
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Definition
dilation of the main pancreatic duct with a stricture
highly echogenic pancreatic duct
echogenic stranding suggesting fibrosis and dilation of secondary ducts. |
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Term
| ERCP demonstrating moderate pancreatitis with dilation of the main pancreatic duct |
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Definition
| There is irregularity and clubbing of secondary ducts. The normal tapering of the duct seen in the pancreatic tail is lost. Short strictures of the main duct are present. This ERCP would best be classified as moderate disease by the Cambridge criteria. |
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Term
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Definition
| possible dilation of the main pancreatic duct and more than 3 dilated side branches |
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Term
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Definition
| marked dilation of the main pancreatic duct the tail and clubbing of most secondary ducts. Short strictures of the main pancreatic duct, particularly toward the tail, are seen |
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Term
| T/F: ALL C panc PX have neural changes. |
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Definition
| T: Pancreatic and pancreatic nerves become enlarged, lose some of their cellular sheath, and are inflamed. Chronic pancreatitis is associated with an increase in the number and size of nerve s. |
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Term
| Quiz: T/F: antioxidants/vitamins are effective supplements to narcotics given at high doses |
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Definition
| F: we give them to minimize narcotics |
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Term
| Other drugs for panc pain? |
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Definition
Neuro-modulators
Anti-inflammatory drugs
Anti-secretory drugs = somatostatin!
Enzymes |
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Term
| T/F: Reduced release of pancreatic proteases may enhance CCK release and cause PAIN! |
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Definition
| T: Both the digestive products of a meal and cholecystokinin (CCK)-releasing factor (RF) stimulate CCK release from the duodenal mucosa. CCK acts directly on pancreatic cells and indirectly through neural pathways to stimulate the pancreas. Through unknown mechanisms, such stimulation has been hypothesized to cause pain. |
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Term
| T/F: An effective way to reduce pain is to give coated exogenous proteases to degrade CCK-RF. |
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Definition
F. Uncoated MAY reduce pain.
When exogenous pancreatic enzymes are taken with a meal, CCK releasing factors are degraded and CCK release in response to a meal is reduced as indicated by the smaller CCK. This decreases pancreatic stimulation and pain. Any benefit from this treatment is likely limited to non-alcoholic patients with early chronic pancreatitis and requires the use of uncoated preparations. |
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Term
| When would you give coated preparations of exog panc enzymes? |
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Definition
if you’re trying to tx malabs need coated!
Uncoated enzyme preparations can be degraded by gastric acid
Specific enzyme formulations are protected from inactivation by gastric acid. The uncoated pill shown in yellow is susceptible to gastric acid. In particular, the activity of lipase is reduced by acid and it is inactivated by pH<4. As shown by the red “X”, lipase can be inactivated by acid in the stomach. The coated preparation shown in blue does not dissolve in the stomach because its coating is resistant to acid, but it does dissolve in the small intestine under non-acidic conditions. |
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Term
| dissolution sites for exog panc enzymes? |
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Definition
| As shown by the yellow tablet, uncoated preparations begin to dissolve in the stomach. As shown by the blue tablet, enteric coated or microencapsulated preparations begin to dissolve only when they reach the alkaline milieu of the small intestine. |
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Term
| Treatments for neuropathic pain in chronic pancreatitis |
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Definition
Interventions
Nerve block
Neurolysis – destroy the nerve
Thoracoscopic splanchnicectomy
Results
Some relief
Usually transient
Proprioceptive (pain) innervation may be too complex for this approach |
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Term
| With a whipple resection what is spared? |
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Definition
Pylorus-sparing Whipple resection person who will benefit is when disease is localized to the HEAD
Pylorus-sparring Whipple resections are performed to relieve pain in chronic pancreatitis. The surgery is also used to treat pancreatic neoplasms and chronic pancreatitis. This operation is usually performed in chronic pancreatitis patients who have failed to experience relief after a lateral pancreatojejunostomy or in patients that do not have a dilated pancreatic duct. Removal of endocrine tissues and the resulting diabetes are a consequence of pancreatic resection that is not observed with lateral pancreatojejunostomies. |
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Term
| Why do Lateral pancreaticojejunostomy |
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Definition
| In this surgical procedure is performed to reduce pain in chronic pancreatitis. As shown, the main pancreatic duct has been opened along its middle and proximal thirds and anastamosed side-to-side into the jejunum. This treatment often provides moderate and long-lasting pain relief and has been known as the Puestow procedure. The use of this procedure requires dilation of the pancreatic duct for the anastomsis to the small intestine. |
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Term
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Definition
| In this surgical procedure, the entire pancreas is removed. Because of the morbidity associated with this procedure, it is seldom performed for the relief of pain in chronic pancreatitis. |
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Term
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Definition
Early - due to food avoidance 2o pain
Late - due to malabsorption
Especially fats
May c/o nausea & vomiting
Further weight loss |
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Term
| QUIZZZ: Malabsorption in CP signs? |
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Definition
Low fecal water/weight ratio…intestinal lining is fine and can abs water although malabs fat.
Vit D Def DOES develop!
When low panc bicarb – you deactivate your enzymes!
Typically low fecal water/weight
Unusual to observe fat-soluble vit def (A,D,E,K)
Lipase reduction prior to amylase reduction
Usually takes 10-20 years to develop
Aggravated by low pancreatic bicarb excretion
Occurs when secretion < 10% baseline
i.e. when > 90% exocrine function is lost |
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Term
| diagnosing exocrine pancreatic insufficiency |
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Definition
Double lumen tube test for diagnosing exocrine pancreatic insufficiency
The secretin test of exocrine pancreatic function is based on the fact that the physiologic response to a meal is an increase in pancreatic fluid and HCO3- secretion. This response is largely due to the acid-dependent release of secretin from small intestine and its subsequent stimulation of pancreatic secretion. As the rate of pancreatic secretion increases in response to secretin, HCO3- secretion increases. As the rate of fluid secretion increases, the concentration of Cl- falls and that of HCO3- increases. The basal HCO3- concentration is about 40 mEq/L; with stimulation, it increases to 80 to 150 mEq/L and the fluid rate to 4 –6 ml/min. In addition to HCO3- concentration and volume, enzyme secretion may be assayed. The test is performed using two aspiration tubes. One is placed in the stomach to remove gastric acid and prevents its stimulation of the pancreas. The second tube is placed just distal to the Ampulla of Vater. After a 1-hr basal collection period, secretin is given intravenously and the collections are continued for 1-2 hrs. In some centers, cholecystokinin or nutrient stimulation are used. A HCO3- response to secretin of less than 80 mEq/l suggests pancreatic disease. Some centers also measure enzyme secretion. The test is generally considered sensitive and specific for pancreatic exocrine insufficiency. However, it is not widely available because it is time-consuming, uncomfortable, and requires careful tube placement. |
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Term
> 7g of fat excretion is steat...
what combo of enzymes is best to bring this down? |
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Definition
enz w/ H2receptor antagonist is best
coated enzymes
and enzymes... |
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Term
| QUIZ: T/F: Endocrine insufficiency like Diabetes is an important predictor of CP but is often missed the months prior to attacks. |
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Definition
False!!!!!!
Endocrine insufficiency later than exocrine
Occurs in 60% patients with CP
Lack of glucagon “Brittle” diabetes
Ketoacidosis & nephropathy unusual
Retinopathy & neuropathy develop in time frame similar to routine DM type I |
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Term
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Definition
Arise in 10-25% cases
Most common in chronic alcoholic pancreatitis
Most common location is the body (rather than head or tail)
Rarely resolve w/o Rx
Should be suspected in pts. w/ sudden increase in pain
Cyst fluid high in amylase |
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Term
| Rx of pancreatic pseudocysts |
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Definition
Surgical excision w/ external or internal drainage BUT MUST WAIT >6wks tfor cyst to mature
PD stenting - if communication or stricture
Endoscopic cyst-gastrostomy/-duodenostomy*
Percutaneous, CT-guided catheter drainage
SQ octreotide may be of benefit |
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Term
| Splenic vein thrombosis in chronic pancreatitis: clinical features and why? |
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Definition
| Inflammatory or mass lesions of the pancreas can cause obstruction and thrombosis of the splenic vein. Since splenic artery flow is usually preserved, the obstruction causes splenomegaly and venous hypertension that is decompressed primarily though gastric collaterals. This gives rise to varices that are predominantly located in the gastric cardia. If the varices bleed, the treatment is splenectomy. |
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Term
| T/F: The second and third portion of the duodenum can be obstructed by pancreatic masses or inflammation. |
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Definition
| TThis includes entrapment by fibrosis in chronic pancreatitis and compression by pseudocysts. Long-standing obstruction associated with pancreatitis can lead to a fixed stricture. The presenting symptoms are those of gastric outlet obstruction with nausea, vomiting, and early satiety. |
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Term
| What clues to Symptoms Suggesting Cancer Development in CP? |
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Definition
Changing pain pattern
Weight loss unresponsive
to enzyme replacements
Development of biliary and/or gastric outlet obstruction
New onset of depression or DM up to TWO YEARS before panc cancer!
Migratory thrombosis |
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