Term
| The pancreatic duct or the Duct of Wirsung |
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Definition
| Helps transport pancreatic juices which aid in digestion. This is supplied by the exocrine glands of the pancreas. |
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Term
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Definition
| joins the CBD just prior to the ampulla of Vater which is located in the duodenum. |
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Term
| Accessory Pancreatic Duct |
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Definition
Most people only have one duct
Also called the Duct of Santorini
Connects at the minor duodenal papilla in the duodenum |
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Term
| Two types of pancreatic tissue: |
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Definition
Exocrine Tissue:
Digestive enzymes :protease, lipase, trypsin, chymotrypsin, amylase
Endocrine Tissue:
Islets of Langerhans
Secrete hormones (insulin, glucagon, somatostatin) |
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Term
Endocrine Function
of pancreas |
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Definition
The endocrine (hormone-producing) cells are group together in the ISLETS OF LANGERHANS
Hormones are directly secreted in the blood
Constitute 1 to 2% of the mass of the pancreas
Combined weight is 1 to 1.5 grams |
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Term
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Definition
Different cell types
Alpha cells produce glucagon
Beta cells produce insulin and amylin
Delta cells produce somatostatin
PP cells produce pancreatic polypeptide
Epsilon cells produce ghrelin
Islets can influence each other through paracrine and autocrine communication. |
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Term
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Definition
Insulin: Activates beta cells (insulin) and inhibits alpha cells (glucagon)
Causes body to take up glucose from the blood and stores glucose as glycogen in the liver and muscle, and stops the use of fat as an energy source (LOWERS BLOOD SUGAR)
Glucagon: Activates alpha and activates beta and delta cells
Released when glucose is low and causes liver to convert stored glycogen into glucose (RAISES BLOOD SUGAR)
Somatostatin: Inhibits alpha and beta cells |
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Term
| Activates beta cells (insulin) and inhibits alpha cells (glucagon) |
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Definition
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Term
| Activates alpha and activates beta and delta cells |
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Definition
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Term
| : Inhibits alpha and beta cells |
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Definition
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Term
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Definition
Inhibitory hormone
Inhibits insulin and glucagon
In the anterior pituitary gland:
Inhibits release of growth hormone and thyroid-stimulating hormone
Suppresses the release of gastrointestinal hormones
Ex. Gastrin, Cholecystokinin (CCK), Secretin, Motilin
Lowers the rate of gastric emptying and reduces smooth muscle contractions and blood flow within the intestines. |
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Term
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Definition
Exocrine function- secreted into the ducts
Produces a bicarbonate solution to help neutralize pH in the duodenum.
Produces enzymes that help break down food tissue
Proteases, lipase, saccharidases
Trypsinogen
Responsible for most of the auto-digestion that occurs during pancreatitis causes pain and complications
Lipase
Activation of lipase produces the necrosis of fat tissue |
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Term
| Responsible for most of the auto-digestion that occurs during pancreatitis causes pain and complications |
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Definition
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Term
| produces the necrosis of fat tissue |
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Definition
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Term
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Definition
Inflammatory process within the pancreas.
Incidence is 1 to 5 per 10,000 per year.
Different causes but more than 85% is caused by ETOH abuse and biliary tract disease. |
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Term
| Acute Pancreatitis- Signs |
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Definition
Abd pain
Usually epigastric and radiates toward the back
Constant NOT colicky
N/V
Possibly guarding/rebound
Decreased bowel sounds
Jaundice
Steatorrhea –pale, foul-smelling/oily stools |
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Term
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Definition
Caused by chronic alcohol intake which is usually 5-10 years BEFORE first attack.
Only 5-10% of individuals develop ETOH pancreatitis
?Related to environmental factors such as high fat diet or smoking.
Seen in individuals who have as little as 2 drinks per day. |
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Term
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Definition
Gallstones travel down the CBD and get lodged in the Ampulla of Vater with can cause obstruction in the outflow of pancreatic juices from the pancreas into the duodenum.
The backflow of the digestive enzymes cause lysis of pancreatic cells pancreatitis |
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Term
| Also caused by microlithiasis which is crystals in bile. |
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Definition
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Term
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Definition
Also caused by microlithiasis which is crystals in bile.
May cause recurrent pancreatitis
Usually seen after TPN, prolonged fasting, rapid weight loss, use of drugs (octrotide and ceftriaxone)
Look for sludge on US |
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Term
| Most common causes of pancreatitis: |
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Definition
Western countries –chronic alcoholism and gallstones which account for 85% of cases!!!
Eastern countries- Gallstones
Children –Trauma
Adolescents and young adults- Mumps |
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Term
Obstructive/Structural
Acute Pancreatitis |
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Definition
Spincter of Oddi dysfunction (stricture/spasm)
Pancreatic divisum
Trauma
Tumor
Post-ERCP |
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Term
| Metabolic Acute Pancreatitis |
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Definition
Hyperlipidemia (triglycerides >1000)
Hypercalcemia (Hyperparathyroidism) |
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Term
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Definition
Pancreatic Cancer
Sphincter of Oddi dysfunction
Stricture
Spasm
Both increase sphincter pressure and increase the resistance
Pancreatic divisum
Failure of the ventral and dorsal ducts to join during development |
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Term
| Acute Pancreatitis- Genetic factors |
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Definition
Cystic fibrosis
Pancreatic insuffiency
Rarely pancreatitis
Familial pancreatitis
Usually presents before age 20
Higher risk for cancer
Attacks usually caused by ETOH, emotional, fatty diets |
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Term
| Elevated amylase greater than 3x the normal value |
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Definition
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Term
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Definition
Rise rapidly over the first 2-12 hours and slowly decline over the next 3-5 days.
The elevation of the lab value does not predict the severity of the attack.
Not exclusively pancreatic in origin: Also found in SBO, perforation, infarction, DU, fallopian tube, salivary glands, CRI
Elevated amylase greater than 3x the normal value – THINK pancreatitis!!! |
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Term
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Definition
Rise with amylase levels but stay elevated longer.
Better choice if you suspect pancreatitis.
More specific for the pancreas |
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Term
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Definition
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Term
| Acute Pancreatitis- Tests |
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Definition
CXR
Can show pleural effusion
Ileus
Sentinel Loop
US
Cholelithiasis but does not show CBD stone
Not really useful because of body habitus and sentinel loop
May show edema of pancreas
Can not see pancreas in 30-40% secondary to bowel gas and obesity
CT Scan with contrast
Most ordered
May show inflammation or fluid around the pancreas
The IV portion of the test helps to identify necrotizing pancreatitis |
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Term
| Acute Pancreatitis- Tests |
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Definition
MRI
About the same information as CT
Helps to identify pseudocyst from necrotic debris
MRCP
Shows Bile Duct Stones
Helpful in people who can’t undergo ERCP
Endoscopic Ultrasound (EUS)
Pancreatic cancers
Ductal stones |
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Term
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Definition
Endoscopic retrograde cholangiopancreatography
Early ERCP (within 24-72 hours) is known to reduce morbidity and mortality. Indications are:
Clinical deterioration or lack of improvement within 24 hours
CBD stones or dilated hepatic ducts
Can introduce infection to sterile pancreatitis
Treats bile duct stones
Shows pancreatic divisum
Shows sphincter of Oddi disease
Watch for aggravation or induction of pancreatitis
More Invasive (watch for bleeding) |
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Term
| pancreatitis labs at admission |
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Definition
| Glucose, Age, LDH, AST, WBC |
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Term
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Definition
| Calcium, Hematocrit, O2, BUN, Base deficit, Sequestration |
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Term
| Acute pancreatitis - Treatment |
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Definition
pain control
bowel rest
nutritional support
antibiotics |
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Term
Pain control
acute pancreatitis |
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Definition
Morphine vs Demerol
Morphine causes Sphincter of Oddi spasm |
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Term
| Nutritional support for acute pancreatitis |
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Definition
TPN
Post-pyloric enteral feeding (past 3rd portion of duodenum) |
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Term
| Surgery for acute pancreatitis |
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Definition
Gas bubbles on CT scan
Positive bacterial culture on FNA
Options:
Necrosectomy with simple drainage
Necrosectomy with closed continuous lavage
Open management with planned staged reoperations. |
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Term
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Definition
Long-standing inflammation of the pancreas.
Alters the normal structure and function.
Can be associated with pancreatic cancer! |
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Term
| Chronic Pancreatitis symptoms |
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Definition
Abd pain
Steatorrhea
N/V
Weight loss
Polyfecalia (multiple BMs) |
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Term
| Chronic Pancreatitis labs |
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Definition
CBC
CMP
Amylase
Lipase
May not be elevated or only mildly elevated
Triglycerides
CXR –often can see calcifications on imaging studies
US
CT scans- often smaller with chronic inflammatory changes and calcifications.
MRCP
ERCP- GOLD STANDARD |
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Term
GOLD STANDARD
chronic pancreatitis |
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Definition
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Term
| To check for pancreatic exocrine dysfunction |
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Definition
| measure the fecal elastase level, less than 200ug/g indicates pancreatic insuffiency |
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Term
| Treatment chronic pancreatitis |
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Definition
Support
Remember analgesia!!
Therapeutic endoscopy
Surgery
Resection
Drainage
Remember ****DM is very common |
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Term
| Pancreatic Enzyme Supplementation |
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Definition
Replacement of pancreatic enzymes are often effective in treating malabsorption and steatorrhea.
Ex. Creon
Inconclusive about reduction in pain. |
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Term
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Definition
Associated with SEVERE pancreatic inflammation.
The inflammation causes cell death with devitalized tissue high risk for infection!
Amount of necrotic tissue is a strong predictor of mortality.
After pancreatic necrosis occurs there are three possible outcomes
Resolution
Pseudocyst
Abscess |
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Term
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Definition
A persistently elevated WBC with left shift and positive blood cultures is suggestive.
The degree of amylase/lipase elevation does not directly indicate degree of necrosis! |
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Term
| Necrotizing pancreatitis tests |
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Definition
CT scan with contrast
Can reveal ischemic pancreatic tissue by decreased contrast uptake
US
Transabdominal
Endoscopic
MRI
Better at distinguishing abscess from cyst |
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Term
| Most common pathogen isolated Necrotizing pancreatitis |
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Definition
| E. coli, Klebsiella pneumoniae, Enterococcus faecalis |
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Term
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Definition
Pseudoscysts are fluid collection that is rich in pancreatic enzymes such as amylase, lipase, and trypsin.
Form over several weeks after the acute necrotizing pancreatitis occurs.
Can be single or multiple
Multiple cysts are often seen in ETOH pancreatitis
Multiple cysts occur in 15% of cases
Fluid can be clear, watery, or xanthochromic
Can persists weeks after the acute pancreatic attack resolves. |
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Term
| Pancreatic Pseudocyst Pathogenesis |
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Definition
Caused by a disruption of the pancreatic duct from the pancreatitis and subsequent extravasation of the pancreatic enzymes.
Two thirds of the patients have demonstratable connections to the pancreatic duct
Most are caused by ETOH pancreatitis and gallstone pancreatitis
75-85% |
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Term
| Pancreatic Pseudocyst Diagnosis |
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Definition
US NOT study of choice secondary to fluid around pancreas during attacks and body habitus
CT scan with contrast
Good at determining wall thickness
ERCP
MRI
Helps determine cyst vs necrotizing abscess
Endoscopic US |
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Term
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Definition
Catheter Drainage
Percutaneous aspiration helps with diagnosis
54% failure rate and a 63% recurrence rate
Percutaneous catheter drainage
Treatment of choice for infected pseudocyst because of rapid drainage and identification of organisms
Endoscopic Drainage
Trained hands
Surgical Drainage –Gold standard
Mortality rate of 3% and complication rate of 24%
Success rate is 85-90% |
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Term
Catheter Drainage
Pseudocyst Treatment |
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Definition
Percutaneous aspiration helps with diagnosis
54% failure rate and a 63% recurrence rate
Percutaneous catheter drainage
Treatment of choice for infected pseudocyst because of rapid drainage and identification of organisms |
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Term
| Gold standard Pseudocyst Treatment |
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Definition
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Term
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Definition
Most pseudocysts resolve on their own!
Outcome is worse in patients who have complications or have the cyst drained.
Presence of pancreatic necrosis is a BAD SIGN! |
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Term
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Definition
A pancreatic abscess is a cavity of pus within the pancreas.
Pancreatic abscesses develop in patients with pancreatic pseudocysts that become infected.
MRI usually better at distinguishing between cyst vs abscess |
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Term
| Pancreatic abscess treatment |
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Definition
Percutaneous drainage
Surgical drainage
The outcome is related to the severity of the infection. Death rate from undrained abscesses is very high!!!! Sepsis
Adequate drainage of pseudocyst may help prevent some cases of abscess formation, but not all are preventable. |
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Term
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Definition
| An acute inflammation of the pancreas accompanied by the formation of necrotic areas and hemorrhage into the substance of the gland; clinically marked by sudden severe abdominal pain, nausea, fever, and leukocytosis; areas of fat necrosis are present on the surface of the pancreas and in the omentum because of the action of the escaped pancreatic enzyme (trypsin and lipase). |
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Term
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Definition
Life-threatening condition with the mortality rate of 50%
Due to the following:
Shock
Disseminated inflammatory response syndrome
Multiple organ failure
Massive GI bleeding
Sepsis
Peritonitis |
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Term
| Hemorrhagic Pancreatitis signs |
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Definition
Pleural effusions
Hematemesis
Grey Turner’s Sign
Cullen’s sign
Melena
Coma |
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Term
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Definition
| Large area of bruising to the flanks |
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Term
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Definition
| Large area of bruising to the umbilical area |
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Term
cullen's sign
grey turner's sign |
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Definition
Both are from blood accumulation within the abdominal fascial planes
Takes 24-48 hours to appear
Predicts a severe case of pancreatitis
High Mortality rate from 10-40%
More indicative of hemorrhagic pancreatitis with retroperitoneal or intrabdominal bleeding. |
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Term
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Definition
It is a congenital abnormality of the ventral and dorsal ducts and one main pancreatic duct is NOT formed.
Only 10% of embryos develop this
In utero, most of the pancreatic enzymes are drained via the dorsal duct that drains into the major papilla and a small amount is drained from the ventral duct via the minor papilla.
HOWEVER, in adults the majority of the enzymes are drained by the ventral duct via the minor papilla. |
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Term
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Definition
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Term
| 4th leading cause of death from cancer. |
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Definition
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Term
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Definition
Median survival is 3-6 months
80-85%of patients present with locally advanced or metastatic disease.
In 2004, 31,800 people in the US were diagnosed with pancreatic cancer, and approximately 31,200 people died.
Prognosis is poor, <5% of patients diagnosed with pancreatic cancer are alive 5 years out.
Complete remission is extremely rare. |
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Term
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Definition
Usually vague and is one reason diagnosis is late.
Upper abdominal pain that may radiate to the back.
PAINLESS Jaundice
Tumors in the head of the pancreas which is near the CBD are likely to cause jaundice (60%)
Clinicians can recognize jaundice 2-3, others 8-9
Loss of appetite
Weight Loss
Diarrhea/Steatorrhea (fatty BMs that float in water)
New onset of DM |
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Term
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Definition
| death very high from sepsis |
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Term
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Definition
| present in one-half of patients with locally unresectable disease, while painless jaundice is present in one-half of patients with a potentially resectable and curable lesion. |
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Term
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Definition
The presence of Jaundice and a PAINLESSLY distended gallbladder is a strong indicator of pancreatic cancer.
Especially cancer in the head of the pancreas
May help distinguish between pancreatic cancer from gallstones. |
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Term
Adenocarcinoma
in pancreas |
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Definition
Are produced by the cells that line the ducts of the pancreas
Very aggressive and account for approximately 95% of the pancreatic cancers with mets likely
Also call exocrine cancers |
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Term
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Definition
LFTS
Total Bili
AST/ALT
ALK Phos
CA19-9
Tumor marker frequently elevated in pancreatic cancer
US
Abd CT with contrast
EUS
ERCP |
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Term
| Whipple procedure (pancreaticoduodenectomy) |
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Definition
Performed in patients with cancer in head of pancreas
Removal of the distal segment of the stomach (antrum), the first and second portions of the duodenum, the head of the pancreas, the distal portion of the CBD, and the gallbladder. |
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Term
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Definition
Reconstruction constists of attaching the pancreas to the jejunum (pancreaticojejunostomy), attaching the CBD to the jejunum (choledochojejunostomy) to allow digestive juices and bile to flow to the GI tract and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through.
Can only be performed in patients likely to survive major operation AND tumor is localized without invading local structures or mets. |
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Term
| Other treatments for pancreatic cancer |
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Definition
Tumors in the tail can be resected via distal pancreatectomy.
ERCP with stent placement
Helps with pain from obstruction/strictures and itching (elevated bilirubin)
Chemotherapy (often gemcitabine) following surgical procedures.
Chemotherapy is also used as a pallative measure for those individuals not suitable for resection
This may increase quality of life with only a modest gain in survival benefit. |
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Term
| Zollinger-Ellison Syndrome |
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Definition
Rare disorder
Causes peptic and duodenum ulcers and tumors in the pancreas and duodenum.
Tumors secrete excess gastrin increase acid in stomach Ulcers
Ulcers are less responsive to treatment
25% of cases are associated with Multiple endocrine neoplasia (MEN) type 1
MEN is a genetic disorder |
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Term
| Zollinger-Ellison Syndrome symptoms |
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Definition
Symptoms:
Burning pain in the abdomen
Often described as gnawing
Diarrhea
N/V
Fatigue
Weakness
Weight Loss
Fear of eating
Bleeding
From Ulcers |
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Term
| Zollinger- Ellison Syndrome tests |
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Definition
Endoscopy
Secretin stimulation test
Measures gastrin levels in response to secretin
Fasting gastrin levels
Antral acidity |
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