Pancreas Function/Disorders

Question 1

which arteries supply the pancreas?

Answer 1

celiac and SMA

Question 2

exocrine pancreas is ___% pancreatic mass

exocrine pancreas makes ______

Answer 2

85%

digestive enzymes, water, bicarb –> duodenum

Question 3

pancreatic embryology

Answer 3

Question 4

common variations in pancreatic duct anatomy

Answer 4

90%- Santorini and major duct connected

10% - fusion does no occur = pancreas divisium –> higher risk for pancreatitis

Question 5

regulation of pancreas secretion

Answer 5

Question 6

what determines bicarb secretion from the pancreas?

Answer 6

duodenal pH >4.5 - sensed in s/secretin cells

Question 7

how does the pancreas avoid digesting itself?

Answer 7

pancreatic enzymes are stored in pancreas and secreted into duodenum as PROENZYMES. Enterokinase at brush border in duodenum converts trypsinogen –> trypsin. Trypsin makes the other zymogens –> active enzymes.

amylase and lipase are stored in active forms b/c there is no starch or TG in the pancreas to be digested

Question 8

5 protective mechanisms in the pancreas

Answer 8

1. synthesis of enzymes as inactive zymogens
2. trypsin inhibitor packaged in zymogen granules
3. segregation of enzymes in membrane bound compartments
4. enterokinase restricted to small intestine
5. acidic pH w/in zymogen inactivates Trypsin

Question 9

Labs in acute pancreatitis

Answer 9

WBC: often elevated

Amylase: leaks from inflamed pancreas. high sensitivity, low specificity

Lipase: sensitive as amylase, but more specific , and remainvs elevated

Question 10

Atlanta criteria for Acute pancreatitis

Answer 10

two or more of the following:

• ​abdominal pain consistent w/ acute pancreatitis: sudden onset upper abdominal pain, often radiating to upper back. steady pain w/ “boring” quality.
• elevated amylase or lipase >3x normal
• confirmatory finding on CT

Question 11

normal amylase, high lipase - interpretation?

Answer 11

delayed presentation of acute pancreatitis

Question 12

how do gallstones cause pancreatitis?

Answer 12

migrate to the cystic duct –> common duct –> can obstruct the ampulla of vater –> pancreatitis and/or cholangitis

Question 13

which pancreatic hormone is most specific in dx pancreatitis?

Answer 13

lipase

lots of things can cause elevation of amylase

Question 14

How do you assess the severity of pancreatitis?

Answer 14

Bedside eval

BISAP >2

• BUN>25, impaired mental status, SIRS, Age>60, pleural effusions

BUN >22

CRP >125 @48 hrs

SIRS persisting through 48 hours

Question 15

what is SIRS?

Answer 15

presence of at least 2

• pulse >90 BPM
• RR >20 or PCO2<32mm Hg
• T> 100.4 or <96.8
• WBC> 12K or <4K

Question 16

what are these and prognosis for each

Answer 16

left = interstitial

• very low mortality and infection (<1%)

right = necrotizing

• high infection rate (30-50%)
• mortality 10-30%

Question 17

what causes acute pancreatitis?

Answer 17

1. alcohol
2. gallstones
3. idiopathic
4. other: high TGs, autoimmune, drugs, IBD, infectious, neoplasm, toxic, iatrogenic (ERCP), trauma, scorpion

Question 18

inherited causes of pancreatitis

Answer 18

altered enzyme activity: trypsinogen mutations

abnormal ion movement: CFTR mutation

metabolic: familial hypertriglyceridemia (TGs <1000)

Question 19

tx for acute pancreatitis

Answer 19

nothing to tx underlying pathophys

supportive care: IV fluids/lytes (EARLY and w/ Lactate Ringers), montioring, analgesia + antiemetics

other txs: Abx, NG tube, nutritional support, urgent ERCP (if gallstones)

Question 20

systemic complications of acute pancreatitis

Answer 20

Question 21

local complications of acute pancreatitis

Answer 21

fluid collection

necrosis

infection

ascites

erosion into adjacent structures

GI obstruction

hemorrhage

Question 22

what is a pancreatic pseudocyst?

Answer 22

localized collection of pancreatic fluid that develops >4 wks after pancreatitis onset

how to distinguish from true pancreatic cysts: absence of epithelial lining

Question 23

how to prevent infection in acute pancreatitis pt?

Answer 23

enteral feeding through jejunal tube! - to maintain gut barrier function

*abx use is controversial for prophylaxis

Question 24

causes of death in acute pancreatitis

Answer 24

early <1 wk: SIRS, multiorgan failure

late: multiorgan failure, pancreatic infections/sepsis

Question 25

features of chronic pancreatitis

Answer 25

* pain * calcification * pancreatic insufficiency

Question 26

what causes chronic pancreatitis?

Answer 26

* cystic fibrosis * hereditary pancreatitis (same conditions as acute) * hypertriglyceridemia * autoimmune * fibrocalcific (equatorial countries)

Question 27

course of chronic pancreatitis

Answer 27

gradually progressive pain at presentation. decreases w/ longstandng disease. calcification, malabsorption, and diabetes increase w/ progression \*increased risk of pancreatic cancer

Question 28

name 5 causes of pain in chronic pancreatitis

Answer 28

* ischemia * pseudocyst * inflammation (general and neural) * duodenal and common duct obstruction * PD obstruction --\> increased pancreatic pressure

Question 29

at what point does pancreatic enzyme deficiency cause steatorrhea?

Answer 29

\<10% lipase output

Question 30

Answer 30

calcifications in chronic pancreatitis

Question 31

tx for chronic pancreatitis

Answer 31

enzyme replacement and H2 blockers pain tx: narcotics, neuro-modulators (antidepressants), anti-inflammatory drugs, somatostatin

Question 32

surgical tx of chronic pancreatitis pain

Answer 32

lateral pancreaticojejunostomy

Question 33

Answer 33

mild acute pancreatitis aka edematous or interstitial pancreatitis separation of pancreatic lobules from eachother b/c edema. no evidence of necrosis in acinus.

Question 34

Answer 34

severe acute pancreatitis acinar tissue is totally necrotic and gone

Question 35

Answer 35

acute pancreatitis w/ pseudocyst: area of pancreas has become liquefied and necrotic. no epithelial lining

Question 36

Answer 36

wall of pseudocyst

Question 37

Answer 37

chronic inflammation, fibrosis in chronic pancreatitis atrophy of acinar tissue

Question 38

pathogenesis of pancreatitis

Answer 38

* ​injury of acinar cells: activation of proenzymes * duct obstruction w/ increased intraductal pressure --\> leakage of pancreatic enzymes * activation of trypsin and other proenzymes

Question 39

necrosis-fibrosis hypothesis

Answer 39

one theory about pathogenesis of chronic pancreatitis repeated episodes of acute pancreatitis --\> focal necrosis, patchy scarring, duct distortion this is probably happening in chronic alcoholics

Question 40

PRSS1

Answer 40

mutant cationic trypsogen gene --\> elimate trypsin last-resort off-switch high incidence of pancreatic carcinoma

Question 41

CF and pancreatitis

Answer 41

defect in electrolyte transport --\> viscous material accumulates in ducts --\> obstruction

Question 42

lab findings, histology and tx in autoimmune pancreatitis

Answer 42

Labs: autoantibodies or high IgG histology: CP w/ ductitis tx: steroids NOT SURGERY