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42 Cards in this Set

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identify the 2 classifications of acute pancreatitis

1. Interstitial (edematous):


most common, milder, NO acinar cell death




2. Necrotizing:


less common (15-20%), severe, most mortalities

signs and symptoms of acute pancreatitis

Epigastric pain** (Hallmark: feels like a knife is in their belly),




N/V




Anorexia




Severe cases “shocky”

trypsinogen is activated by .....

cathepsin B

pancreatic enzymes without pro-enzyme form

amylase




lipase

2 most common causes of pacreatitis

alcohol




gallstones

elevated IgG4

autoimmune pancreatitis

sausage shaped pancreas

autoimmune pancreatitis

1. most specific serological marker for acute pancreatitis




2. drug that can give you a false positive

1. Lipase (3X uln)




2. heparin

best serological marker for prognosis

BUN




>20 = intravascular depletion

how to differentiate macroamylassemia from acute pancreatitis

they both have elevated serum amylase




look at the urine amylase:creatinine ratio:


1. macroamylasemia: close to 0


2. acute pancreatitis: elevated

PRSS1

autoimmune pancreatitis

#1 cause of chronic pancreatitis

alcohol




increases viscosity of pancreatic secretions, causes sphincter of Oddi spasm, loss of R protein

most sensitive and specific test for chronic pancreatitis

fecal elastase




early phases of pancreatic insufficiency




<200 = pancreatic insufficiency

pancreatic calcifications on x-ray

confirmatory diagnosis for chronic pancreatitis

two things you see in chronic pancreatitis but not acute pancreatitis

statorrhea




diabetes mellitus

Pancreatic Enzyme Replacement for chronic pancreatitis:




1. non-enteric coated


- what does it treat?


- what do you give with it?




2. enteric coated


- what does it treat?

1. non-enteric coated


- pain (high in peptidase)


- antacids (PPI)




2. enteric coated


- steatorrhea (high in lipase)

most important factor for gallstone formation

gallbladder stasis

charcot's triad

cholangitis




1. fever


2. pain


3. jaundice

reynold's pentad

charcot's triad +:




4. shock


5. encephalopathy

who get's gallstones the most

PIMA indian women

how would you test for gallbladder disease?

Ultrasound 1st (gallstone --> you’ll see Post-acoustic shadowing)




THEN CCK simulated HIDA Scan (but do not stimulate with CCK if there are known gallbladder stones!!!!)




won't see on x-ray because gallstones are radioluscent

Black Pigment stones:

increased unconjugated bilirubin, most commonly due to Hemolysis




Mostly salt of unconjugated bilirubin

Brown Pigment Stones:

Due to infection (3rd world country)




Contain calcium bilirubinate, calcium palmitate, mucin, biliary epithelia, and cholesterol


Bacterial cell bodies are seen at the core

prognosis for pancreatic adenocarcinoma (exocrine tumor)

Overall 5 year survival: 3-5% LOWEST OF ALL CANCERS!!

diagnosis of insulinoma

Hypoglycemia + elevated insulin with pancreas mass.




72 hour fast: if Insulin/glucose > 0.3 = insulinoma! Tumor of Beta islet cell




Symptoms: HA, confusion,light-headness, visual sx’s, irrational behavior, drowsiness, coma

diagnosis of VIPoma

Secretory diarrhea + increased serum VIP




Symptoms: fasting large volume diarrhea (>3L/day), hypokalemia, hypochlorohydria, flushing

diagnosis of GRFoma

Acromegaly + increased growth hormone level +pancreatic mass

diagnosis of glucagonoma

tumor of alpha islet cells




increased serum glucagon >1000pg/ml + pancreatic mass




dermatitis ***Necrolytic migratory erythema***, glucose intolerance, weight loss, anemia,chronic diarrhea




Tx: octreotide/ surgery

what is a klatskin tumor




symptoms? how do they die?




Tx?

Cholangiocarcinoma at junction of left and right intrahepatic ducts.




PAINLESS Jaundice. Die of hepatic failure or cholangitis.




TX: resection (hepatojejunostomy)

acute pancreatitis with:




ALT > 3X ULN

gallstone pancreatitis

acute pancreatitis with:




CRP > 150

severe acute pancreatitis

how do you diagnose acute pancreatitis

2 out of 3:




1. characteristic epigastric pain radiating to back (knife stabbed through them)




2. + CT findings




3. lipase >3X ULN

treatment of acute pancreatitis

mostly supportive:




FLUIDS!!! (monitor BUN closely)




naso-jejunal feeding tube




(don't give antibiotics if they only have interstitial [do give for necrotizing, biliary obstruction or abscess?])




narcotics may worsen ileus



pancreaticpseudocyst


VS.


acute peripancreatic fluid collection

Timing is KEY:




pseudocyst: 4-6 weeks after acute episode




acute peripancreatic fluid collection: shortly after acute episode

treatment of chronic pancreatitis

1. diet (low fat, small meals)




2. pancreatic enzyme replacement




3. chronic pain control (stop drinking and smoking)

when should you do a cholecystectomy for gallbladder disease patients that could potentially have cancer?

any PSC pt with a polyp




any polyp > 1cm




porcelain gallbladder




Adenocarcinoma (radical cholecystectomy,right lobectomy, trisegmentectomy)



gallbladder adenocarcinoma:




diagnosis


symptoms


treatment

(most common GB cancer)




Diagnosis:


- Increased ALP/Bilirubin.


- CEA/ CA 19-9 may be elevated.




Symptoms: Pain is initial complaint, hepatomegaly, palpable mass, ascites. Jaundice, malignant cholecysto-enteric fistula


Treatment:


- 80% have unresectable tumors. 1-6% 5 year survival.


- Surgery: radical cholecystectomy, right lobectomy, trisegmentectomy.


- Chemo/XRT NOT helpfl





diagnosis of pancreatic adenocarcinoma

no calcification in ductal adenocarcinoma (seeing calcification is good because it means it's not ductal)




85% have increase CEA level




CA19-9 may be useful to follow tumor? and most commonly associated with pancreatic cancer?

Insulinoma:




insulin:glucose > ___?___

0.3

necrolytic migratory erythema

glucagonoma

pancreatic tumor with acromegaly

GRFoma

pancreatic tumor with secretory diarrhea

VIPoma