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99 Cards in this Set
- Front
- Back
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Where is the pancreas located?
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behind stomach in upper abdomen on the right side
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What are the endocrine functions of the pancreas?
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makes glucagon, insulin, somatostatin
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What are the exocrine functions of the pancreas?
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secretes digestive enzymes and bicarbonate into the duodenum (small intestine)
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What kind of organ is the pancreas?
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glandular organ
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Where is the Islet of Langerhans located?
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pancreas
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What cells produce insulin?
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beta
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What cells produce glucagon?
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alpha
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What cells produce somatostatin?
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delta
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What digestive enzymes are synthesized in the acinar cells of the pancreas?
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Lipase, colipase, trysinogen, chymotrypsinogen, procarboxypeptidase, proelastase, amylase, ribonuclease, and deoxyribonuclease
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What do centro-acinar cells secrete?
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bicarbonate
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Do acinar cells perform endocrine or exocrine function?
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exocrine
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How many liters of isotonic fluid (water, electrolytes, enzymes) do acinar cells secrete per day?
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1-2L
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The protein enzymes that acinar cells secrete are zymogens. What does this mean?
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A zymogen (or proenzyme) is an inactive enzyme precursor.The pancreas secretes zymogens partly to prevent the enzymes from digesting proteins in the cells in which they are synthesised
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Where do the pancreatic juices flow?
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Down the pancreatic duct to the Ampulla of Vater
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What sphincter releases the pancreatic juices and where is this located?
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Sphincter of Oddi into the duodenum
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What is the pH of the pancreatic juices?
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8.3
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What converts trypsinogen to trypsin?
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enterokinase (in duodenal mucosa)
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What activates all other zymogens other than trypsinogen?
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once trypsinogen is coverted to trypsin in the duodenal mucosa (by enterokinase) it activates all the other zymogens
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What are the 3 phases of pancreatic enzyme secretion?
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cephalic phase/ phase I, gastric distention/ phase II, intestinal phase/hormonal phase/phase III
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What occurs in the cephalic phase of pancreatic enzyme secretion?
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sight, smell, taste, and anticipation of food activate the vegus nerve to activate the secretion of bicarbonate and pancreatic enzymes
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What occurs during the phase II/gastric distention of pancreatic enzyme secretion?
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food in stomach causes stretch which releases pancreatic enzymes
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What occurs during the phase III/ intestinal phase/ hormonal phase of pancreatic enzyme secretion?
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chyme and acid stimulate cholecystokinin (CCK) and secretin (SC) release from the intestinal mucosa
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What stimulates the release of CCK?
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fatty acids and amino acids
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What stimulates the release of SC?
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ph ~ 4.5
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What is the function of CCK?
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cholecystokinin stimulates acinar cells to release juice low in water and bicarbonate but high in enzyme content
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What is the function of SC?
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secretin prompts ductular cells to increase water and bicarbonate
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What is the function of Vasoactive intestinal polypeptide?
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similar to SC but secretin effects on exocrine pancreatic secretion are much less potent
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What is another name for somatostatin?
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ocretotide
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What does somatostatin do in regards to the pancreas?
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inhibits enzyme secretion via cholinergic transmission
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Where is 80% of the body's serotonin located?
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enterochromaffin cells
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What causes the release of serotonin in the intestine?
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duodenal acidification
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What is the role of serotonin in digestion?
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currently investigating a role in postprandial pancreatic secretion
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What is a sudden onset related to anatomical obstruction or traumatic injury of the pancreas called?
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acute pancreatitis
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Is recovery of pancreatic function likely in acute pancreatitis?
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yes
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What term describes the inflammation of the pancreas characterized by edema and cellular exudate?
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interstitial pancreatitis
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What term describes the inflammation of the pancreas characterized by fat and extrapancreatic necrosis?
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necrotizing pancreatitis
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What is the prognosis in mild acute pancreatitis?
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self limiting (interstitial)
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What usually occurs in severe acute pancreatitis?
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Autodigestion has progressed to necrosis, and hemorrhage of pancreatic tissue and into retroperitoneal space (necrotizing)
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What is the pathophysiology of acute pancreatitis?
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premature activation of trypsinogen to trypsin which leads to zymogen activation and autodigestion of the pancreas. The damaged acinar cells release cytokines which recruit neutrophils, macrophages that enhance the inflammatory response
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What occurs as a result of vascular damage during acute pancreatitis?
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kinin release promoting capillary permeability and edema. This leads to the translocation of bacteria from the colon resulting in bacterial infection. Activated pancreatic enzymes can also be released into the circulation damaging distant organs
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What are the local and acute complications in pancreatitis?
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fluid collection, pancreatic ascites, pancreatic necrosis, infection, abscess, shock
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What are the local and delayed complication in pancreatitis?
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pseudocyst, GI bleeding
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What etiologic risk factors are responsible for 70% of acute pancreatitis?
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gallstones and alcohol abuse
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What are the class 1 medications in commonly prescribed group that contribute to pancreatitis?
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aspirin, opiates, corticosteroids, estrogens, furosemide, SMX-TMP, Tetracycline, Valproic Acid
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What does the acronym "I get smashed" stand for?
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I(idiopathic) G(allstone) E(thanol) T(rauma) S(teroids) M(umps) A(utoimmune disease) S(corpion sting) H(ypercalcemia or hypertriglyceridemia) E(RCP) D(rugs and duodenal ulcers) - all causes of pancreatitis
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What viruses are associated with pancreatitis?
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paramyxovirus, Epstein-Barr, cytomegalovirus
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What are the symptoms associated with pancreatitis?
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pain in upper abdomen radiating to back (varying severity; worsen with food ingestion), N/V, abdominal distention, steatorrhea; severe cases: hypotension, oliguria (shock), dyspnea
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What are the physical exam findings in pancreatitis?
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marked epigastric pain (diffuse tenderness on palpation with rebound tenderness), ab distention and tympanic, bowel sounds decreased or absent, vitals normal (hypotension, tachycardia, low grade fever, dyspnea, tachypnea in severe??), jaundice and altered mental status
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In pancreatitis, thrombocytopenia and increased INR are associated with what degree of acute pancreatitis?
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severe
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In pancreatitis, what lab results suggest gallstone pancreatitis?
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increased liver transaminases, alkaline phosphatase, and bilirubin
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What do serum amylase greater than 3x normal suggest?
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acute pancreatitis; presistent elevation suggest extensive necrotic damage
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How long is amylase elevated in acute pancreatitis?
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elevated 4-8 hours following attack, should peak with 24 hours. Amylase returns to normal over the following 8- 14 days. Level 3 times normal are highly suggestive of pancretitis. Persistent elevations suggest extensive necrotic damage
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What does marked hypocalcemia suggest in pancreatitis?
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Marked hypocalcemia indicates severe necrosis and is a poor prognostic sign
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What may be associated with may be associated with leukocytosis, hyperglycemia, hypoalbuminemia,
mild hyperbilirubinemia, and elevations in serum alkaline phosphatase and hepatic transaminases? |
acute pancreatitis
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What does an increase in serum lipase mean?
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Serum lipase is specific to the pancreas, and concentrations are usually
elevated. The increases persist longer than serum amylase elevations and can be detected after the amylase has returned to normal. |
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What is the gold standard imaging test for pancreatitis?
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CT scan
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What is the APCHE II threshold for severe AP?
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>=8. Acute Physiology and Chronic Health Evaluation System is considered one of the best predictors of severity on admission
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What is the clinical course in mild AP?
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self limiting, spontaneous resolution wihtin 3-5 days
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What is the clinical course in necrotic pancreatitis?
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mortality 10%
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What is the clinical course in infected necrotic pancreatitis?
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mortality 30-40%
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Which is higher mortality rate idiopathic&postoperative AP or gallstone&alcohol induced AP?
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idiopathic and postoperative AP have a higher mortality rate
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Does mortality rate increase with each AP episode?
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no it decreases
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What are the tx goals in AP?
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relieve pain, nausea, replace fluids, minimize systemic complications, prevent necrosis and infections
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In mild disease AP, what are the drug tx?
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analgesics (try APAP first, then NSAID, finally opioid), nausea (zofran or promethazine)
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In mild disease AP, what is the non-drug tx?
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fluid replenishment, hold food until bowel sounds are present. First few days start with clear liquid diet and avoid fat. Progress to 6 small meals daily. Follow fat-restricted diet
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How many grams of fat/d in AP?
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40g
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What are the general categories of tx in severe pancreatitis?
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aggressive fluid replacment, symptom management (insuling for hyperglycemia, electrolyte replacement), analgesia, nutritional support
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In severe pancreatitis analgesia therapy, what was the gold standard and why is it not anymore?
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Merperidine- was gold standard, risk for seizures in renal insufficiency- not a formulary item
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What are the two narcotics given in severe pancreatitis?
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morphine and hydromorphone
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What is the dosing for morphine in severe pancreatitis?
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5-10mg IV a 4 h; thought to cause spasm of Sphincter of Oddi and pancreatitis
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What is the dosing for hydromorphone in severe pancreatitis?
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0.2 to 0.6 mg IV q 2-3h
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Are antisecretory medications indicated for treating pain in severe pancreatitis?
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PPI and H2RA have no evidence of efficacy in prevention of pain associated with pancreatitis. Can treat/help treat mucosal bleeding
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What medication is indicated for the prevention of necrosis in severe pancreatitis?
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octreotide; decreases mortality, sepsis, LOS
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What is the dosing for octreotide in severe pancreatitis?
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0.1mg SC q 8 h
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What is the moa of octreotide in severe pancreatitis?
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potent inhibitor of pancreatic enzyme secretion
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Does EBM support octreotide use in severe pancreatitis?
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no studies are conclusive
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Who should receive infection prophylaxis in severe AP?
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only patients with severe AP complicated by necrosis
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What Abx should be used in prophylaxis of infection in severe necrotic AP?
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Imipenem-cilastin 500mg q8h OR flagyl+cipro x 10-14 days for PCN allergies
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How is enteral nutrition achieved while avoiding the stimulation of secretion of pancreatic enzymes during pancreatitis?
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insertion of feeding tube into jejunum bypasses the cephalic and gastric phases of pancreatic stimulation thus pancreas is not stimulated to increase output
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What formula of enteral nutrition is best for pancreatitis pts?
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elemental and hydrolyzed formulas best tolerated
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What is the result of chronic pancreatitis?
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results in functional and structural damage to the pancreas in which loss of pancreatic function is permanent (both exocrine and endocrine)
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What is the pathophys of ethanol induced chronic pancreatitis?
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appears to progress from inflammation to
cellular necrosis, and fibrosis occurs over time. Chronic alcohol ingestion causes changes in pancreatic fluid that create intraductal protein plugs that block small ductules. This results in progressive structural damage in the ducts and acinar tissue. Calcium complexes with the protein plugs, eventually resulting in destruction of pancreatic tissue. |
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What is responsible for 70% of chronic pancreatitis cases?
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prolonged alcohol consumption
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What are the complications in chronic pancreatitis?
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pancreatic pseudocyst, abcess, ascites (pancreatic), common bile duct obstruction, cholangitis, secondary biliary cirrhosis
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What are the symptoms in chronic pancreatitis?
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epigastric pain, pain radiating to back (deep-seated, positional, nocturnal, unresponsive to medication, mild to sever, may be aggravated by eating), N/V
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What are the signs of chronic pancreatitis?
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steatorrhea, diarrhea, bloating, weight loss (due to malabsorption of protein and fat), vit b12 malabsorption (brain, nerve damage), pancreatic diabetes (occurs late)
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What are the lab test results for chronic pancreatitis?
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WBC, fluids, electrolytes are normal; amylase and lipase are normal unless pancreatic duct is blocked or pseudocyst
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What imaging technique is used for chronic pancreatitis?
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ultrasound, look for calcification of pancreas
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What are the classic signs and symptoms of chronic pancreatitis?
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heavy alcohol use, recurrent upper ab pain
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What is the triad in diag of chronic pancreatitis?
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calcification of pancreas, steatorrhea, diabetes
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How long does it take for pain to occur in chronic pancreatitis?
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5-10 y following onset
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How long does it take for steatorrhea, calcification, and diabetes to occur in chronic pancreatitis?
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10-20 years after drinking
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What are the tx goals in chronic pancreatitis?
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control ab pain, correct malabsorption with pancreatic enzymes, insulin to treat diabetes
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What can the avoidance of alcohol in chronic pancreatitis achieve?
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decrease pain
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What drug pain tx are first line in chronic pancreatitis?
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APAP, NSAIDS, Tramadol. Pain meds should be on a scheduled basis to keep dosing low
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For pain control in chronic pancreatitis, what is the nutritional tx?
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6 small meals/d and restricted fat diet of 40-60g/d
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What are the pancreatic enzyme formulations used to treat malabosorption?
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pancreaze, creon, zenpep
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What is the place in therapy in chronic pancreatitis for anti-secretory drugs?
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PPI and H2RA can modify the gastric ph and lower acid secretion which improves the efficacy of pancreatic enzyme tx. used to help in malabsorption
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What does chronic pancreatitis therapeutic outcome depend on?
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patients' ability to abstain from alcohol and tobacco
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