Diseases of the Exocrine Pancreas

Diseases of the Exocrine Pancreas
Presentation by: Emre Conklu, DO

Anatomy

* Divided into 4 parts: head, neck, body, and tail, located retroperitoneally.
* The head of the pancreas attaches firmly to the duodenum.
* The head rests posteriorly on the IVC, and R renal artery/vein.
* Sphincter of Oddi- is composed of smooth muscle that controls the flow of bile and pancreatic juice into the duodenum.

Blood Supply

* Derived mainly from branches of the splenic, gastroduodenal, and superior mesenteric arteries.
* The head is supplied by the superior and inferior pancreaticoduodenal arteries, branches of the gastroduodenal and super mesenteric arteries.

Lymphatics

* Follow the blood vessels
* Efferent vessels drain to the celiac, hepatic, and superior mesenteric lymph nodes.

Nerve Supply

* Derived from the vagus and thoracic splanchnic nerves passing through the diaphragm.
* Symp/Parasymp fibers reach the pancreas by the celiac and superior mesenteric plexus.

Physiology

* Bulk of the pancreas is composed of pancreatic exocrine cells and their associated ducts.
* Embedded within this exocrine tissue are the Islets of Langerhans, endocrine cells that secrete insulin and glucagon.
* Flow of exocrine juice acinar cell-> acini->intralobular ducts-> main pancreatic duct.
* Packages of zymogen granules have an acidic ph and low calcium concentration. Also packaged with protease inhibitors.
* 2 major pancreatic proteases are trypsin and chymotrypsin-Digest proteins.
* Lipase digests dietary fat.
* Amylase digests starch to maltose

Lipase

* In acute pancreatitis, reaches a max level in 24 hours and remains elevated for 8-14 days.
* Superior sensitivity and specificity than amylase in detection of acute pancreatitis.
* At levels 3X normal, has 100% sensitivity and specificity for detection of acute alcoholic pancreatitis.

Amylase

* Max level reached in 12-20 hours, maintained levels for 2-4 days.
* Activity in human tissues: Pancreas, salivary glands, tonsil, fallopian tube, lung, thyroid, malignant neoplasms.
* Rises in many conditions such as bowel obstruction/perforation, parotitis, ectopic pregnancy, radiation, cirrhosis, hepatitis.

Acute Pancreatitis

* Most common cause is EtOH consumption, followed by gallstones. Other causes include post-ERCP, certain meds, and hypertryglyceridemia.
* Blacks have 3x higher rates than white Americans, HIV/AIDS due to increased pancreatic infections and medication history.

Etiology

* Biliary tract Dz
* Drugs
* Abdominal Trauma
* Abdominal Surgery
* ERCP
* Viral Infections
* Penetrating gastric or duodenal ulcers
* Pancreatic CA
* Renal Failure
* Occupational exposure to chemicals such as methanol, mercuric chloride, naphthalenes, lead, and organophosphates
* Scorpion bites, obstruction at ampulla by carcinoma or Crohns disease
* Hypotensive shock.
* Idiopathic

Differential Dx

* PUD
* Acute Cholecystitis
* AAA Rupture
* Intestinal Obstruction
* Early Acute Appendicitis
* Mesenteric vascular obstruction
* DKA

Prognostic Signs in Acute Pancreatitis
During initial 48 hours


Enzyme Markers

* Amylase rises quickly but returns to normal in 3-4 days.
* Lipase- more accurate than amylase in diagnosis.
* Absolute level of serum amylase or lipase does not correlate with severity.

Major Adverse Factors

* Hypotension
* Need for massive fluid replacement
* Respiratory failure
* Hypocalcemia
* Hemorrhagic peritoneal fluid
Physical

* Epigastric tenderness and guarding, pain may lessen with leaning forward.
* Tachycardia, shock->vomitting and dehydration
* Fever
* Delirium
* Hypoactive bowel signs
* Hypocalcemia
* Cullen’s and Grey Turner Signs
* Jaundice

Labs

* Amylase Increase
* Lipase Increase
* Lipase/Amylase ratio increase=Alcoholic pancreatitis
* Serum trypsin level most accurate indicator of acute pancreatitis.
* Leukocytosis, Increase/Decrease in Hct
* BUN increase due to dehydration
* Liver tests may be abnormal due to hepatic involvement.
* Hypocalcemia-Free fatty acids chelate calcium, causing saponification in the retroperitoneum.
* Hypernatremia due to dehydration

Diagnostic Imaging Studies

* Abdominal CT Scan-Contrast-enhanced
* Abdominal US for gallstones
* Abdominal X ray for ileus and calcifications
* ERCP for recurrence of unknown cause, preoperative planning, or trauma to ducts.
* MRCP
* CT guided fine needle aspiration for infected acute necrotizing pancreatitis.

Treatment


* Increase intravascular volume with hydration, measure UO
* NPO
* NG suction
* Control pain-- -> caution with morphine
* Correct metabolic abnormalities.
* TPN for prolonged cases.

Complications

* GI Bleeding- DIC , liver diseases
* Renal Failure- hypovolemia
* Hypoxemia – ARDS
* Abdominal Hemorrhage

Pancreatic Divisum
Pancreatic Adenocarcinoma
Cancer of the Exocrine Pancreas
Risk Factors
History
Physical Findings

* Abdominal mass
* Ascites
* Jaundice
* Palpable gallbladder
* Supraclavicular lymphadenopathy
Initial Presentation

* Varies according to tumor location
* Tumors in the pancreatic body or tail usually present with pain and weight loss.
* Tumors in the head present with steatorrhea, weight loss, and jaundice.

Diagnostic Imaging Studies
Serum Tumor Markers
Other Risk Factors
Molecular Pathogenesis
Cholecystitis
Calculous Cholecystitis
Ascending Cholangitis
Gallstone Ileus
Pneumobilia
History
Exam
Studies

Treatment

Diseases of the Exocrine Pancreas.ppt

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Male Genital Problems

Male Genital Problems
PResentation by: Eric Quimbo

Anatomy
* Penis
o 3 cylindrical bodies
+ Corpus Cavernosum (2)
+ Corpus Spongiosum (1)
o Tunica albuginea
o Buck’s Fascia
* Testes
o Tunica albuginea
o Epididymis
o Tunica vaginalis
+ Torsion risk
# Lack of posterior fixation
+ Parietal portion
# Hydrocele

Physical Examination

* Well-lit, warm room
* Visual inspection
* Penis
* Scrotum
o Mass?
+ If present, carcinoma until proven otherwise
o Lie of the testes?
* Inguinal canal
* Prostate

Scrotum

* Scrotal Edema
* Scrotal Abscess
o Must differentiate if phlegmon in scrotal wall vs. intrascrotal organs
* Fournier Gangrene
o Polymicrobial, necrotizing infection of the perineal subcutaneous fascia.
o Painful, erythematous/edematous scrotum
o DM is risk factor
o Tx – aggressive fluid resus, broad spectrum antibiotic coverage, HBO
o Mortality 20 %

Penis

* Balanoposthitis
o Inflammation of glans and foreskin
o Recurrence – can be sole presenting sign of DM
o Treat type of infection, good hygeine, topical antifungals
* Phimosis
o Inability to retract foreskin
o Emergent if inability to void
o Tx - Definitive – circumcision, Consider topical steroids at tip QD x 4-6 weeks
* Paraphimosis
o Inability to reduce proximal edematous foreskin back to position
o True urologic emergency
o Tx – compress glans several mins, tight wrapping of glans with 2 inch bandage x 5 mins, small needle punctures, or dorsal incision of the band.
* Entrapment Injuries
o String, metal rings, wire
o Human hair
+ 2 – 5 y/o
+ Check with retrograde urethrogram (urethral integrity) and doppler (blood supply)
+ Not a sign of child abuse
* Fracture
o Tear/rupture of corpus caverosa/tunica albuginea
o Hx trauma during sexual activity
o “snapping sound”
o Check retrograde urethrogram
o Surgical indication
o Check XR….
Priaprism

* Urologic emergency
* Complications – urinary retention, impotence 35%
* Causes – anti-impotence meds (papaverine, PGE), anti-hypertensives (hydralazine, prazosin, CCB), psych (chlorpromazine, trazodone, thioridazine), sickle cell in children
* 2 types
o High flow (rare)– nonischemic, nonpainful, traumatic fistula between cavernosal artery & corpus cavernosum, dx with doppler, and treated with embolization
o Low flow – more common, more painful, dx by aspiration dark acidic intracavernosal blood
* Treatment
o Pain control
o Terbutaline 0.25 – 0.5 mg SC q20-30 mins as needed
o Pseudoephedrine 60 – 120 mg PO if within 4 hours
o If sickle cell – exchange transfusion
o Corporal aspiration

Testes and Epididymis
Prostate

* Acute prostatitis
Urethra

* Urethritis
* Urethral Structure
Urinary Retention
* H&P important
* Voiding history
o Problems with holding/initiating?
o Manner of the stream, complete or interrupted?
o Feeling of bladder emptiness afterwards?

Quiz Answers
Male Genital Problems.ppt

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Gastrointestinal Imaging

Gastrointestinal Imaging
Presentation by:Rajneesh Mathur D.O.

Basic Imaging Techniques

* Plain Film Radiography
o Quick, Easy, Inexpensive
o “Snapshot” of a dynamic system
o Technique
+ Bones
+ Upper quadrants
+ Flanks
+ Mid-Abdomen
+ Lower Abdomen

Plain Film Radiography Continued

* Acute Abdominal Series
o Supine
+ Detects fluid/blood in peritonuem
+ Detects gas in bowel
o Upright
+ Air Fluid Levels
o Left Lateral Decubitus
o Upright CXR
+ Best for free air

Contrast Radiography

* Barium Sulfate
o Standard for contrast GI studies
o Insoluble, High viscosity
o Not absorbed by the GI tract
* Gastrograffin
o Soluble, Low viscosity
o Not absorbed by the GI tract
o Laxative Effect
+ Not recommended in Peds

Computed Tomography

* Imaging of SOLID organs
* View of RETROPERITONEUM
* Oral Contrast
o Identify bowel
* IV Contrast
o Blood Vessels
* 2 Phases


Radionuclide Scanning

* Replaced by Ultrasound in ED secondary to time

Ultrasonography

* Inexpensive
* Non-Invasive
* Air is a poor conductor
* Solid structures conduct well

Specific Gastrointestinal Conditions

* Plain Film Radiography
* Abdominal CT
* Ultrasound
* Air Contrast or Barium Enema
* Angiography
* Radionuclide Scanning
* MRI

Plain Film Radiography

* In past, every belly pain got plain films
o 10 to 40% of the time it does not change clinical management
o Get it for
+ SBO
+ Free Air
+ Ileus
+ Bowel Ischemia
+ Foreign Bodies

Abdominal Computed Tomography

* Diagnostic Tool of Choice for:
o Diverticulitis
o Pancreatitis
o Pancreatic Pseudocysts
o Aortic Aneurysm
o Blunt Trauma
o Appendicitis
* Can pinpoint a diagnosis in 95% of cases where clinical judgment fails to narrow a wide range of potential diagnoses

Ultrasonography

* Initial study for patients with
o RUQ pain
o Pelvic Pain
o Acute Appendicitis



Air Contrast or Barium Enema

* Used for
o Intussusception
o Has been replaced by CT for suspected abdominal aortic aneurysm
o May be helpful in evaluation of patients with lower GI bleed

Angiography
Radionuclide Scanning

* Can be useful as an adjunct to Ultrasound when suspicion of
o Cholecystitis
o Cystic Duct obstruction
o No Role in the imaging of the GI tract in the ED

MRI
Gastrointestinal Imaging.ppt

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