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CAMILLE OKELBERRY
DANIELLE QUINTON
TONI BROWN
Physiology
Physiology of Pancreas
Endocrine function
Insulin
Glucagon
Somatostatin
Lipolytic enzymes
Digests fatty chyme
Secreted in inactive form
Pancreatic lipase
Vagus nerve
Hormones
Cephalic Phase
Gastric Phase
Gastrin: secreted in response to distension of stomach
Stomach distension also causes release of pancreatic enzymes
Intestinal Phase
Responsible for most of the secretion
Response to hormones secreted by upper intestinal mucosa
Secretin, CCK
Acute Pancreatitis
Pancreatitis
Acute
Mild
Chronic
Severe
Acute Pancreatitis
Sudden inflammation of the pancreas
Can sometimes result in a systemic inflammatory
related is 15/100,000
Non-gallstone related is 25/100,000
300,000 hospital admissions/year for treatment of
acute pancreatitis
African Americans are 2 to 3 times more likely to
develop pancreatitis than Caucasians
Etiology
Alcohol
Gallstones
Hypertriglyceridemia
Hypercalcemia
Certain medications
Genetics/gene mutations
Alcohol
Oxidation of ethanol to acetaldehyde activates
Gallstones
Hypertriglyceridemia
Triglycerides are carried by chylomicrons in the
blood
If there is an excess amount of triglycerides, there
will be an excess amount of chylomicrons
When the chylomicrons are larger than 900 mg/dL
they have the ability to block capillaries in the
pancreas
This can lead to ischemia, alteration of acinar cells
and increased lipase release
Increased lipolysis and free fatty acids in the blood
can lead to inflammation, free radicals and necrosis
Hypercalcemia
Increased calcium over a prolonged period of time
Gene mutations
One of the mutations occurs in the cystic fibrosis
Medications
Opiates
Tetracycline
Steroids
Furosemide
Acetaminophen
Erythromycin
Rifampin
Estrogen preparations
Pathophysiology
Sudden intense abdominal attacks
If mild, the patient can withhold feeding for a couple
Diagnosis
Blood amylase and lipase levels
CT/MRI test
Ultrasound
Ransons Criteria
Diagnosis - CT Scan
Ransons Criteria
The criteria that classifies the severity of pancreatitis
includes:
Age >55
White blood cell >16,000 m3
Blood glucose levels >200 mg
Lactic dehydrogenase >350 units/L
Aspartate transaminase >250 units/L
Ransons Criteria
During the first 48 hours:
Hematocrit decrease of >10 mg/dL
Blood urea nitrogen increase of >5 mg/dL
Arterial PO2 <60 mm Hg
Base deficit >4 mEq/L
Fluid sequestration >6000 mL
Serum calcium level <8 mg/mL
Treatment
Medication
Surgery (for severe acute pancreatitis)
Treatment - Surgery
Remove the gallbladder
Remove inflamed parts of the pancreas
Remove necrotic tissue and pseudocysts
ERCP
Treatment - ERCP
Endoscopic Retrograde Cholangiopancreatography
Special technique designed to treat complications of
Prognosis
The higher the prognosis score, the poorer the
outcome
Patients with mild acute pancreatitis have a low
mortality rate while those with severe acute
pancreatitis are more likely to have complications
and therefore have a higher death rate
Mortality for mild acute pancreatitis is <1% while the
death rate for severe acute pancreatitis can be 10% to
30 % depending on sterile versus infected necrosis
Alcohol
Prevalence
Prevalence
Prevalence of Drinking: (In 2012)
87.6 percent of people ages 18 or older reported that they
10th
Graders
12th
Graders
Lifetime
26.80
[49.30]
[66.00]
Past Year
20.80
[44.00]
60.20
Past Month
9.00
[23.50]
37.40
National Survey on Drug Use and Health: Trends in Prevalence of Alcohol for
Ages 12 or Older, Ages 12 to 17, Ages 18 to 25, and Ages 26 or Older; 2013 (in
percent)*
Drug
Alcohol
Ages 12 to
17
Ages 18 to
25
Ages 26 or
Older
Lifetime
[81.50]
30.80
83.80
87.30
Past Year
66.30
[24.60]
76.80
69.60
Past Month
52.20
[11.60]
59.60
55.90
In 2012, about 9.3 million people ages 1220 (24.3 percent of this age
group) reported drinking alcohol in the past month (24.7 percent of
males and 24 percent of females)
What is a drink?
A standard drink
12 ounces of beer
8 ounces of malt liquor
5 ounces of wine
or 1.5 ounces (a "shot") of
80-proof distilled spirits
or liquor (e.g., gin, rum,
vodka, or whiskey)
Drinking Terms
Moderate Drinking: Up to 1 drink per day for women and up to 2 drinks per
Metabolism
Highly toxic and
known carcinogen
CO2
and
H2O
Cardiomyopathy
(stretching and drooping of
heart muscle), arrhythmias
(irregular heart beat),
stroke, high blood
pressure
Steatosis (fatty
liver), alcoholic
hepatitis, fibrosis,
cirrhosis
Alcohol-related Mortality
Nearly 88,000 people (approximately 62,000 men and 26,000 women) die
In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent
Alcohol misuse is the fifth leading risk factor for premature death and
disability; among people between the ages of 15 and 49, it is the first
worldwide
Health Benefits
Decreased risk for heart disease and mortality due to heart disease
Decreased risk of ischemic stroke (in which the arteries to the brain
become narrowed or blocked, resulting in reduced blood flow), and
Decreased risk of diabetes
Chronic Pancreatitis
Chronic inflammation
of the pancreas that
leads to permanent
damage (necrosis)
Physiology
Inhibits
secretions of
hormones like
GH, TSH,
CCK, insulin
Released in response
to ingestion; regulates
food intake
Causes
Heavy alcohol use
Elevated triglycerides
Autoimmune disorders
Genetic conditions (cystic
fibrosis, hereditary
pancreatitis)
Blocked pancreatic duct
or common bile duct
Inherited pancreatitis (2
or more immediate family
members with a history of
pancreatitis)
Diagnosis
Blood tests are NOT helpful, but sometimes test for
Transabdominal Ultrasound
1. Sound waves are sent toward
Endoscopic Ultrasound
1. Spray a solution to numb
Medical Treatment
No cure for chronic
pancreatitis
Treat symptoms,
decrease pain
Avoid triggers
Pancreatic enzyme
replacement (PERT)
Antioxidants
or both)
2. If nonopioids do not relieve pain, mild opioids (like
codeine) are given
3. If mild opioids do not relieve pain, strong opioids
(like morphine) are given
MNT
Avoid alcohol
Quit smoking
Avoid high-fat foods
Vitamins and minerals
as needed
MNT cont.
MAIN GOALS: 1) Provide optimal nutrition support
and 2) decrease pain my minimizing stimulation of
the exocrine pancreas
Small frequent meals
Low-fat
Vegetable based oils
Treat vitamin B12, A, D, E, K deficiencies
Maintain acid-base balance (using antacids, H2receptor antagonists, or proton pump inhibitors
Insulin and nutrition therapy
Alternative Therapy
Yoga
Massage therapy
Therapeutic Touch
Physical Exercise
Meditation
Laughter
Acupuncture
Pomegranate seeds?
Pancreatic Cancer
Pancreatic Cancer
Fourth leading cause of death from cancer in the U.S.
5 year survival rate is 4%
American Cancer Society estimates that in 2014
Pancreatic Cancer
Risk Factors
Age
Smoking
Most significant
Twice as likely to get CA
Chronic pancreatitis
Lots of associations between diseases and pancreatic CA, but
cause-and-effect relationship has not been established
Pancreatic Cancer
S/S
Pain
Jaundice
Wt loss
Dull epigastric pain
Back pain
DVT
Pancreatic Cancer
Tumor on head of pancreas- obstructs bile flow,
jaundice
Tumor on body of pancreas- impinges celiac
ganglion pain
Tumor on tail of pancreas- metastasizes before
symptoms appear
Diagnosis
Pt hx
Physical exam
Elevated serum bilirubin and alkaline phosphate
Suggest pancreatic cancer, but not diagnostic
Ultrasound
CT scans
Percutaneous fine-needle aspiration cytology
Misses the smaller, more curable tumors
Treatment
Surgical resection of tumor
Most cancers have metastasized before it is diagnosed
Radiation, chemotherapy
Whipple Procedure
Whipple Procedure
Pancreaticoduodenectomy (PD)
Removal of head of pancreas, distal bile duct,
Liver
Gallbladder
Removed
Jejunum
Whipple Procedure
Post-operation symptoms
N/V, bloating, early satiety, abdominal pain
Dumping
Weight loss d/t pancreatic insufficiency
Diabetes d/t decreased insulin production
Nutrient deficiencies d/t malabsorption
Ca, Zn, Cu, Se
Vits A, E, D, K
Whipple Procedure
Treatment of symptoms (similar to any gastric
surgery)
Case Study
Hx
Dx of depression
s/p appendectomy age 12
No tobacco use
Family hx: Mother: breast CA; Father: HTN
Alcohol use: 6 pack beer, 4-5 shots bourbon daily; weekends: wine
and other mixed drinks
Sample diet
Breakfast
Celery w/ PB
Raisins
Wheat thins
AM Snack
Toast with jam
String cheese (LF)
Carrots
Lunch
Grilled cheese
Chicken noodle soup
PM Snack
Dinner
Pasta
Spinach Salad w/ LF dressing
HS Snack
Apple
Pudding
References
References
Pagana KD, Pagana TJ. Mosbys Manual of
References
http://www.pancreasfoundation.org/patient-information/chronicpancreatitis/
http://www.drugabuse.gov/drugs-abuse/alcohol
http://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-facts-and-statistics
Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic
cancer. Gastroenterology. 2013;144(6):1252-1261.