What You Should Know about the Pancreas for the Physician Assistant Exam
The pancreas is an important organ that has many functions in the body, both endocrine and exocrine and will be covered on the Physician Assistant Exam (PANCE). Concerning endocrine function, the pancreas produces insulin, glucagon, and somatostatin (or it’s supposed to). Concerning exocrine function, the pancreas secretes digestive enzymes such as the proteases, lipase, and amylase. It secretes bicarbonate as well.
Common abnormalities of the pancreas that you’ll likely find on the PANCE include acute pancreatitis, chronic pancreatitis, and pancreatic cancer. Be aware that pancreatitis and pancreatic inefficiency can also contribute to malabsorption of certain essential vitamins and nutrients.
Pancreatitis is inflammation of the pancreas. Acute pancreatitis can be a source of increased morbidity and mortality. The two most common causes of acute pancreatitis include gallstones and alcohol abuse. Other causes include high triglycerides, medications, and infections.
The clinical presentation of acute pancreatitis is usually left upper-quadrant pain or midepigastric pain with radiation to the back.
Two physical examination signs of acute pancreatitis include Cullen’s sign and Grey Turner’s sign. Cullen’s sign refers to periumbilical bruising related to acute pancreatitis. Grey Turner’s sign refers to bruising and ecchymosis of the flank area, related to hemorrhagic pancreatitis.
The diagnosis of acute pancreatitis is suggested by an elevated amylase and lipase. The lipase, which can be very elevated, is the most specific test for pancreatitis.
An abdominal plain film may exclude other etiologies. The radiograph may range from unremarkable to a localized ileus of a segment of the small intestine or the colon cutoff sign in advanced disease. The pancreas may be calcified on a radiograph, which can be a sign of chronic pancreatitis.
The diagnosis of acute pancreatitis is confirmed by a CT scan of the abdomen with IV contrast. On CT, you see significant edema and inflammation of the pancreas. A phlegmon may or may not be present. A pancreatic pseudocyst, which is a fluid-filled area around the pancreas, may be present.
Acute pancreatitis increases the body’s systemic inflammatory response system. Pancreatitis can have many complications, both local and systemic. Locally, a pseudocyst may form. If the pancreatitis is aggressive, it can transform into a hemorrhagic pancreatitis or a necrotizing pancreatitis. Systemic complications can include multi-organ dysfunction syndrome, including worsening of liver and kidney function. Lung function can deteriorate through the formation of acute respiratory distress syndrome.
Various scores have been used to evaluate the acuity of someone with pancreatitis in the ICU. Examples include the SOFA score and the APACHE score. When assessing the severity of pancreatitis, one scoring system that you may be asked about is Ranson criteria. This scoring system includes looking at certain parameters at the time of admission and 48 hours later.
At the time of admission, parameters include a person’s age, blood glucose level, WBC count, AST level, and LDH level.
Pancreatitis can cause third spacing of fluid, and the patient can be liters behind in terms of volume requirements. Recall that the third space is the area of the body that normally does not collect fluid. The management of acute pancreatitis includes making the patient NPO; aggressive, aggressive hydration with normal saline; and intravenous pain medication.
Aggressive volume resuscitation is needed because of the third spacing of fluids. Labs are monitored and a workup is begun, including evaluation of the biliary tract and a fasting lipid profile.
Which of the following medications can be used in the treatment of acute necrotizing pancreatitis?
(A) Amoxicillin (Amoxil)
(B) Imipenem-cilistatin (Primaxin)
(C) Levofloxacin (Levaquin)
(D) Metronidazole (Flagyl)
(E) Doxycycline (Doryx)
The correct answer is Choice (B). In someone with necrotizing pancreatitis, imipenem-cilistatin is the one antibiotic that has been used effectively to treat the infection.
How to treat chronic pancreatitis
With chronic pancreatitis, the nature of the pain is the same as with acute pancreatitis — left upper-quadrant pain or midepigastric pain with radiation to the back. However, the labs are a little different. The lipase may be normal to just slightly high. In this case, you’re dealing not with acute pancreatitis per se but with an exacerbation of chronic pancreatitis.
For the PANCE, be aware of one telltale sign of chronic pancreatitis: You can see calcification of the pancreas on an abdominal radiograph. You can also see this calcification on a CT scan.
Two complications deriving from chronic pancreatitis are diabetes and malabsorption. In the case of malabsorption, the patient often needs supplemental pancreatic enzymes, which he or she takes with each meal.
How to recognize pancreatic cancer
Pancreatic cancer is a bad cancer with a very high mortality rate. If you see a test question that concerns painless jaundice, think pancreatic cancer until proven otherwise; obstructive jaundice that’s usually painless is the most common presentation of pancreatic cancer. The jaundice comes from blockage of the bile duct.
Other signs of pancreatic cancer include weight loss, itching, and abdominal distention. Sometimes the patient feels pain with radiation to the back. Risk factors for pancreatic cancer include obesity, advanced age, tobacco use, diabetes, diets high in meat and low in fruits and vegetables, and alcoholism.
Here are other key points to be aware of concerning pancreatic cancer:
The tumor marker associated with pancreatic cancer is CA 19-9.
Diagnostic studies used in evaluating pancreatic cancer include the CT scan and endoscopic ultrasound. The head of the pancreas is the most common site of diagnosis of tumors. Tumors located in the body or tail of the pancreas tend to be more aggressive.
Histologically, pancreatic cancer is an adenocarcinoma.
Pancreatic cancers do not respond well to chemotherapy, so treatment is mainly surgical. A pancreaticoduodenectomy is used to remove the carcinoma when it’s at the head of the pancreas. If the body and/or tail is affected, often the treatment is a distal pancreatectomy. With this surgery, the spleen is often removed. Both procedures are major surgeries, and the prognosis for a person with a pancreatectomy is very poor.