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systems- GI > pancreatic disease > Flashcards

pancreatic disease Flashcards

1
Q

what is acute pancreatitis?

A

Acute inflammation of the pancreas
Upper abdominal pain
Elevation of serum amylase (> 4 x upper limit of normal)
May be associated with multi-organ failure in severe cases

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2
Q

aetiology of acute pancreatitis?

A 
Alcohol Abuse (60-75%)
Gallstones (25-40%)

Trauma - blunt/postoperative/post-ERCP
Misc. - Drugs (steroids, azathioprine, diuretics)
- Viruses (mumps, coxsackie B4, HIV, CMV)
- Pancreatic carcinoma
- Metabolic (calcium, triglycerides, temp)
- Auto-immune
Idiopathic ~10%

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3
Q

what is the pathology of acute pancreatitis?

A

primary insult –> release of activated pancreatic enzymes –>autodigestion–> pro-inflammatory cytokines, reactive oxygen species, oedema, fat necrosis, haemorrhage

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4
Q

investigations for acute pancreatitis

A

Blood tests: amylase/lipase, FBC, U&Es, LFTs, Ca2+, glucose, arterial blood gases, lipids, coagulation screen
AXR (ileus) & CXR (pleural effusion)
Abdominal ultrasound (pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced)

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5
Q

assessement of acute pancreatitis

A 
White cell count >15 x 109/l
Blood glucose >10 mmol/l
Blood urea >16mmol/l
AST >200 iu/l
LDH >600 iu/l
Serum albumin <32 g/l
Serum calcium <2.0 mmol/l
Arterial PO2 <7.5 kPa

glasgow criteria >3
CRP>150

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6
Q

management of acute pancreatitis

A 
Analgesia (pethidine, indomethacin)
Intravenous fluids 
Blood transfusion (Hb <10 g/dl)
Monitor urine output (catheter)
Naso-gastric tube
Oxygen
May need insulin
Rarely require calcium supplements
Nutrition (enteral or parenteral) in severe cases
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7
Q

management of pancreatic necrosis

A

CT guided aspiration

 antibiotics ± surgery

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8
Q

management of gallstones

A

EUS/MRCP/ERCP

 Cholecystectomy

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9
Q

complications of actue pancreatitis

A

Abscess antibiotics + drainage

Pseudocyst
fluid collection without an epithelial lining

Persistent hyperamylasaemia and/or pain

Dx by ultrasound or CT scan

Complications: jaundice, infection, haemorrhage, rupture

<6 cm diameter resolve spontaneously

Endoscopic drainage or surgery if persistent pain or complications

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10
Q

outcome of acute pancreatitis

A

Mild AP (75-80% of cases) - mortality <2%
Severe AP - mortality 15%
Subsequent course dependent on removal of aetiological factor(s)

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11
Q

what is chronic pancreatitis?

A

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function’

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12
Q

whos more likely to get chronic pancreatitis?

A

males

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13
Q

chronic pancreatitis aetiology

A

Alcohol (80%)
Cystic Fibrosis (CP in 2%)
high frequency of CFTR gene mutations in CP
Congenital anatomical abnormalities
Annular pancreas
Pancreas divisum (failed fusion of dorsal & ventral buds)
Hereditary pancreatitis: rare, auto. dom.
Hypercalcaemia
Diet: ?antioxidants decrease in tropical pancreatitis

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14
Q

what are the genes associated with pancreatitis?

A

PRSS1
SPINK1
CFTR

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15
Q

pathogenesis of chronic pancreatitis?

A 
Duct obstruction
calculi
inflammation
protein plugs
?Abnormal sphincter of Oddi function
spasm: increase of intrapancreatic pressure
relaxation: reflux of duodenal contents
?Genetic polymorphisms
Abnormal trypsin activation
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16
Q

pathology of chronic pancreatitis?

A

Glandular atrophy & replacement by fibrous tissue
Ducts become dilated, tortous & strictured
Inspissated secretions may calcify
‘Exposed’ nerves due to loss of perineural cells
Splenic , superior mesenteric & portal veins may thrombose -> portal hypertension

17
Q

clinical features of chronic pancreatitis?

A 
Abdominal pain (85-95%)
exacerbated by food &amp; alcohol; severity decreases with time

Weight loss (pain, anorexia, malabsorption)

Exocrine insufficiency

fat malabsorption –> steatorrhoea

decrease in fat soluble vitamins (A,D,E,K), decrease in Ca2+/Mg2+
protein malabsorption ->  weight loss, decrease in vit B12

Endocrine insufficiency – > Diabetes in 30%
Misc.: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma

18
Q

investigations of chronic pancreatitis

A

Plain AXR (30% have calcification of pancreas)

Ultrasound: pancreatic size, cysts, duct diameter, tumours

EUS

CT scan

Blood tests:
Serum amylase increase  in acute exacerbations
decrease albumin, Ca2+/Mg2+, vit B12
increase LFTs, Prothrombin time (vit K), glucose

Pancreatic function tests (Lundh, pancreolauryl)

19
Q

how to control the pain of chronic pancreatitis

A

avoid alcohol
pancreatic enzyme supplements
opiate analgesia (dihydrocodeine, pethidine)
Coeliac plexus block
referral to pain clinic/psychologist
Endoscopic treatment of pancreatic duct stones and strictures
Surgery in selected cases

20
Q

exocrine and endocrine management of chronic pancreatitis

A

Low-fat diet (30-40 g/day)
Pancreatic enzyme supplements (eg. Creon, Pancrex); may need acid suppression to prevent hydrolysis in stomach
Vitamin supplements usually not required

Insulin for diabetes mellitus (oral hypoglycaemics usually ineffective)

21
Q

prognosis of chronic pancreatitis

A

Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
Continued alcohol intake  50% 10 yr survival

Abstinence  80% 10 yr survival

22
Q

epidemiology of carcinoma of pancreas

A 
Incidence: 11/100 000 pop/year (increasing)
Males>Females
80% in 60-80 year age group
More common in Western countries
highest rates in Maoris &amp; Hawaiians
23
Q

pathology of carcinoma in pancreas

A 
75% are duct cell mucinous adenocarcinoma (head 60%, body 13%, tail 5%, multiple sites 22%)
Other pathological types:
carcinosarcoma
cystadenocarcinoma (better prognosis)
Acinar cell
24
Q

clinical features of carcinoma of the pancreas

A

Upper abdominal pain (75%) - Ca body & tail
Painless obstructive jaundice (25%) - Ca head
Weight loss (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans
Ascites, portal hypertension

25
Q

physical signs of carcinoma in pancreas

A 
Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites, splenomegaly
Supraclavicular lymphadenopathy
PRESENCE OF ABOVE SIGNS USUALLY INDICATES AN UNRESECTABLE TUMOUR
Palpable gallbladder (with ampullary carcinoma)
26
Q

imaging of carcinoma of the pancreas

A

USS
CT
MRI
EUS

27
Q

management of carcinoma of pancreas?

A

Radical surgery - pancreatoduodenectomy
(Whipple’s procedure)
Patient is fit, Tumour <3 cm diameter, No metastases
Operative mortality ~5%
Palliation of jaundice
stent, palliative surgery - cholechoduodenostomy
Pain control (opiates, coeliac plexus block, radiotherapy)
Chemotherapy only in controlled trials

28
Q

prognosis of carcinoma of the pancreas

A 
Inoperable cases: 
mean survival <6 months
1% 5yr survival
Operable cases:
15% 5 yr survival
Ampullary tumours 30-50% 5 yr survival
29
Q

clinical features of acute pancreatitis

A

Abdominal pain (may radiate to back)
Vomiting
Pyrexia
Tachycardia, hypovolaemic shock
Oliguria, acute renal failure
Jaundice
Paralytic ileus
Retroperitoneal haemorrhage (Grey Turner’s & Cullen’s signs)
Hypoxia (respiratory failure in severe cases)
Hypocalcaemia (tetany rare)
Hyperglycaemia (occasionally diabetic coma)
Effusions (ascitic & pleural; high amylase)

systems- GI (40 decks)

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