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Alimentary System > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

Acute Pancreatitis Definition

A
  • ACUTE INFLAMMATION OF PANCREAS (sudden onset + sig. mortality)
    • Results in UPPER ABDOMINAL PAIN
    • ELEVATED SERUM AMYLASE (>4x upper normal limit; normal = ~90)
    • Could be ass. w/ MULTI-ORGAN FAILURE IN SEVERE CASES

prognosis dependant on sorting out aetiological factor

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2
Q

Acute Pancreatitis Presentation

A

Symptoms:
• ABDOMINAL PAIN
• NAUSEA, VOMITING, COLLAPSE
• OLIGURIA, ACUTE RENAL FAILURE

  • JAUNDICE
  • PARALYTIC ILEUS (ileus = lack of movement in intestines leading to build-up of intestinal contents & potentially intestinal obstruction - this can be due to paralysis of intestinal muscles)
  • RETROPERITONEAL HAEMORRHAGE (Grey Turner’s & Cullen’s signs)
  • HYPOXIA (REPIRAOTRY FAILURE if SEVERE)
  • HYPOCALCAEMIA (TETANY RARE)
  • HYPERGLYCAEMIA (occasionally DIABETIC COMA)
  • EFFUSIONS (ASCITIC & PLEURAL, HIGH AMYLASE)
Signs:
• PYREXIA
• TACHYCARDIA, HYPOVOLAEMIC SHOCK
• DEHYDRATION
• ABDOMINAL TENDERNESS
• CIRCULATORY FAILURE
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3
Q

Acute Pancreatitis Investigations

A

Bloods:
• FBC
• U+E
• LFT

  • AMYLASE/LIPASE
  • Ca2+
  • GLUCOSE & LIPIDS
  • ABG - systemically unwell
  • COAGULATION SCREEN

Imaging:
• AXR (ileus) & CXR (pleural effusion) - may also show perforated abscess

  • ABDOMINAL USS (pancreatic oedema, gallstones, pseudocyst)
  • CT (contrast enhanced - useful for complications e.g. ~ 4 - 10 days for necrosis, severity + monitor pt. for disease)
  • ERCP & ENDOCSCOPIC USS (jaundice & cholangitis)
    • MRCP & EUSS = if stones don’t show up
    • ERCP = only if pt. jaundiced, biliary obstruction, documented gallstone blockage
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4
Q

Acute Pancreatitis Managment

A 
Assess severity:
• WCC > 15x109/L
• BLOOD GLUCOSE > 10 mmol/L
• BLOOD UREA > 16 mmol/L
• AST > 200 iu/L
• LDH > 600 iu/L
• SERUM ALBUMIN < 32 g/L
• SERUM CALCIUM <2 mmol/L
• ARTERIAL PO2 < 7.5kPa
  • GLASGOW CRITERIA = SCORE < 3 is SEVERE PANCREATITIS w/I 48 HRS of ADMISSION
  • CRP > 150 mg/L also INDICATES SEVERE PANCREATITIS
General:
• ANALGESIA = PETHIDINE, INDOMETHACIN
• IV FLUIDS
• BLOOD TRANSFUSION (if Hb < 10 g/dL)
• MONITOR URINE OUTPUT = CATHETER
• NGT
• O2
• INSULIN (may req.)
• Ca2+ SUPPLEMENTS (rarely req.)
• NUTRITION (ENTERAL - better/PARENTERAL) IN SEVERE CASES

Specific:
• PANCREATIC NECROSIS = CT GUIDED ASPIRATION = ANTIBIOTICS ± SURGERY (try to avoid pt. going into surgery)

* May be STERILE/INFECTED = NECROSECTOMY * GALLSTONES = EUSS/MRCP/ERCP = CHOLECYSTECTOMY

Precipitating Factors:
• CHOLELITHIASIS = ERCP & ES, CHOLECYSTECTOMY

  • ALCOGOL = ABSTINENCE, COUNSELLING
  • ISCHAEMIA = CAREFUL SUPPORT, CORRECT CAUSE
  • MALIGNANCY = RESECTION/BYPASS
  • HYPERLIPIDAEMIA = DIET, LIPID LOWERING DRUGS
  • ANATOMICAL ABNORMALITIES = CORRECT if POSS.
  • DRUGS = STOP/CHANGE

Complications:
• ABSCESS = ANTIBIOTICS + DRAINAGE

  • PSEUDOCYST:
    • FLUID COLLECTION w/o EPITHELIAL LINING
    • PERSISTENT HYPERAMYLASAEMIA ± PAIN
    • DIAGNOSIS/INVESTIGATIONS = USS/CT
    • COMPLICATIONS = JAUNDICE, INFECTION, HAEMORRHAGE, RUPTURE
    • < 6cm in diameter = SPONTANEOUSLY RESOLVE

PERSISTENT PAIN/COMPLICATIONS = ENDOSCOPIC DRAINAGE/SURGERY

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5
Q

Acute Pancreatitis Aetiology

A

• I = IDIOPATHIC

* G = GALLSTONES, GENETIC - CF
* E = ETHANOL
* T = TRAUMA

* S = STEROIDS
* M = MUMPS (&amp; OTHER INFECTIONS)/MALIGNANCY
* A = AUTOIMMUNE
* S = SCORPION STINGS/SPIDER BITES
* H = HYPERLIPIDAEMIA/HYPERCALCAEMIA/HYPERPARATHYROIDISM (METABOLIC DISORDERS)
* E = ERCP
* D = DRUGS (TETRACYCLINES, FUROSEMIDE, AZATHIOPRINE, THIAZIDES, MANY OTHERS)

ANATOMICAL ABNORMALITIES, ISCHAEMIC, PANCREATINC CARCINOMA

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6
Q

Chronic Pancreatitis Definition

A
  • CONTINUING INFLAMMATORY DISEASE of the PANCREAS
    • Characterised by IRREVERSIBLE GLANDULAR DESTRUCTION
    • Typically PAIN ± PERMANENT LOSS of FUNCTION
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7
Q

Chronic Pancreatitis Epidemiology

A

MALES > FEMALES

AGE = 35 - 50yrs

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8
Q

Chronic Pancreatitis Prognosis

A
  • DEATH from COMPLICATIONS of ACUTE-ON-CHRONIC ATTACKS, CV COMPLICATIONS of DM, ASS. CIRRHOSIS, DRUG DEPENDANCE, SUICIDE
    • CONTINUED ALCOHOL INTAKE = 50% 10yr SURVIVAL
    • ABSTINENCE = 80% 10yr SURVIVAL
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9
Q

Chronic Pancreatitis Presentation

A

• EARLY DISEASE = ASYMPTOMATIC

• ABDOMINAL PAIN = EXACERBATED by FOOD &amp; ALCOHOL, SEVERITY DECREASES w/ TIME
	○ DEBILITATING PAIN, ass. w/ BINGES - BECOME MORE FREQ. &amp; LESS TREATABLE by ABSTINENCE

* WGT. LOSS (PAIN, ANOREXIA, MALABSORPTION)
* EXOCRINE INSUFFICIENCY = STEATORRHOEA (fat malabsorption), reduced fat soluble vitamins &amp; Ca2+/Mg2+, WGT. LOSS (protein malabsorption)
* ENDOCRINE INSUFFICIENCY = DIABETES, reduced vitamin B12
* MISCELLANEOUS = JAUNDICE, PORTAL HYPERTENSION, GI HAEMORRHAGE, PSEUDOCYSTS, PANCREATIC CARCINOMA, DUODENAL OBSTRUCTION (uncommon)
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10
Q

Chronic Pancreatitis Investigations

A

Bloods

* SERUM AMYLASE (increase in acute exacerbations)
* REDUCED AMYLASE, Ca2+/Mg2+, VITAMIN B12
* INCREASED LFTs, PROTHROMBIN TIME (vitamin K), GLUCOSE
* PANCREATIC FUNCTION TESTS (not anymore)

Imaging

* PLAIN AXR - pancreatic calcification
* USS - pancreatic size, cysts, duct diameter, tumours
* CT
* ERCP/MRCP
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11
Q

Chronic Pancreatic Management

A

Pain Control

  • AVOID ALCOHOL!!! + COUNSELLING
  • PANCREATIC ENZYME SUPPLEMENTS
  • OPIATE ANALGESIA = DIHYDROCODEINE, PETHIDINE
  • COELIAC PLEXUS BLOCK
  • REFERRAL to PAIN CLINIC/PSYCHOLOGIST
  • ENDOSCOPIC TREATMENT of PANCREATIC DUCT STONES & STRICTURES
  • SURGERY in SELECTED CASES (suspicious of MALIGNANCY, INTRACTABLE PAIN) = DRAINAGE/RESECTION - has complications e.g. cysts/pseudocysts, pancreatic duct stenosis, colonic strictures

Exocrine & Endocrine Control

  • LOW FAT DIET = 30 - 40 g/day (& LOW PROTEIN as well)
  • PANCREATIC ENZYME SUPPLEMENTS = CREON, PANCREX
    • ACID SUPPRESSION to prevent HYDROLYSIS in STOMACH
  • INSULIN = for DM (oral hypoglycaemics ineffective - pancreatic damage)
  • Vitamin supplements not usually req.
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12
Q

Chronic Pancreatitis Aetiology

A

O = OBSTRUCTION of MPD
○ TUMOUR = ADENOCARCINOMA, IPMT
○ SPHINCTER of ODDI DYSFUNCTION
○ PANCREATIC DIVISUM
○ DUODENAL OBSTRUCTION = TUMOUR, DIVERTICULUM
○ TRAUMA
○ STRUCTURE = POST-NECROTISING RADIATION

A = AUTOIMMUNE

T = TOXIN
○ ETHANOL - related to amount & length of consumption
○ SMOKING
○ DRUGS

I = IDIOPATHIC

G = GENETIC
○ AUTOSOMAL DOMINANT (Condon 29 & 122)
○ AUTOSOMAL RECESSIVE (CFTR, SPINK1, Codon A etc.)

E = ENVIRONMENTAL
○ TROPICAL CHRONIC PANCREATITIS

R = RECURRENT INJURIES
○ BILIARY
○ HYPERLIPIDAEMIA
○ HYPERCALCAEMIA

CONGENITAL ANATOMICAL ABNORMALITIES, HERDITARY PANCREATITIS

mainly ALCOHOL

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13
Q

Chronic Pancreatitis Pathogenesis + Pathology

A

PATHOGENESIS

  • DUCT OBSTRUCTION = CALCULI, INFLAMMATION, PROTEIN PLUGS
  • ABNORMAL SPHINCTER of ODDI FUNCTION ? = SPASM resulting in INCREASED INTRAPANCREATIC PRESSURE, RELAXATION resulting in REFLUX of DUODENAL CONTENTS
  • GENETIC POLYMORPHISMS ? = ABNORMAL TRYPSIN ACTIVATION

PATHOLOGY

  • GLANDULAR ATROPHY & REPLACEMENT by FIBROUS TISSUE
  • DUCTS become DILATED, TORTUOUS & STRICTURES
  • INSPISSATED SECRETIONS may CALCIFY
  • EXPOSED NERVES due to LOSS of PERINEURAL CELLS
  • SPLENIC, SMV & PORTAL VEINS may THROMBOSE = PORTAL HYPERTENSION
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14
Q

Pancreatic Carcinoma Epidemiology

A

MALES > FEMALES

80% in 60 - 80yrs

MORE COMMON in WESTERN COUNTRIES (highest rates in Maoris & Hawaiians)

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15
Q

Pancreatic Carcinoma Prognosis

A
  • INOPERABLE = MEAN SURVIVAL < 6 MONTHS, 1% 5yr SURVIVAL

* OPERABLE = 15% 5yr SURVIVAL, AMPULLARY TUMOURS 30 - 50% 5yr SURVIVAL

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16
Q

Pancreatic Carcinoma Presentation

A

Asymptomatic = incidental finding

Symptoms:

  • UPPER ABDOMINAL PAIN (75%) - body & tail
    • Could be BACK PAIN
  • PAINLESS OBSTRUCTIVE JAUNDICE (25%) - head
  • WGT. LOSS (90%)
  • RECURRENT BOUTS of PANCREATITIS
  • DIABETES
  • ANOREXIA, FATIGUE, DIARRHOEA/STEATORRHOEA, NAUSEA, VOMITING
  • TENDER SUBCUTAENOUS FAT NODULES (like erythema nodusum, due to metastatic fat necrosis)
  • THROMBOPHLEBITIS MIGRANS (episodes of vessel inflammation due to blood clot - recurrent/appear in diff. locations over time
  • ASCITES, PORTAL HYPERTENSION

Signs:

  • HEPATOMEGALY
  • JAUNDICE
  • ABDOMINAL MASS
  • ABDOMINAL TENDERNESS
  • ASCITES, SPLENOMEGALY
  • SUPRACLAVICULAR LYMPHADENOPATHY

PRESENCE of ABOVE SIGNS usually INDICATE UNRESECTABLE TUMOUR

• PALPABLE GALLBLADDER (w/ ampullary carcinoma)

17
Q

Pancreatic Carcinoma Investigations

A

Bloods

• General Bloods, CA 19-9

Imaging/Invasive

  • CXR
  • USS
  • CT, MRI
  • ERCP, MRCP
  • EUSS + FNA
  • LAPAROSCOPY/LAPAROSCOPY USS
  • PERITONEAL CYTOLOGY
  • PERCUTANEOUS NEEDLE BIOPSY

• PET SCAN

18
Q

Pancreatic Carcinoma Management

A

MAJORITY of PT. HAVE ADVANCED DISEASE AT PRESENTATION & < 10% OPERABLE

• RADICAL SURGERY = PANCREATODUODENECTOMY (WHIPPLE'S PROCEDURE)

	○ FIT PT., TUMOUR < 3cm in diameter, NO METASTASES
	○ FITNESS = BASIC Hx &amp; EXAMINATION, CXR, ECG, RESPIRATORY FUNCTION TESTS, PHYSIOLOGICAL SCORING SYSTEM (none established), FULLY INFORMED CONSENT VITAL

* PALLIATION of JAUNDICE = STENT, PALLIATIVE SURGERY - CHOLECHODUODENOSTOMY/BYPASS
* PAIN CONTROL = OPIATES, COELIAC PLEXUS BLOCK, RT
* CHEMOTHERAPY only in controlled trials

Alimentary System (5 decks)

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