Briefly describe the exocrine function of the pancreas.
Ductal cells release alkaline fluid in response to secretin Acinar cells secrete digestive enzymes in response to secretaogues (CCK, secretin, substance P, VIP, ACh and bombesin) - Amylase - Chemotryospin - Trypsinogen - Lipase - Phospholipase - Cholesterol Esterase
What are the cells within the islets of Langerhans?
Beta-cells = insulin
Alpha-cells = glucagon
Delta-cell = somatostatin
PP or Gamma-cells = pancreatic polypeptide
How are gallstones detected?
- over 90% of gallstones
- can detect microlithiasis
What is biliary colic?
Consant pain that occurs when a gallstone temporarily blocks the gallbladder neck or cystic duct
Typically in the right upper quadrant, and lasts 4-6 hours
- pain is releived when the stone disimpacts and moves on
Usually the presenting feature of gallstones
How often is acute cholecystitis due to gallstones?
90% of the time
What are the risk factors for gallstones/acute cholecystitis?
Female Fat Forty Fair Fertile Hormonal therapy Rapid weight loss
What are the signs and symptoms of acute cholecystitis?
Biliary colic - may radiate out to right shoulder (Murphy's sign) Fever Nausea Deranged LFTs - elevated ALT, AST, ALP - mildly elevated bilirubin and amylase
What symptoms are associated with biliary sepsis (cholangitis)?
Charcots triad - fever - jaundice - RUQ pain Reynolds pentad - fever - jaundice - RUQ pain - mental confusion - spetic shock
What are some of the causes of cholangitis?
Gallstones - main Biliary manipulation Hepatobiliary malignancy - pancreas - bile duct
What blood results would you expect to see with cholangitis associated biliary sepsis?
Obstructive LFTs Raised bilirubin Raised amylase (maybe) Positive blood cultures (50%) - E.Coli - Klebsiella - Enterococcus
How is cholangitis associated biliary sepsis treated?
Broad spectrum antibiotics
Describe the presentation of acute pancreatitis.
Acute, severe upper abdominal pain - 50% radiates to the back Partially relived by bending forward Severe - multi-organ failure - pleural effusion - asites 5-10% painless Jaundice (if gallstone disease) 3% of patients - Cullen's sign or Grey Turner sign - non-specific - represents reteroperitoneal bleeding in pancreatic necrosis
How is acute pancreatitis diagnosed?
Elevated serum amylase (>3x ULN)
- rises within 6-12 hours and has a short half-life
- beware of normal amylase in late presenters
- may be lower in alcoholic pancreatitis and hypertriglyceridaemia pancreatitis
Serum lipase elevated
What are the possible causes of acute pancreatitis?
I GET SMASHED I - idiopathic G - gallstones E - ethanol T - trauma S - scorpion sting M - mumps/malignancy A - autoimmune S - steriods H - hyperlipidaemia E - ERCP D - drugs
How can acute pancreatitis be classified?
Interstitial oedematous acute pancreatitis
Necrotising acute pancreatitis
Mild acute pancreatitis (no organ failure or complications)
Moderately severe pancreatitis (organ failure <48hrs and/or local complications)
Severe acute pancreatitis (persistant organ failure >48hrs)
How is acute pancreatitis managed?
Supportive in mild cases
- fluid replacement
- pain control
- PO/enteral nutrition
- antibiotics if they are septic
Treat the underlying cause (e.g. stop drinking)
Persistance symptomatic fluid collections >4 weeks need drainage
What is chronic pancreatitis?
Parenchyma replaces with fibrous tissue
Acute pancreatitis/recurrent pancreatitis/chronic pancreatitis progression
What are the symptoms of chronic pancreatitis?
Increased risk of pancreatic cancer
What are the possible causes/risk factors of chronic pancreatitis?
TIGAR-O T - toxic I - idiopathic G - genetic (PRSS1, CFTR) A - autoimmune R - RAP/SAP associated O - obstructive (e.g. tumour)
How is chronic pancreatitis diagnosed?
Cacification on imaging
Aspiration of duodenal secretions at ERCP
Labelled carbon breath test (for PEI)
Wedge biopsy or section of resected pancreas
What is the treatment of chronic pancreatitis?
Potent analgesia (opiates) Duct drainage Address exocrine and endocrine needs Smoking cessation Alcohol cessation Surgery - pancreaticojejunostomy/distal pancreatectomy
What are the possible mechanisms of pancreatic exocrine insufficiency?
Reduced secretion of exocrine fluid due to pancreatic disease
Low CCK release due to duodenal disease
Acidic duodenal pH due to gastric hypersecretion or low bicarbonate secretion
Abnormal aboral transit due to surgery
Name some possible causes of PEI.
Acute pancreatitis Chronic pancreatitis Cystic fibrosis - thick mucous in pancreas blocks ducts Pancreatic cancer Diabetes mellitus - trophic effect of insulin - autonomic neuropathy Pancreatectomy Gastrectomy - strech receptors that allow pancreatic juice release aren't activated Coelaic disease IBD Zollinger-Ellison syndrome - increased gastrin secretion
What are the clinical consequences of PEI?
Malnutrition and not diarrhoea - steatorrhoea Deficient nutritional status associated with - pain episodes - hospitalisation - CV events - fracture risk (osteoporosis) - infection risk
How is PEI diagnosed in clinical practice?
Don’t always need confirmation tests
Direct/indirect faecal elastase
Morphological evaluation of the pancreas in chronic pancreatitis patients
A trial of PERT in suspected patients
What is the aim of therapy for PEI?
Avoidance of steatorrhoea, weight loss and maldigestion-related symptoms
Toe ensure normal nutritional status
How is PEI managed?
Enteric coated pancreatin mini-microspheres (Creon 25,000 units, 2 caps per meal, 1 cap for snacks)
If that isn’t enough
- add a PPI and increase enzyme dose
If that isn’t enough
- check for other causes of malabsorption and treat
Why is the mortality rate for pancreatic carcinoma so high?
Late presentation Systemic disease at presentation Nihilistic attitude of the medical profession - 'brought it upon themselves' Inappropriate selection for treatment Correct access for treatment
What are the clinical features of pancreatic carcinoma?
Jaundice (if CBD obstruction) or mets Abdominal/back pain Weight loss Recent diagnosis of diabetes (<2 years) Acute pancreatitis Migratory thrombophlebitis - inflamed vein near skin surface Double duct sign
What are the risk factors for pancreatic carcinoma?
Smoking Male Alcohol Chronic pancreatitis BMI Family history Genetic - HNPCC - FAP - BRCA2
How is pancreatic cancer diagnosed?
CT or MRI
How is pancreatic cancer treated?
Whipple's Resection Oncology Palliative care - chemotherapy (folfirinox, gem, gem-cap, gem-abraxane) - coealic axis neurolysis - stenting (for jaundice) - PERT to minimise weight loss - thoracoscopic splanchnicectomy