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CP3 SURGERY > HPB - The Pancreas > Flashcards

HPB - The Pancreas Flashcards

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1
Q

Sx acute pancreatitis (SOCRATES)

A 
S - epigastric pain 
O - sudden (if cause = gallstones), gradual if b./c alcohol 
R - back 
A - N+V (prominent) 
T - pain incr for hrs, then plateaus for a few days 
E.- coughing/deep breathing 
R - sitting forward + up 
S - severe
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2
Q

Signs acute pancreatitis

A 
TachyC + sweaty 
Tachypnoea 
Fever
Ileus 
Jaundice 
Rigid abdomen 
Cullen's sign 
Grey-Turners sign
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3
Q

What is Cullens sign

A

Periumbilical discoloration due to haemorrhage into peritoneal space (in acute pancreatitis)

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4
Q

What is Grey-Turners sign

A

Discoloration of the flanks in acute pancreatitis

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5
Q

If brusing signs occur in an individual w/ acute pancreatitis, what does this signify

A

A worse prognosis

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6
Q

Aetiology acute pancreatitis (I GET SMASHED)

A 
Idiopathic 
Gallstones (/ other duct obstruction) 
Ethanol 
Trauma 
Steroids (direct acinar damage) 
Mumps 
Autoimmune 
Scorpion venom 
Hyper - lipidaemia/thyroid. Hypothermia 
ERCP
Dx - thiazides/sulphonamides/ACEi/NSAIDs
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7
Q

Pathology of acute pancreatitis

A

Insult to pancreas –> marked elevation intracellular Ca –> leakage enzymes –> acute inflamm.
Liberation digestive enzymes –> extensive tissue necrosis esp fat

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8
Q

What is periductal necrosis

A

Necrosis of acinal cells adjacent to ducts

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9
Q

What is periductal necrosis generally due to

A

Obstruction ie gallstones

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10
Q

What is panlobular necrosis

A

Necrosis of whole acinar lobule

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11
Q

/ What is panlobular necrosis generally due to

A

Dx/toxins/virus/metabolic insults

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12
Q

What is perilobular necrosis

A

Necrosis of peripheries of lobules

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13
Q

What is perilobular necrosis generally due to

A

Poor vascular perfusion ie. shock/hypothermia

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14
Q

Acute Mx of pancreatitis

A 
A-E + supportive Tx 
Aggressive fl resus , catheter + CVP monitor 
Hrly: pulse, BP, U/O + bloods 
Analgesia (STRONG)
NBM
PPI 
Anticoag 
Consider ITU
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15
Q

Why should a patient being treated for acute pancreatitis be kept NBM?

A

to rest the pancreas

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16
Q

further Mx of acute pancreatitis is gallstones suspected

A

ERCP

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17
Q

further Mx of acute pancreatitis if abscess or necrosis on CT

A

laparotomy + debridment

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18
Q

what % of pt w/ acute pancreatitis req ITU

A

15%

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19
Q

What % of ITU admissions with pancreatitis end in death

A

50%

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20
Q

Early complications pancreatitis (6)

A 
Shock (hypoV/septic) 
ARDS
Renal failure 
DIC
Hypocalcaemia 
Hyperglycaemia
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21
Q

Late complications pancreatitis (5(

A 
Pancreatiic pseudocyst 
Abscess 
Bleeding from elastase erodign through major vessel 
Thrombosis of aa --> bowel necrosis 
Fistulae
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22
Q

What is a pancreatic pseudocyst?

A

Collections of pancreatic fl and tissue debris around the pancreas

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23
Q

When does a pancreatic pseudocyst occur

A

4-6 weeks after acute pancreatits

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24
Q

Features of pancreatic pseudocyst

A

N+V
Epigastric pain
Elevated amylase

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25
Ix acute pancreatitis - bloods
``` FBC CRP U+E LFT Glucose Ca Coagulation Lactate ```
26
Why do CRP when Ix acute pancreatitis
Indication of severity and prognosis
27
Why do lactate when Ix acute pancreatits
Indication of progression
28
When to repeat bloods in acute pancreatitis to assess severity
24+48h
29
When is serum amylase a sensitive marker of acute pancreatitis
If measured within 24hrs | And if > 3x norm
30
Which other conditions can also raise amylase (3)
Cholecystitis GI perforations Mesenteric infarcton
31
Which marker is moer sensitive and specific than amylase in acute pancreatitis>
lipase
32
How long is lipase elevated for in acute pancreatitis
72hr
33
Imaging to Ix acute pancreatitis
``` AXR = mandatory Erect CXR CT MRCO USS Endoscopic USS ```
34
What are you looking for on AXR to diagnose acute pancreatitis (3)
Sentinel loop Small bowel ileus Calcification of the pancreas
35
Why do an erect CXR when Ix acute pancreatitis
Assess for perforation
36
Why do a CT when Ix acute pancreatitis
For ID abscess, necrosis, pseudocyst | If repeated at 72hr can assess severity necrosis
37
When is MRCP particularly useful in acute pancreatitis
When ddx between l + s inflamm mass
38
What scoring system best predicts the prognosis of acute pancreatitis
The Modified Glasgow criteria
39
What score on the Glasgow Criteria prompts admission to ITU
3 or >
40
The Glasgow Criteria (8) (PANCREAS)
``` PaO2 <8 Age >55 Neutrophils - WCC >15 Ca <2 Enzymes: LDH >600 + AST >200 Albumin <32 Sugar - glucose >10 ` ```
41
What does the APACHE II do
Allocations of points for assessment of A = clinical parameters B age C = co-morbidities
42
What APACHE II score indicates severe acute pancreatitis
>9
43
What is the Ranson criteria
Includes age + lab scores on admission, then clinical findings at 48hrs to give mortality risk figure
44
Metabolic complications acute pancreatitis (5)
``` Hyperglycaemia Hypocalcaemia Hypermagnesia Reduced Se albumin Malabsoprtion vit ADEK ```
45
Def pseudocyst
Localised fluid collection rich in pancreatic enzymes, with a non-epithelialized wall containing fibrous/granulation tissue
46
From when do pseudocysts occur
day 10 after pancreatitis
47
PS pseudocyst (6)
``` Deep persistent abdominal pain ABdo pain Anorexia jaundice sepsis pleural effusion ```
48
Ix pseudocyst (5)
``` Amylase +/- elevation LFTs may be abnormal Abdo CT = gold standard MRI (DDx from necrosis) ERCP ```
49
Complications of pseudocyst
Bleeding Infection GI obstruction Ruputre
50
Mx pseudocysts
Most req supporive care + reg monitoring | Some req drainage
51
Indications for drainage of pseudocyst (3)
Complications Relief of Sx Concerns RE malignancy
52
Age - pancreatic carcinoma
Pt >60
53
RF pancreatic carcinoma (4)
Smoking Alcohol DM Chronic pancreatitis
54
PS carcinoma of head of pancreas
PS earlier Painless jaundice May develop pain as progresses
55
O/E carcinoma head of the pancreas (4)
Signs related to obstructive janducie HSmegaly/ascites Palpable abdo mass Courvoisiers sign
56
Sx carcinoma of body/tail pancreas
PS later Dull abdo pain R to back Partially relieved by leaning forwards Non-specific B Sx = common
57
What can either pancreatitc cancers PS with
Acute pancreaitis | DM
58
Trousseau's syndrome
Thrombosis of superficial/deep leg vv related to pancreatic carcinoma
59
Ix pancreatic cancer - bloods (6)
``` FBC U_E LFT CA 19.9 or CEA Amylase (rarely elevated) ```
60
Imaging Ix pancreatic cancer (4)
USS - confirm obstruction + duct dilatation CT EUS +/- biopsy - location, spread of tumour + LN involv Staging lapraoscopy
61
What type of cancers are the majority of pancreatic cancers
Ductal adenocarcinomas
62
% of pancreatic carcinomas by location
60% head 25% body 15% tail
63
What % of pancreatic tumours are islet cell tumours
<2%
64
What syndrome can islet cell tumours occur w/
MEN syndrome
65
Sx of insulinoma
Sx hypoglycaemic events | Gross weight gain
66
Are the majority of insulinomas malignant or benign
Benign
67
PS glucagonoma
Often asymp | Or 2' DM
68
PS gastrinoma (4)
Zollinger-Ellison syndrome w/ oesophagitis GI ulcers Diarrhoea
69
PS somatostatinoma
DM (insulin release inhib) Achlorrhydria (gastrin release inhib) Gall stones (CCK release inhib)
70
Sx VIPoma
Profound diarrhoea
71
What % of pancreatic tumours are resectable
15%
72
Name of surgery pancreatic tumours
WHipples procedure | Pancreatoduodenectomy
73
What post surgery improves pancreatic cancer survival
chemotherapy
74
Is palliative surgery used in panc cancer
No | no benefit
75
Palliative Mx pancr tumour
ERCP/stent | to help jaundice + anorexia
76
Med survival pancreatic cancer
<6m
77
5y survival pancreatic cancer without whipples procedure
<2%
78
5 y survival pancreatic cancer with Whipples procedure
10-15%

CP3 SURGERY (19 decks)

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