What are poor prognostic indicators for acute pancreatitis?
- Elevated serum blood urea nitrogen level > 7.1mmol/L
- Hematocrit > 44%
- Elevated creatinine level
Diagnostic criteria for chronic pancreatitis
- Clinical Features: pain, recurrent attacks of pancreatitis,
weight loss - Imaging: calcifications, ductal dilatation or inflammatory
masses, exocrine pancreatic insufficiency, diabetes mellitus
Chronic pancreatitis
- Presentation
- Complications
- Progressive inflammatory changes of the pancreas –> permanent structural damage and impaired exocrine + endocrine function
Presentation
- Abdominal pain (dominant feature), worse post prandially
- Pancreatic insufficiency
Fat malabsorption –> (steatorrhea), fat soluble vitamins, B12 deficiency
Glucose intolerance/diabetes
Complications
- Pseudocysts
- Bile duct/duodenal obstruction: from fibrosis of pancreatic head or compressive effects of pseudocyst
- Pancreatic ascites or pleural effusions
Chronic Pancreatitis
- Diagnosis
- 72 hour quantitative faecal fat: >7g fat/day is diagnostic for malabsorption
- Faecal elastase: sensitive and specific test for pancreatic EXOCRINE dysfunction
- Abdo Xray: calcification of pancreatic duct vascular calcifications
- CT: pancreatic atrophy, duct dilatation, parenchymal + intraductal calcifications
- MRCP: progressive glandular atrophy
Chronic Pancreatitis
Management
- Malabsorption: pancreatic enzyme supplementation
- Steatorrhea: restrict fat intake, lipase supplementation, medium chain trigs
- Pain
- Endocrine: treat like diabetes
Causes of inherited pancreatitis
- Hereditary pancreatitis: autosomal dominant, increased risk of malignancy, recurrent mild attacks > 5yo, involved with PRSS1 gene
- SPINK1 mutation
- Cystic fibrosis gene mutations
- Variant common chymotrypsin C
- Autoimmune pancreatitis
Mild recurrent attacks
Associated with Sjogrens, primary biliary cholangitis, RA
Raised serum IgG4
Responds to steroids
What gene is associated with hereditary pancreatitis?
Trypsinogen gene ‘PRSS1’
Increased risk of cancer
Indications for hereditary pancreatitis testing
Symptomatic individuals who meet any of the following
- Unexplained documented episode of pancreatitis as child
- Idiopathic chronic pancreatitis, particularly when the onset of pancreatitis occurs <25yo
- Fam hx of pancreatitis without known cause
- Relatives with mutations associated with hereditary pancreatitis - PRSS1
- Recurrent attacks of acute pancreatitis with no identifiable cause
How do you treat a pseudocyst which has occurred secondary to acute pancreatitis?
Drain
Name benign and pre-malignant pancreatic lesions
Benign
- Pseudocyst
- Serous cystadenoma
Premalignant/Malignant
- Mucinous cystic neoplasm (MCN)
- Intraductal papillary mucinous neoplasm (IPMN)
- Neuroendocrine tumour
Risk factors for pancreatic cancer
- Age > 50yo
- Smoking
- Heavy alcohol
- High BMI
- DM
- Fam Hx
Associated Conditions
- Chronic pancreatitis
- CF
- Obesity
- Diabetes
- Intraductal papillary mucinous neoplasms
Genetic Syndromes
- BRCA1, BRCA2
- Lynch syndrome
- FAMMM (familial atypical multiple mole melanoma)
- Hereditary pancreatitis
Which of the following is most likely to be deficient in a patient poorly compliant to diet for coeliac disease? A. Iron B. Vitamin B12 C. Folate D. Calcium E. Vitamin K
A. Iron as absorbed in proximal small bowel (duodenum)
Genetic conditions associated with pancreatic cancer
- Familial component in 10% of cases
- Peutz Jeghers Syndrome
- Lynch syndrome (9-11x fold risk)
- BRCA1/2 - risk with BRCA 2 more established
What new treatment is available for BRCA mutated metastatic pancreatic cancer?
Olaparib (PARP Inhibitor)
Associated with significant benefit in progress free survival but not overall survival
Complications of pancreatic cancer
- Biliary obstruction
- Gastric outlet obstruction
- Tumour associated abdo pain - consider celiac plexus neurolysis/radiotherapy
- Pancreatic exocrine insufficiency - steatorrhoea, abdo cramps - require creon
- Thromboembolic disease
- GI bleeding
Treatment for pancreatic cancer
- Rarely resectable at time of presentation - if then Whipple’s procedure - pancreaticoduodenectomy, head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
- Adjuvant Chemo: 5FU or gemcitabine
- Locally Advanced: chemoradiotherapy, chemo alone to “downstage”
Metastatic Disease
- Folfirinox (5FU, irinotecan, oxaliplatin) - improved survival when compared to gemcitabine but increase toxicity
- Gemcitabine alone
• BRCA positive - olaparib
Side effect of gemcitabine
Pneumonitis
Treatment for pancreatic cancer
1st Line: 5FU, Oxaliplatin, Irinotecan
Very toxic - diarrhoea (all), peripheral neuropathy, neutropenia
40% survival with triple therapy
