Pancreas

Question 1

What % of all malignancy is carcinoma of the pancreas?

Question 2

Typical prevalence for carcinoma of pancreas

Answer 2

> 60 and 60% male (oxford handbook say more female)

Question 3

Risk factors for pancreatic carcinoma

Answer 3

Smoking
Alcohol
High adiposity - central obesity

Family Hx

Carcinogens
DM
Chronic pancreatitis

Possibly high fat/red meat/processed meat diet

Question 4

What type of carcinoma is common?

Answer 4

Ductal adenocarcinoma

Metastasise early and present late

Question 5

Location of pancreatic cancer normally

Answer 5

60% in head
25% in body
15% in tail

A few in ampulla of vater or pancreatic islet cells

Question 6

Oncogene usually involved in pancreatic cancer

Answer 6

95% have KRAS2 activation

Question 7

Features of pancreatic head cancer

Answer 7

Painless obstructive jaundice

Obstruction of pancreatic duct can lead to pancreatic damage causing abnormalities in glucose homeostasis and therefore diabetes

Question 8

Features of body or tail of pancreas carcinoma

Answer 8

Abdominal/epigastric pain - radiates to back and relieved on leaning forward

Also non-specific symptoms such as anorexia, weight loss

Question 9

Investigations in pancreatic cancer

Answer 9

Transabdominal ultrasound - less reliable for body or tail cancers because of overlying bowel gas

CEA and Ca 19-9 can be elevated

Contrast CT scan

ERCP - usually for palliative treatment but can be good for cytology if diagnosis is in question

Question 10

Rarer features of pancreatic cancer

Answer 10

Thrombophlebitis migrans
Non-bacterial thrombotic endocarditis
Portal hypertension - splenic vein thrombosis

Question 11

Signs of cancer of head of pancreas

Answer 11

Jaundice and pruritus
Gall bladder may be palpable - Courvoisier’s sign (palpable gall bladder, painless and jaundice = pancreatic malignancy)

Hepatomegaly - mets

Lymphadenopathy

Ascites - mets

Question 12

Treatment for pancreatic cancer

Answer 12

Most present with metastatic disease and are not suitable for radical surgery

Can do pancreatoduodenectomy - Whipples - if no mets

Chemotherapy delays progression

Palliation of jaundice and obstruction

Pain - opiates or radiotherapy

Question 13

Prognosis for pancreatic cancer

Answer 13

Poor

5 year survival = 3%, 5-14% with whipples

Question 14

What is acute pancreatitis?

Answer 14

Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion - initiated by acute injury

Question 15

Causes of acute pancreatitis?

Answer 15

GET SMASHED

Gall Stones
Ethanol
Trauma

Steroids

Mumps and other viruses

Autoimmune - PAN = polyarteritis nodosa

Scorpion venom

Hyperlipidaemia, hypothermia, hypercalcaemia

ERCP and emboli

Drugs
Azathioprine
Sulfonamides
Sulindac
Tetracycline
Valproic acid,
Didanosine
Methyldopa
Estrogens
Furosemide
6-Mercaptopurine
Pentamidine
Corticosteroids
Octreotide

Question 16

Symptoms of acute pancreatitis?

Answer 16

Gradual/sudden severe epigastric or central abdominal pain

Radiates to back

Relieved by sitting forward

Vomiting

Question 17

Signs of acute pancreatitis

Answer 17

May be mild

Tachycardia, fever, hypotension
Jaundice
Shock, ileus (decreased bowel sounds)
Rigid abdomen + tenderness

Periumbilical bruising = Cullen’s sign
Flank bruising = Grey Turner’s sign

Question 18

Blood tests in acute pancreatitis

Answer 18

Serum amylase - 3x upper limit of normal if measured within 24 hours of onset of pain - back to normal after 3-5 days

Urinary amylase - remains elevated for longer

Serum lipase - elevated and for longer

CRP - assessing severity and prognosis

Question 19

Imaging in acute pancreatitis

Answer 19

Erect chest xray - exclude gastroduodenal perforation (raises serum amylase)

Abdominal ultrasound - gall stone cause of pancreatitis

CT to assess degree of pancreatic necrosis

MRCP - degree of damage and gall stone identification

ERCP - gall stone removal

Question 20

Assessment of severity of pancreatitis

Answer 20

PANCREAS

• PaO2 less than 8
• Age older than 55
• Neutrophils > 15 x 109/l
• Calcium less than 2mmol/L
• Renal Function Urea > 16mmol/L
• Enzymes LDH > 600iu/L AST >200iu/L
• Albumin less than 32g/l
• Sugar (glucose) >10mmol/L

3 or more positive factors detected within 48hours of onset suggests severe pancreatitis
- Prompt transfer to ITU/HDU

Question 21

Managment of acute pancreatitis

Answer 21

NBM - NG tube to decrease pancreatic stimulation
IV fluids
Analgesia - tramadol or morphine

May need debridement of necrotic tissue

Antibiotics

DVT prophylaxis

Question 22

Early complications of acute pancreatitis

Answer 22

Shock or sepsis
ARDS
Renal failure 
Hypocalcaemia 
Hyperglycaemia

Question 23

Late complications of acute pancreatitis

Answer 23

Necrosis
Pseudocyst
Abscesses
Bleeding - elastase eroding a major vessel
Thrombosis in SMA - causing bowel necrosis

Recurrent pancreatitis

Question 24

Pathology of chronic pancreatitis

Answer 24

Trypsin activation
Increased pancreatic enzyme activity (trypsin) leads to precipitation of proteins within duct lumen - form plugs

Obstruction, hypertension and further damage

Question 25

Presentation of chronic pancreatitis

Answer 25

Epigastric pain - through to back, relieved by leaning forward Hot water bottles chronically on sore areas (epigastrium and back) cause erythema ab igne's ``` Bloating Steatorrhoea Weight loss Diabetes Symptoms relapse and worsen ```

Question 26

Causes of chronic pancreatitis

Answer 26

``` Alcohol - 70% Familial (rare) CF Haemochromatosis Pancreatic duct obstruction high PTH Congenital Autoimmune ```

Question 27

Investigations in chronic pancreatitis

Answer 27

Amylase and lipase may be elevated Raised glucose Ultrasound CT - shows pancreatic calcification and dilated pancreatic duct MRCP - more subtle disease diagnosis Endoscopic ultrasound - doubt about diagnosis

Question 28

DDX of chronic pancreatitis

Answer 28

Similar presentation to pancreatic cancer

Question 29

Management of pain in chronic pancreatitis

Answer 29

NSAIDs and opiates for short-term flare up TCA, pregabalin for chronic pain Coeliac axis block Many patients become pain free after 6-10 years Can do surgery in unretractable pain

Question 30

Other management of chronic pancreatitis

Answer 30

Fat-soluble vitamins Lipase Low fat diet No alcohol Treat diabetes

Question 31

Complications in chronic pancreatitis

Answer 31

Pseudocysts Diabetes Biliary obstruction - ascites, gastric varices Pancreatic carcinoma

Question 32

What is Trousseau sign of malignancy?

Answer 32

Thrombophelbitis migrans - particularly associated with pancreatic and lung cancer