Pancreas Disease Flashcards
(58 cards)
1
Q
What causes pancreatitis
A
Most common Gall stone Ethanol Trauma - post ERCP / post op Drugs
S - steroids / NSAID / sulphonamide M - malignancy A - Autoimmune / azathioprine S - Scorpion venom H - hyperlipid / hypothermia / hyper Ca / hyper PTH E - emboli / vascular D - drugs V - virus (HIV)
2
Q
What drugs can cause
A
Steroid NSAID Azathioprine Suphonamide Meleasasine - 5ASA Diuretic Sodium valproate
3
Q
What does hyperlipiaemia cause
A
Pancreatitis most common
Gall stone
ISchaemic bowel
4
Q
What is the issue with lipid
A
Rise in acute inflammation
Need to check 2+ weeks after
5
Q
What are Ddx for high amylase
A
Pseudocyst Mesenteric infarct Perforated viscous Cholecystitis Infection DKA Obstruction Drugs Renal failure
6
Q
What is the pathophysiology of pancreatitis
A
Injury Enzyme release Auto digestion = necrosis Amylase + lipase released Oedematous and haemorrhagic gland Non bacterial inflammation Cytokine release + SIRS
7
Q
What is mild pancreatitis
A
No organ failure
8
Q
What is severe
A
Organ failure >48 hours
Local complications
Glasgow score >3
9
Q
What is DDX of pancreatitis
A
Perforated ulcer Acute cholecystitis Biliary colic High obstruction - vomit etc MI Ruptured AA Mesenteric iscahemia
10
Q
How do you Dx pancreatitis
A
2+ of Abdo pain consistent with pancreatitis (acute severe epigastrium, radiates to back, better sitting forward, reaches max in a few hours) Serum lipase or amylase >3x Vomiting (unlike perforation) Characteristic findings on CT
11
Q
What are other symptoms of pancreatitis / consequences
A
Low grade Fever Tachycardia Shock Diarrhoea Constipation (ileus) Dehydration Tender and rigid abdomen - acute Can be haemodynamically unstable due to 3rd space loss
Consequences Jaundice due to CBD or oedema Hypocalcaemia - fat binds to Ca 3-8 days after Hyperglycaemia ARDS Effusion due to high amylase Cullens (umbilical) Grey turner (flank) due to retroperitoneal haemorrhage = severe
12
Q
How do you Dx pancreatitis and why do you do certain
A
Raised amylase x4 Raised lipase Increased CRP FBC - leucocytosis LFT (Cause) , U+E (AKI) , Ca, glucose, lipids, lactate ABG if low sats Imaging to look for complication not Dx
13
Q
What imaging in pancreatitis
A
CT = DIAGNOSTIC - oedema/ indistinct margin
AXR - ileus / effusion / calcification / rule out perforation
Abdo USS for gall stone
EUS - stones
ERCP if LFT worsening
14
Q
When do you do CT
A
Severe Uncertain after 24 hours See complications Deterioration 48 hours after to look for complications
15
Q
What does Glasgow score take into account
If >3 = HDU / ITU for organ support
A
PANCREAS PaO2 <8 Age >55 Neutrophils / WBC >15 Calcium low <2 / CRP high Renal - urea >16 Enzymes - LDH and AST / LFT raised and lactate Albumin low <32 Sugar - glucose >10 (high) \+ Progressive hormone failure
16
Q
What is important to remember
A
Amylase NOT prognostic
17
Q
How do you treat pancreatitis
What enzyme should they get
A
ABCDE Analgesia NBM NGT to decompress stomach Oxygen Fluid resus Catheter Monitor HR, BP, UO Daily FBC, U+E, Ca, glucose, amylase, ABG Encourage nutrition or NG tube Creon =. pancreatic enzyme supplement TPN if ileus Insulin? Calcium? Treat underlying cause - early cholecystectomy / ERCP CT scan Organ support - isotrope / ventilation / dialysis Alcohol cessation
18
Q
What are non-local complications of pancreatitis
A
Organ failure Shock ARDS Pleural effusion Renal failure DIC Metabolic disturbance - hypocalcium, hyperglycaemia Paralytic Ileus Encephalopathy Sepsis
19
Q
What are local complications usually 1-2 weeks after development
A
Acute fluid collection - can lead to pseudocyst / abscess Pseudocyst Abscess Stricture Fistula Peritonitis Pancreatic necrosis Haemorrhage Thrombosis
20
Q
What are the symptoms of a pseudocyst
A
Persistent increased amylase / abnormal LFT
Fever
Pain
Can rupture and fluid can tract
21
Q
What are complications of pseudocyst
A
Infection
Rupture
Erosion into vessels = bleed
22
Q
What causes pseudocyst
A
Pancreatic juice in fibrous capsule arise 4 weeks after
Can form not due to pancreatitis
23
Q
What do you do for acute fluid collection
A
Avoid drain as risk of infection
24
Q
What do you do for pseudocyst
A
USS / CT / ERCP Conservative as most will resolve Wait 12 weeks FNA if doesn't Surgery and drain if ruptures / pressure on organs
25
Why conservative
Risk of infection
26
What causes abscess
Infected pseudocyst
27
How do you treat
Ax and drain
28
What do you do for pancreatic necrosis
```
CT guided aspiration
If infected give Ax
Mostly conservative
Drainage / laparotomy
Nutrition is important
```
29
What are complications of necrosis
Haemorrhage
Portal hypertension
Stricture
30
What do you do for gallstone
ERCP
| Lap chole
31
When do you give Ax
Diagnosed infection of necrosis
Biliary obstruction
Cholangitis
Otherwise none as not an infection
32
What is chronic pancreatitis
Irreversible grandular destruction
| Affects endocrine and exocrine
33
What causes chronic pancreatitis
```
Alcohol = most common cause
CF
Smoking
Haemochromatosis
Autoimmune
Hypercalcaemia
Hyperparathyroid
Obstruction - tumour / fibrosis
```
34
What are the symptoms of chronic pancreatitis
```
Abdominal pain - worse after food
Vomiting after food
Bloating
Weight loss due to malaborption
Steathorrhoea - post 20 year
DM - post 20
Protein malabsorption - B12 / weight loss
Jaundice
```
35
How do you Dx chronic
Blood - raised amylase / decreased albumin / LFT / PT / glucose
Fetal elactase - assess exocrine
36
What imaging is used in chronic
USS = 1st line
CT confirms with calcification
AXR - calcification
ERCP
37
If chronic vomiting what do you do
Endoscopy
Coeliac
Blood test
38
How do you manage chronic
```
Avoid alcohol
Analgesia / coeliac plexus block
Creon + fat soluble vitamins
Insulin
Endoscopic Rx of duct
Surgery if malignancy
Low fat diet
```
39
What are the complications of chronic
```
Portal hypertension
Haemorrhage
Pseudocyst
DM
Cancer
Obstruction
Chronic pain
Aneursm / thrombosis of splenic vein
```
40
What is most common pancreatic cancer and where
Adenocarcinoma
| Head of pancreas = 70%
41
What mutation
KRAS
42
What are the symptoms that make you suspect
Painless obstructive jaundice due to biliary tree being obstructed = most common
Pain in RUQ / back relieved sitting forward at L1-L2 suggest tail of pancreas
Weight loss
Anorexia
Often present late as asymptomatic until block biliary
43
What are other symptoms
```
Fatigue
Pale stool
Steathorrheoa due to malabsorption
DM - loss of endocrine
Diarrhoea
N+V
Dyspepsia
Bowel change
Portal hypertension
Palpable GB
HSM
Acute pancreatitis on top
```
44
What are RF for pancreatic cancer
```
Age
Chronic pancreatiti
Smoking
Obesity
Alcohol
HNPCC / MEN / BRCA
Stomach ulcer
H.pylori
```
45
What does painless obstructive jaundice + palpable GB suggest
Malignancy until proven otherwise
| Known as Courvosier law
46
How do you Dx
Who gets urgent CT
```
Blood test
CA19-19 marker
USS - dilatation
CT = Dx
EUS with biopsy
```
Urgent if >60, weight loss + diarrhoea / pain / constipation / DM
47
What do you do if mass and jaundice
ERCP and stent
48
What do you do if mass no jaundice
USS
| Biopsy
49
What do you do if cancerous
CT
| Laparoscopy prior to Whipple to look for mets
50
How do you treat
Treat and fix jaundice if can't operate
Whipple if mass operable (remove head, GB, CBD, duodenum and pylorus) for tumour of head
Pancreatectomy for tumours of tail
Adjuvant chemo
51
What signs suggest can't operate
```
DM
Ascites
Palpable GB
HSM
Enlarged Ln
```
52
What do you do for palliation if can't operate
```
Must relief jaundice
ERCP +- stent
Palliative bypass
Duodenal stent if gastric obstruction
Gastrostomy for feed
Chemo or RT
Creon
PPI
PAIN
```
53
What are risks with pancreatic cancer
```
Present late as vague
Obstruction - abnormal LFT
Increased calcium
Blood clot
Splenic vein thrombosis
Thrombophlebitis migrans
Portal hypertension - ascites / HSM / GB
```
54
Mnemonic for pancreatitis Glasgow score
```
P - Pao2 <8
A - age >55
N - neutrophilic / WCC >15
C - calcium <2
R - renal urea >16
E - enzyme LDH / AST
A - albumin <32
S - sugar BG >10
```
Other
Lactate high
Progressive organ failure and high CRP
55
What is pseudocyst
Fluid collection closed in fibrous capsule / granulation tissue unlike acute fluid collection
56
When is it chronic
>6 weeks
57
What tests for causes of pancreatitis
EUS
ERCP - if LFT worsening as could be due to gall stone
USS
CT / MRI
58
How do you monitor cases of severe pancreas
```
Vital signs
Urine output
CVP
HR
Blood glucose
FBC, U+E, LFT, clotting, calcium, blood glucose, amylase
```
