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Pancreas Disease Flashcards

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1
Q

What causes pancreatitis

A

Gall stone
Ethanol
Trauma - post ERCP / post op

S - steroids
M - malignancy
A - Autoimmune
S - Scorpion venom
H - hyperlipid / hypothermia / hyper Ca / hyper PTH
E - emboli / vascular
D - drugs
V - virus (HIV)

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2
Q

What drugs can cause [5]

A 
Azathioprine
Suphonamide
Mesalazine - 5ASA
NSAID / steroid
Furosemide
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3
Q

What does hyperlipiaemia cause [3]

A

Pancreatitis most common
Gall stone
Ischaemic bowel

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4
Q

Causes of high amylase levels [8]

NB Amylase is non-specific and non prognostic

A 
Pseudocyst
Mesenteric infarct
Cholecystitis
Infection
DKA
Obstruction
Drugs
Renal failure
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5
Q

What is the pathophysiology of pancreatitis [6]

A
  1. Digestive enzymes activated & released
  2. Auto digestion = necrosis
  3. Non-bacterial inflammation
  4. Release of cytokines
  5. Edema and haemorrhage
  6. Cytokine release > SIRS
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6
Q

Mild pancreatitis - clinical definition?

Presentation [2]

A

No organ failure
Patient systemically well
Localised abdominal pain

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7
Q

What is severe pancreatitis? [3]

A

Organ failure >48 hours
Local complications
Glasgow score >3

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8
Q

What is DDX of pancreatitis [6]

A 
Perforated ulcer
Acute cholecystitis 
Biliary colic 
High obstruction - vomit etc
MI, Ruptured AA
Mesenteric iscahemia
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9
Q

Pancreatitis presentation:

What is needed for a diagnosis? [3]

A

2+ of:

  • Abdo pain consistent with pancreatitis
  • Serum lipase or amylase >3x
  • Characteristic findings on CT
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10
Q

Pancreatitis presentation:

  • Describe abdominal pain [5]
  • General signs [4]
  • Abdominal signs [4]
A

Characteristics of abdominal pain in pancreatitis:

  • Severe epigastric pain
  • Radiating to back
  • Vomiting, retching
  • Relieved by tripod position
  • Diarrhea, constipation (ileus)

General signs:

  • Low grade fever
  • Tachycardia, Shock
  • Hypoxic (ARDS)
  • Jaundice
  • Abdomen tender, rigid, no BS
  • Cullens sign (bluish discoloration, periumbilical)
  • Grey-Turners sign (flank bruising)
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11
Q

Investigations: pancreatitis
Bloods [5]
Describe LFT results you would see [3]

A 
FBC - leukocytosis
Ca low, Glc low, lactate up
ABG - risk of acute respiratory failure, metabolic upset due to ischemic bowel
Elevated serum amylase 
U&E (AKI)

LFTs

  • Mainly direct bilirubin increased
  • ALT & AST: Mild increase
  • VERY Elevated ALP
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12
Q

Describe the course that serum amylase follows in pancreatitis [4]

Diagnostic imaging: pancreatitis [3]

A

400U suggestive of pancreatitis
>1000U diagnostic
Rises within 6h
Returns to normal 3-5d after

Diagnostic imaging: pancreatitis
Abdo USS: gallstones
AXR: colon cut off sign, sentinel loop, ileus
IV contrast enhanced CT

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13
Q

When do you do CT [3]

A

Uncertain after 24 hours
Clinical deterioration
Organ failure, sepsis (necrosis) after 3-10d of admission

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14
Q

Severity stratification tool for pancreatitis [8]

A

Assesses severity of pancreatitis:

GLASGOW 3 (mnemonic)
Glucose
LDH
Age
Serum calcium, albumin and urea
Gasping for O2 (PaO2)
WBC 3
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15
Q

What is important to remember

A

Amylase NOT prognostic

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16
Q

Describe immediate management of pancreatitis [7]

A 
ABCDE
Admit to HDU/ITU
Analgesia, Oxygen, Fluid resus, Catheter
NG tube and NBM
Creon = pancreatic enzyme supplement
Organ support - isotrope / ventilation / dialysis 
Alcohol cessation
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17
Q

What are non-local complications of pancreatitis [7]

A 
Organ failure eg renal
Shock
ARDS
DIC, Sepsis
Metabolic disturbance - hypocalium, hyperglycaemia 
Paralytic Ileus
Encephalopathy
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18
Q

What are local complications [9]

A 
Acute fluid collection - can lead to pseudocyst / abscess 
Pseudocyst 
Abscess
Stricture
Fistula, Peritonitis
Pleural effusion
Pancreatic necrosis
Pseudoaneurysm
Portal/splenic vein thrombosis
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19
Q

What are the symptoms of a pseudocyst [4]

A

Persistent increased amylase / abnormal LFT
Fever
Pain
Can rupture and fluid can tract

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20
Q

What are complications of pseudocyst [3]

A

Infection
Rupture
Erosion into vessels = bleed

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21
Q

What causes pseudocyst

A

Pancreatic juice in fibrous capsule arise 4 weeks after

Can form not due to pancreatitis

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22
Q

What do you do for acute fluid collection [3]

A

50% resolve spontaneously; only percutaneously aspirate if suspect infection or symptomatic
Avoid drain as risk of infection

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23
Q

Investigations for pseudocysts [3]
When should you do diagnostic imaging? [1]
Procedure to remove? [3]

Study These Flashcards
A

EUS, CT, ERCP

Do these tests after 4 weeks as only then it is visible

Procedure: endoscopic/laparoscopic/open cystogastrostomy

24
Q

When do you choose intervention over conservative management? [2]

Study These Flashcards
A

If >6cm and >12w then unlikely to resolve. Conservative as most will resolve unless symptomatic/complicated

25
What causes abscess
infected pseudocyst
26
How do you treat abscess [2]
Abx and drain
27
What do you do for pancreatic necrosis [4]
Mostly conservative unless infected otherwise: - CT guided aspiration - Give antibiotics - Necrosectomy
28
What are complications of necrosis [3]
Haemorrhage Portal hypertension Stricture
29
What do you do for gallstone [2]
ERCP (Endoscopic retrograde cholangiopancreatography) | Laparoscopic cholecystectomy
30
When do you give Abx [4]
Diagnosed infection of necrosis Biliary obstruction Cholangitis Otherwise none as not an infection
31
What is chronic pancreatitis [2]
Irreversible grandular destruction | Affects endocrine and exocrine
32
What causes chronic pancreatitis [5]
``` Alcohol, Smoking Congenital abnormalities of pancreas, CF Haemochromatosis, Autoimmune Hypercalcaemia, Hyperparathyroid Obstruction - tumour / fibrosis ```
33
Presentation: chronic pancreatitis Describe the pain felt in pancreatitis [4] Associated symptoms [4] Symptoms that present 20y after onset of pain [3]
Epigastric pain - bores through to back - worse 15-30 mins after meal - may be relieved by sitting forward, hot water bottle (erythema ab igne) - Bloating - Steatorrhea - Jaundice - Vomiting after food Symptoms that present 20y after onset of pain [3] Weight loss & malabsorption, DM
34
Lab investigations in chronic pancreatitis [7]
- Amylase (up) - Albumin (low) - LFT - PT - Glucose (hyperglyc) - Fecal elactase - assess exocrine - Breath tests eg C-hiolen
35
What imaging is used in chronic [4]
Abdo USS CT abdo with IV contrast or AXR (calcification confirms dx) ERCP
36
If chronic vomiting what do you do [3]
Gastroscopy Coeliac Blood test
37
Describe immediate management of chronic pancreatitis [3] Describe surgical procedures [2]
1. Analgesia / coeliac plexus block 2. Creon + fat soluble vitamins 3. Nutrition: low fat, no alcohol Insulin Pancreatectomy or pancreatojejunostomy (duct drainage procedure)
38
What are the complications of chronic [8]
``` Portal hypertension Haemorrhage Pseudocyst DM Pancreatic cancer Biliary Obstruction Chronic pain Local arterial aneurysm / thrombosis of splenic vein ```
39
What is most common pancreatic cancer [2]
Adenocarcinoma | Head
40
What mutation
KRAS
41
Presentation of pancreatic cancer [4]
1. Painless obstructive jaundice (head) 2. Epigastric pain radiating to back and relieved by sitting forward (body or tail) - Vague abdominal pain means late presentation 3. Anorexia, weight loss, DM (loss of endocrine function) 4. Acute pancreatitis
42
What are other clinical features [9]
``` N+V, diarrhea Steatorrhea, DM - loss of exocrine Dyspepsia Bowel change Portal hypertension HSM Hypercalcemia Marantic endocarditis Nephrosis if renal vein mets ```
43
What are RF for pancreatic cancer [6]
``` Age Pancreatitis Smoking, Alcohol Obesity HNPCC / MEN / BRCA Stomach ulcer, H.pylori ```
44
What does painless obstructive jaundice + palpable GB suggest? What is this clinical sign?
Malignancy Courvoisier’s sign
45
How do you diagnose? [4]
Blood test - CA19-19 marker (prognostic) - LFT (obstructive jaundice picture) USS - dilatation CT = Dx
46
What do you do if mass and jaundice [2]
ERCP and stent
47
What do you do if mass but no jaundice [2]
USS | Biopsy
48
What do you do if cancerous [2]
CT | Laparoscopy prior to Whipple to look for mets
49
How do you treat [3]
Medical mx of jaundice Whipple's resection if mass is operable Adjuvant chemo
50
What signs suggest can't operate [5]
``` DM Ascites Palpable GB HSM Enlarged LN ```
51
What do you do for palliation [7]
``` ERCP +- stent - jaundice Palliative bypass Gastrostomy for feed Chemo or RT Creon PPI High dose opiates, coeliac plexus block ```
52
What are the sequelae of pancreatic cancer [5]
``` Obstruction - abnormal LFT Increased calcium Blood clot, Splenic vein thrombosis Thrombophlebitis migrans Portal hypertension - ascites / HSM / GB ```
53
How do you monitor cases of severe pancreas [5]
``` Vital signs Urine output CVP Blood glucose FBC, U+E, LFT, clotting, calcium, blood glucose ```
54
What is Whipple's resection? [3] | Indication?
Pancreaticoduodenectomy - Removal of pancreas head, portion of bile duct, gallbladder, duodenum and part of stomach - Stomach is re-joined with intestine Ind: Resectable lesions at pancreatic head
55
What surgery would you do for tail lesions?
Laparoscopic resection
56
Timing of cholecystectomy [3] Mild acute pancreatitis Severe acute pancreatitis Complicated acute pancreatitis
Mild Acute Pancreatitis - during the Same admission Severe Acute Pancreatitis- should be delayed until inflammatory process settled Complicated Acute Pancreatitis- cholecystectomy should be done when these are resolved or dealt with surgically

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