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Flashcards in Pancreatic Disease Deck (29)
1

What is Acute Pancreatitis?

-Acute inflammation of the pancreas
-Upper abdominal pain
-Elevation of serum amylase (>4 times the upper limit of normal)
-May be associated with multi-organ failure in severe cases

2

What is the aetiology of acute pancreatitis?

Alcohol abuse (60-75%)
Gallstones (25-40%)

Trauma: blunt, post op, post-ERCP

Misc:
-Drugs (steroids, azathioprine, diuretics)
-Virus' (mumps, coxsackie B4, HIV, CMV)
-Pancreatic Carcinoma
-Metabolic (Increased calcium and triglycerides. Decreased temperature)
-Auto-immune

Ideopathic

3

What is the pathogenesis of Acute pancreatitis?

Primary insult causes activated pancreatic enzymes to be released.

Autodigestion causes:
-oedema, fat necrosis and haemorrhage
-Reactive oxygen species, pro-inflammatory cytokines

4

What are Ecchymoses?

Subcutaneous spot of bleeding with diameter over 1cm.

Around the umbilicus and the flanks are what to keep an eye out for in acute pancreatitis.

Indicate severe nectrotising pancreatitis

5

What blood tests would you carry out as part of the investigations for acute pancreatitis?

Amylase/Lipase
FBC, U+Es
LFT, Ca
Glucose, Lipids
ABGs
Coagulation screen

6

What imaging techniques would you use in investigation into acute pancreatitis?

AXR (ilius), CXR (pleural effusion)
Abdominal USS (Pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced)

7

How do you assess severity in acute pancreatitis?

White cell count >15x10^9/l
Blood Glucose >10 mol/l
Blood urea >16mmol/l
AST >200iu/l
LDH >600iu/l
Serum albumin 3 = SEVERE
(within 48hrs of admission)

CRP >150mg/l also indicates severe pancreatitis

8

What is the general management of acute pancreatitis?

Analgesia (pethidine, indomethacin)
IV Fluids
Blood transfusion (Hb

9

What is the specific management of Acute pancreatitis?

Pancreatic Necrosis:
-CT guided aspiration
-Antibiotics +/- surgery

Gallstones
-EUS/MRCP/ERCP
-Cholecystectomy

10

What are the management of complications in acute pancreatitis?

Abscess = antibiotics and drainage

Pseudocyst =
-Fluid collection without an epithelial lining
-Persistent hyperamylasaemia and/or pain
-Dx by ultrasound or CT scan
-Complications: jaundice, infection, haemorrhage, rupture
-

11

What is a pseudocyst?

Fluid collection without an epithelial lining
Persistant hyperamylasaemia and/or pain
Dx by ultrasound or CT scan
Complications = jaundice, infection, haemorrhage, rupture

12

Define chronic pancreatitis

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and or permanent loss of function

13

What is the epidemiology of chronic pancreatitis?

Prevalence = 0.01% in Japan -> 5.4% in S. India
Incidence = 3.5/100,000 pop per year
Males > females
Age 35-50 years

14

What is the aetiology of chronic pancreatitis?

Alcohol (80%)
Cystic Fibrosis (CP in 2%)
-High Frequency of CFTR mutations in CP
Congenital anatomical abnormalities
-Annular Pancreas
-Pancreas Divisum (failed fusion of dorsal and ventral buds)
Hereditary Pancreatitis: rare, auto. dom.
Hypercalcaemia

15

What genes are associated with Pancreatitis?

PRSS1 - Cationic trypsinogen
SPINK 1 - Pancreatic secretory trypsin inhibitor
CFTR

16

What is the pathogenesis of chronic pancreatitis?

Duct obstruction:
-Calculi
-Inflammation
-Protein plugs

?Abnormal sphincter of Oddi function
-spasm increases intrapancreatic pressure
-Relaxation: reflux of duodenal contents

?Genetic polymorphisms
-Abnormal trypsin activation

17

What is the pathology of chronic pancreatitis?

Glandular atrophy and replacement by fibrous tissue
Ducts become dilated, tortuous and structured
Inspissated secretions may calcify
Exposed nerves due to loss of perineurall cells
Splenic, superior mesenteric and portal veins may thrombose -> portal hypertension

18

What are the clinical features of chronic pancreatitis?

Early disease is asymptomatic

ABDOMINAL PAIN (85-95%)
-Exacerbated by food and alcohol; severity decreases with time

WEIGHTLOSS (pain, anorexia, malabsorption)

Exocrine insufficiency
-Fat malabsorption -> steatorrhoea
----decrease in fat soluble vitamins, Ca and Mg
-Protein malabsorption
----WEIGHTLOSS and decreased it B12

Endocrine insufficiency -> DIABETES in 30%

Misc: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma

19

What are the investigations for chronic pancreatitis?

Plain AXR (30% have calcification of pancreas)
USS = Pancreatic size, cysts, duct diameter, tumours
EUS
CT scan

Blood tests =
-Serum amylase (raised in acute exacerbations)
-Decreased albumin, Ca, Mg, Vit B12
-Increased LFTs, Prothrombin time (Vit K), glucose

Pancreatic function tests (Lundh, pancreolauryl)

20

What is the management of chronic pancreatitis?

PAIN CONTROL

Avoid alcohol
Pancreatic enzyme supplements
Opiate analgesia (dihydrocodeine, pethidine)
Coeliac plexus block
Referral to pain clinic/ psychologist
Endoscopic treatment of pancreatic duct stones and strictures
Surgery in selected cases

21

how do you manage exocrine and endocrine problems in chronic pancreatitis?

Low fat diet
Pancreatic enzyme supplements (e.g. Creon, Pancrex)
-May need acid suppression to prevent hydrolysis in stomach
Vitamin supplements usually not required

Insulin for diabetes mellitus

22

What is the prognosis in chronic pancreatitis?

Death from complications of acute on chronic attacks
Cardiovascular complications of diabetes
Associated cirrhosis
Drug dependence
Suicide

Continued alcohol intake -> 50% 10 year survival
Abstinence -> 80% 10 year survival

23

What is the epidemiology for carcinoma of the pancreas?

Incidence: 11/100,000 pop/year (increasing)
Males>Females
80% in 60-80 year age group
More common in western countries
- Highest rates in Maoris and Hawaiians

24

What is the pathology for carcinoma of the pancreas?

75% are duct cell mucinous adenocarcinoma
(Head 60%, body 13%, tail 5%, multiple sites 22%)

Other pathological types
-carcinosarcoma
-cystadenocarcinoma (better prognosis)
-Acinar cell

25

What are the clinical features of pancreatic cancer?

Upper ABDOMINAL PAIN (75%)- Ca body and tail
Painless obstructive JAUNDICE (25%)- Ca head
WEIGHTLOSS (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans
Ascites, portal hypertension

26

What are the physical signs of carcinoma of the pancreas?

Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites, splenomegaly
Supraclavicular lymphadenopathy (shows an unresectable tumour)
Palpable gallbladder (with ampullary carcinoma)

27

What imaging do you use in pancreatic carcinoma?

USS
CT
MRI
EUS

28

What is the management of pancreatic carcinoma?

Majority of patients have advanced disease at presentation and

29

What is the prognosis of pancreatic cancer?

Inoperable cases:
-Mean survival