Pancreatic Disease Flashcards by Ben Johnston

Define Acute Pancreatitis

Sudden onset inflammation of the pancreas

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How does acute pancreatitis present?

Severe Epigastric pain (may radiate to the back)
Vomiting/Nausea
Pyrexia

Can also cause a number of less common symptoms:

Jaundice
Acute Renal Failure
Tachycardia (hypovolaemic shock)
Retroperitoneal haemorrhage
Effusions (Ascites/pleural)
Paralytic Ileus

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What do we call the visible signs of retroperitoneal haemorrhage in acute pancreatitis?

Grey Turner’s (on the flanks) & Cullen’s (Around the umbilicus) Signs

Both are severe bruising in the subcutaneous fat

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How do we differentiate mild and severe acute pancreatitis?

Severe comes with organ failure or local complications.
Its determined by the modified glasgow criteria, if 3 or more of the criteria are +ve its severe.

A raised CRP also indicates its severe

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What are the glasgow criteria for acute pancreatitis?

PANCREAS

PaO2 (<8)
Age >55yrs
Neutrophilia (Raised WCC)
Calcium (Low)
Renal Function (High Urea)
Enzymes (Raised LDH and AST/ALT Ratio)
Albumin (Low)
Sugar (Blood Glucose raised)

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What are the local complications of acute pancreatitis?

Fluid Collection
Pseudocysts
Pancreatic Abscesses or necrosis

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What are the common causes of acute pancreatitis?

Alcohol abuse is the biggest
Gallstones
Idiopathic

Can also be blunt trauma or post-op.

Rarely drugs/viruses/pancreatic carcinoma/metabolic/auto-immune

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How do gallstones cause acute pancreatitis?

They raise intra-ductal pressure preventing flow of digestive enzymes out

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What blood tests do we do for pancreatic disease?

Serum amylase/lipase (raised)
Glucose/U&E (Raised)
LFT (Raised AST/ALT)
FBC (Raised WCC)
Albumin (low)
Ca2+ (low)
ABG (can be low)
Coagulation Screen

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What imaging can be done for acute pancreatitis?

AXR -
CXR - Pleural Effusion
Abdominal US - Gall stones, Pseudocyst, pancreatic oedema
CT

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What emergency care do we give for an acute pancreatitis case?

HDU/ITU:

Analgesia
IV fluids
Transfusion (If necessary)
Catheterise
NG tube to maintain nutrition
O2 (can go into resp. failure)
Insulin
Ca supplement

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Why do we catheterize an acute pancreatitis patient?

We want to monitor urine output in order to monitor Kidney function.
acute pancreatitis can cause kidney failure which show up as small urine volume (Oliguria)

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How would we treat pancreatic abscess/necrosis as a complication of acute pancreatitis?

CT guided fine needle aspiration

Then antibiotics and/or surgery as necessary

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What is a pseudocyst?

A fluid collection without an epithelial lining

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What would indicate presence of a pseudocyst in acute pancreatitis?

Persistantly high serum amylase and/or pain.

Diagnose with US or CT

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What further problems can a pseudocyst cause?

Jaundice
Infection
Haemorrhage
Rupture

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How do we treat a pseudocyst?

Endoscopic drainage or surgery if it doesnt dissapear alone

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How do we treat acute pancreatitis?

Emergency supportive care
Treat the complications
Treat the underlying causes (e.g. alcohol, abstinence, surgery etc)

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Define Chronic Pancreatitis?

Continuing inflammatory disease of the pancreas characterized by irreversible glandular destruction and typically causing pain and/or impairment of function

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What causes Chronic Pancreatitis?

O-A-TIGER
Obstruction - Main Pancreatic duct e.g. Cystic Fibrosis
Autoimmune
Toxin - Alcohol is the biggest cause of CP
Idiopathic
Genetic
Environmental
Recurrent injury

Also can be a congenital anatomical abnormality such as annular pancreas divisum where the ventral/dorsal pancreatic buds fail to fuse

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Name a genetic cause for Chronic Pancreatitis?

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Hereditary CP

Its a rare autosomal dominant disorder

Name an environmental cause of Chronic Pancreatitis?

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Tropical Chronic Pancreatitis

What can cause recurrent pancreatic injury?

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Hyperlipidaemia or hypercalcaemia

What happens to the pancreas in Chronic Pancreatitis?

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Glandular atrophy & fibrous replacement.
Ducts become dilated/tortuous/strictured
Inspissated secretions can calcify
Nerves can become exposed
Splenic/Sup Mesenteric/Portal veins can thrombose

What does inspissated mean?

Thickened in consistency

How do nerves become exposed in Chronic Pancreatitis?

Perineural cells are lost

What is consequence of thrombosis of the portal vein, splenic vein or superior mesenteric vein?

Portal hypertension

How does Chronic Pancreatitis present?

Early CP is often asymptomatic - Abdominal pain exacerbated by food or booze - Weight loss due to pain/anorexia/malabsorption - Exocrine insufficiency - Endocrine insuffciency Also less commonly: Jaundice/Portal hypertension/GI hemorrhage/Pseudocysts

What are the consequences of hormonal insufficiency in Chronic Pancreatitis?

Exocrine: - Fat Malabsorption -> Steatorrhea - Protein Malabsorption -> Weight loss Endocrine: - Diabetes

How would we investigate suspected Chronic Pancreatitis?

``` AXR - May see pancreatic calfication US - Large pancreas, cysts, duct diameter, tumours Endoscopic US CT Bloods Pancreatic Function Tests ```

What would we see on Chronic Pancreatitis bloods?

Low: Albumin, Ca, Mg, B12 Raised LFTs, prothrombin time, glucose Raised serum amylase in an acute exacerbation

What kind of pancreatic function test are there?

- Faecal/Serum enzymes - Diagnostic Enzyme replacement - Pancrealauryl test, response of enzymes to stimulus

How do we manage Chronic Pancreatitis?

- Pain control - Hormonal management - Surgery if indicated

What kind of pain control is there for Chronic Pancreatitis?

- Avoid alcohol - Opiate analgesia - Pain clinic referal - Endoscopically treat pancreatic duct stones/strictures - Some surgeries - Coeliac plexus block

Explain a coeliac plexus block?

Done by injection Suppresses of destroys coeliac plexus This prevents pain long term.

How do we manage the exocrine/endocrine sides of Chronic Pancreatitis?

- Low Fat Diet | - Pancreatic Enzyme supplements (they may require acid suppression therapies to survive the stomach)

What would indicate surgery in Chronic Pancreatitis?

``` Malignancy Intractable pain Complications: - Duct/duodenal Stenosis - Biliary Obstruction or colonic stricture - Cyst/pseudocyst - Thrombosis or gastric varices - Compression of portal vein ```

What surgical options are there for Chronic Pancreatitis?

Depends on the cause and complications. - CBD Stent or bypass - Endoscopic PD sphincterectomy/dilatation/lithotripsy - Cyst drainage - Resection - Thorascopic Splanchectomy

Who is most at risk of pancreatic carcinoma?

Westerners in their 60s-80s

What are the risk factors for a pancreatic carcinoma?

``` Smoking Chronic Pancreatitis FAP (Familial Adenomatous Polyposis) Hereditary Pancreatitis Adult onset diabetes of less than 2 yrs ```

What types of pancreatic carcinoma are there?

- Duct Cell Mucinous Adenocarcinoma - 75% of total (msot are in the head) - Carcinosarcoma - Cystadenocarcinoma - Acinar Cell

Whats a cystadenocarcinoma?

Basically the malignancy forms a cyst containing retained secretions

What are the common clinical features of pancreatic carcinoma?

- Upper Abdominal pain - Painless, slow, obstuctive jaundice - Weight loss Also loads of less common stuff like Anorexia - Fatigue - Steatorrhea - vomiting/nausea - ascites - portal hypertension etc

What signs would indicate an unresectable pancreatic carcinoma?

``` Hepatomegaly Jaundice Abdominal mass/tenderness Ascites Splenomegaly Supraclavicular lymphadenopathy ```

In what form of pancreatic carcinoma would you feel a palpable gall bladder?

An ampullary carcinoma (not technically of the pancreas but related)

What investigations could we do for suspected pancreatic carcinoma?

(Assuming each test comes up +ve for mass/carcinoma etc this is the suggested progression) 1) Abdominal US +/- CT/EUS If they're jaundiced do an ERCP with stent. 2) Then Percutaneous needle biopsy 3) CT/EUS/Laparoscopy/Laparotomy to stage Bloods, CXR and tumour marker tests are also possible

How do we determine if someone is fit for surgery?

- Recieve fully informed consent - CXR/ECG/Resp function tests - Performance status

What surgeries are available for pancreatic carcinoma?

- Pancreatoduodenectomy (whipples procedure) - Pylorus Preserving Pancreatic Duodenectomy (PPPD) - Stent or cholechoduodenostomy for jaundice

How does the whipples procedure work?

You remove the duodenum and pylorus. | Then anastomose the stomach, bile duct and pancreas directly to the small intestine

How does PPPD work?

Remove duodenum and diseased part of pancreas. | Then anastomose the pylorus, bile duct and pancreas directly to the small intestine

What is a cholechoduodenostomy?

Surgical anastomoses of the bile duct straight to the duodenum

What is the prognosis for Pancreatic Cancer??

Inoperable - <6months Operable - 15% survive to 5 yrs Only 10% are operable by presentation anyway I.e. no fuckin sunshine an rainbows over here

Pancreatic Disease Flashcards

(52 cards)