Define Acute Pancreatitis
Sudden onset inflammation of the pancreas
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
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
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
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)
What are the local complications of acute pancreatitis?
- Fluid Collection
- Pseudocysts
- Pancreatic Abscesses or necrosis
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
How do gallstones cause acute pancreatitis?
They raise intra-ductal pressure preventing flow of digestive enzymes out
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
What imaging can be done for acute pancreatitis?
AXR -
CXR - Pleural Effusion
Abdominal US - Gall stones, Pseudocyst, pancreatic oedema
CT
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
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)
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
What is a pseudocyst?
A fluid collection without an epithelial lining
What would indicate presence of a pseudocyst in acute pancreatitis?
Persistantly high serum amylase and/or pain.
Diagnose with US or CT
What further problems can a pseudocyst cause?
Jaundice
Infection
Haemorrhage
Rupture
How do we treat a pseudocyst?
Endoscopic drainage or surgery if it doesnt dissapear alone
How do we treat acute pancreatitis?
- Emergency supportive care
- Treat the complications
- Treat the underlying causes (e.g. alcohol, abstinence, surgery etc)
Define Chronic Pancreatitis?
Continuing inflammatory disease of the pancreas characterized by irreversible glandular destruction and typically causing pain and/or impairment of function
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
Name a genetic cause for Chronic Pancreatitis?
Hereditary CP
Its a rare autosomal dominant disorder
Name an environmental cause of Chronic Pancreatitis?
Tropical Chronic Pancreatitis
What can cause recurrent pancreatic injury?
Hyperlipidaemia or hypercalcaemia
What happens to the pancreas in Chronic Pancreatitis?
- 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
