Pancreatic Disease Flashcards by Chloe Lee

What are the features of acute pancreatitis?

Acute inflammation
Upper, central epigastric pain
Elevation of serum amylase

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Describe mild acute pancreatitis

Associated with minimal organ dysfunction and uneventful recovery

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Describe severe acute pancreatitis

Associated with multi-organ failure or local complication:
• Acute fluid collections 
• Pseudocyst
• Pancreatic abscess  
• Pancreatic necrosis

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What is the aetiology of acute pancreatitis?

Gallstones
Alcohol

• Trauma: blunt/post-operative/post-ERCP 
• Pancreatic carcinoma
• Drugs (steroids, diuretics)
• Viruses (mumps, HIV)
• Hypercalcaemia
• Lipid abnormalities 
Idiopathic

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What is alcohols role in acute pancreatitis?

Direct invasion
Increased sensitivity to stimulation
Oxidation products (acetaldehyde)
Non-oxidative metabolism (fatty acid ethyl esters)

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How does gallstones cause acute pancreatitis?

Passage of gallstones essential

* Raised pancreatic ductal pressure

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How does ERCP cause acute pancreatitis?

Endoscope used to to examine the pancreatic and bile ducts - can increase pancreatic ductal pressure

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Describe the pathophysiology of alcohol/gallstones/ERCP causing acute pancreatitis

Primary insult -> release of activated pancreatic enzymes -> autodigestion:
• Pro-inflammatory cytokines
• Reactive oxygen species 
• Oedema 
• Fat necrosis 
• Haemorrhage

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What are the symptoms of acute pancreatitis?

Abdominal pain (may radiate to back)
Nausea, vomiting
Collapse

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What are the signs of acute pancreatitis?

Pyrexia
Dehydration (hypovolemic shock)
Abdominal tenderness
Circulatory failure

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What investigations are used for acute pancreatitis?

Blood tests: U+Es, FBC, serum amylase, ABG, lipids, LFT, glucose, Ca
CXR (pleural effusion)
AXR (ileus)
USS (pan. Oedema, gallstones, pseudocyst)
CT Scan

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What is used to assess the severity of the acute pancreatitis and state the ranges?

Glasgow Criteria: severe > 3 
White cell count > 15x109/L
Glucose > 10 mmol/L
Urea > 16mmol/L
AST > 200 IU/L
LDH > 700 IU/L
Serum albumin < 32g/l
Serum calcium < 2mmol/l
Arterial PO2 < 60 mmHg

Clinical Assessment
CT Scanning
Individual markers: CXR, CRP, IL6 TAP

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What is the managements of the different precipitating factors?

Cholelithaiasis: ERCP & ES, cholecystectomy (check for gallstones)
Alcohol: Abstinence, counselling
Ischaemia: careful support
Malignancy: resection or bypass
Hyperlipidaemia: diet, lipid lowering drugs
Anatomical abnormalities: correction if possible
Drugs: stop or change

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What is the general management of acute pancreatitis?

Analgesia
IV fluid
Blood transfusion (if anaemia)
Monitor urine output (catheter)
Naso-gastric tube
Oxygen
May need insulin (diabetic)

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What is the specific management for acute pancreatitis?

Pancreatic necrosis: 
• CT guided aspiration 
• Antibiotics 
• May need surgery 
Infected necrosis: laparotomy (could cause haemorrhage, portal hypertension, pan. Duct stricture

Gallstones
• EUS/MRCP/ERCP
• Cholecystectomy

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What are the two possible complications of acute pancreatitis?

Abscess and pseudocyst

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How do you manage an abscess in acute pancreatitis?

Antibiotics and drainage

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How do you investigate and manage a pseudocyst in acute pancreatitis?

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USS or CT
< 6cm diameter -> revolve spontaneously
Endoscopic drainage or surgery if persistent pain or complications

What is a pseudocyst and what are possible complications of it?

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Fluid collection without an epithelial lining
Persistent hyperamylasemia (and pain)
Complications: jaundice infection, haemorrhage, rupture

What is chronic pancreatitis?

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Continuing inflammation of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function of the endo and exocrine glands of the pancreas

What is the aetiology of chronic pancreatitis (O-A-TIGER)?

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Obstruction of MPD
Autoimmune
Toxin - ethanol, smoking, drugs
Genetic - recessive CFTR gene mutation
Environment - tropical chronic pancreatitis
Recurrent injuries

What are the recurrent injuries which can cause chronic pancreatitis?

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Biliary
Hyperlipidaemia
Hypercalcaemia

What can cause obstruction of MPD in chronic pancreatitis?

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Tumour, sphincter of Oddi dysfunction, Pancreatic divisum, duodenal obstruction, trauma, structure (post necrotising radiation

Describe the pathology of chronic pancreatitis

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Glandular atrophy & replacement by fibrous tissue
Ducts become dilated, tortous & strictured
Inspissated secretions may calcify
Exposed nerves due to loss of perineural cells
Splenic, superior mesenteric & portal veins may thrombose -> portal hypertension

What are the clinical features of chronic pancreatitis?

* Abdominal pain * Weight loss (pain, anorexia, malabsorption) * Pancreatic exocrine insufficiency: fat malabsorption -> steatorrhoea * Endocrine insuffiency diabetes * Jaundice * Duodenal obstruction * Upper GI Haemorrhage

What investigations are used for chronic pancreatitis?

* CT scan: pancreatic size, cysts, ducts * Plain AXR * ERCP/MRCP * EUS * Serum amylase increase * Decrease albumin, Ca, Vit B12 * Increase LFTs, glucose

What is the management for chronic pancreatitis?

* Abstinence of alcohol * Analgesia * Avoid high fat, high protein diet * Pancreatic enzyme supplements (for steatorrhoea) * Insulin for diabetics * Coeliac plexus block (stop pain)

What types of surgery is used for chronic pancreatitis?

Drainage and resection

What are five different types of resection surgeries available for chronic pancreatitis?

* Duodenum-preserving pancreatic head resection (DPPHR) * Pylorus preserving pancreatoduodectomy (PPPD) * Whipple’s pancreatico-duodenectomy * Spleen-preserving distal pancreatectomy * Central pancreatectomy

What complications can occur during surgery for chronic pancreatitis?

* Pancreatic duct stenosis * Cyst / pseudocysts * Biliary tract obstruction * Splenic vein thrombosis / gastric varices * Portal vein compression / mesenteric vein thrombosis * Duodenal stenosis * Colonic stricture

What is the treatment of chronic pancreatitis?

* PD stenosis and obstruction: endoscopic PD sphincterotomy, dilateion and lithrotripsy * Management of chronic pseudocyst * CBD stening or bypass * Thorascopic splanchnectomy * Coeliac plexus block (inject ethanol to numb the nerves of the pancreas)

Name five risk factors for pancreatic carcinoma

* Smoking * Chronic pancreatitis * Adult onset DM of less than 2 years duration * Hereditary pancreatitis * Inherited predisposition (Periampullary cancer is a feature of FAP)

Describe the pathology of pancreatic carcinoma

75% are duct cell mutinous adenocarcinoma (mostly head of p.) Other pathological types: • Carcinosarcoma • Cystadenocarcinoma • Acinar cell

What are the clinical features of pancreatic carcinoma?

* Abdominal pain (Ca of body & tail) * Painless obstructive Jaundice (Ca head) * Weight loss + anorexia * Vomiting * Tender subcutaneous fat nodules due to metastatic fat necrosis * Thrombophlebitis migrans * Ascites, portal hypertension

What is Thrombophlebitis migrans?

Recurrent episodes of vessel inflammation due to blood clot

What are the signs of pancreatic carcinoma?

* Hepatomegaly * Jaundice * Abdominal mass * Abdominal tenderness * Ascites, splenomegaly * Supraclavicular lymphadenopathy Signs above usually indicate unresectable tumour • Palpable gallbladder (with ampullary carcinoma)

What investigations are used for pancreatic carcinoma?

``` General: blood tests and CXR Tumour markers: CA19-9 Imaging/Invasive: • USS • ?ERCP • CT • MR, MRCP • Laparoscopy + Lap USS • Peritoneal cytology • Percutaneous needle biopsy • PET ```

What is the best modality for staging pancreatic carcinoma?

What is the best modality for detecting liver metastases in pancreatic carcinoma?

Laparoscopy (if positive then its inoperable)

What is the management of pancreatic carcinoma if there is liver metastases?

Give ERCP and stent to bypass duodenal structure and stop jaundice

What is used to assess patient for surgery?

``` • History and excamination • CXR, ECG • Respiratory function test • Physiological ‘scoring system’ o None o Performance status 1-5 o Lactate threshold • Fully informed consent is vital ```

What is the palliative management of pancreatic carcinoma?

Drainage: o Obstructive jaundice o Duodenal obstruction

What is the management of pancreatic carcinoma?

* Most ptient present at late stage and <10% operable * Radical surgery: pancreatoduodenectomy (Whipples) * Palliation of jaundice: stent, palliative surgery (cholechoduodenostomy) * Pain control (opiates, coaeliac plexus block, radiotherpay) * Chemotherapy

Pancreatic Disease Flashcards

(43 cards)