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Yr2 GI Joe > Pancreatic disease > Flashcards

Pancreatic disease Flashcards

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1
Q

What is acute pancreatitis?

A

Inflammation of the pancreas with elevation of serum amylase (>4x) and multi-organ failure in severe cases

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2
Q

What is the incidence and mortality rate with acute pancreatitis?

A

Incidence of 20-300/million

Mortality of 6-12/million

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3
Q

What are the causes of acute pancreatitis?

(GETSMASHED)

A

Gallstones (25-40%)

Ethanol (60-75%)

Trauma

Steroids

Malignancy

Autoimmune

Scorpion sting

Hypertriglycerides / hypercalcaemia

ERCP

Drugs

(+ Idiopathic 10%)

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4
Q

Describe the pathology in acute pancreatitis

A

Primary insult causes the release of pancreatic enzymes

This causes Autodigestion leading to oedema, fat necrosis & haemorrhage

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5
Q

How does acute pancreatitis present (symptoms)?

A

Presents as acute emergency to hospital

Upper Abdominal pain (may radiate to back)

Nausea & Vomitting

Loss of appetite

Shivering

Fever

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6
Q

What are the clinical signs of Acute pancreatitis?

A

Epigastric tenderness (with gaurding)

Pyrexia

Tachycardia, hypovolaemic shock

Oliguria (acute renal failure)

Jaundice

Ascites / pleural effusions

Paralytic ileus

Retroperitoneal haemorrhage (Grey Turner’s & Cullen’s signs)

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7
Q

What investigations are done (first line) for a diagnosis of acute pancreatitis?

A
  1. Bloods: Serum amylase (> 4x), Serum Lipase (> 3x)
  2. Contrast enhanced CT scan

Source - BMJ

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8
Q

After diagnosis, investigations may be done to determine the cause.

What investigations could be done?

A

Gallstones - Abdo US + Liver function test

Bloods - FBC, Ca2+, Lipids, LFT^, Glucose, U&E’s

CXR - will identify pleural effusions

AXR - will identify ileus

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9
Q

What is the Glasgow criteria?

A

Criteria for assessng the severity of Acute pancreatitis, through analysis of several aspects of the Blood of the patient.

A score >3 = Severe pancreatitis

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10
Q

What are the cut off values for the Glasgow criteria?

A

White Blood cells >15x109/l

Glucose >10 mmol/l

Urea >16mmol/l

AST >200 iu/l

LDH >600 iu/l

Albumin <32 g/l

Calcium <2.0 mmol/l

PO2 <7.5 kPa

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11
Q

What CRP level indicates sever pancreatitis?

A

CRP > 150 mg/l

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12
Q

How should an acute pancreatitis patient be managed on admission?

A

Analgesia (morphine, pethidine, indomethacin)

IV fluids

Blood transfusion (Hb <10 g/dl)

Catheter (to monitor urine output)

Naso-gastric tube

Oxygen

Others: Insulin, Calcium supplements, Nutrition

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13
Q

Pancreatic necrosis is a complication of serious pancreatitis.

How is it managed?

A

CT guided aspiration

Followed by Antiobiotic treatment

Occasionally, surgery is required

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14
Q

Gallstones are a common cause of Acute pancreatitis.

How is this managed?

A

Gallstones usually identified by adbominal US scan

This is investigated using either EUS, MRCP or ERCP

Managed through Cholecystectomy

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15
Q

What is a cholycystectomy?

A

Surgical removal of the gallbladder

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16
Q

An abscess is a complication of Acute Pancreatitis

How is it treated?

A

Antibiotics

CT guided drainage

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17
Q

What is a pseudocyst (of the pancreas)?

A

Collection of Pancreatic fluids with a wall of fibrous tissue or granulation (but no epithelial lining)

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18
Q

What would indicate that a patient with Acute pancreatitis has developed a pseuodocyst?

A

Persistant Hyperamylaseaemia and/or Pain

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19
Q

How is a pseudocyst diagnosed?

A

Patient with symptoms is investigated using Abdominal Ultrasound or CT

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20
Q

What are the risks/complications of pseudocysts?

A

jaundice, infection, haemorrhage, rupture

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21
Q

Do all pseudocysts require surgical action?

A

Nah fam

If < 6cm - it will resolve

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22
Q

How is a pseudocyst managed?

A

Endoscopic drainage or surgery if persistent pain or complications

(Endoscopic is preffered)

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23
Q

What is the mortality of acute pancreatitis?

Study These Flashcards
A

Mild < 2%

Severe - 15% (pretty high eh)

24
Q

What is chronic pancreatitis?

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A

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

25
How important is ethnicity/origin concerning someones likelihood of getting chronic pancreatitis?
Highly variable, for example: in Japan there is a 0.01% prevalence in S.India there is a 5.4% prevalence In UK, **3.5 / 100,000 /year**
26
Describe the Age and gender shit for chronic pancreatitis
Male \> Female Typical age is 35-50 years
27
What causes chronic pancreatitis?
**Alcohol abuse** (80%) Cystic fibrosis Congenital abnormalities Hereditary pancreatitis Hypercalcaemia Diet
28
How likely is someone with Cystic fibrosis to develop chronic panc?
2% of CF patients have Chronic panc High frequency of CFTR gene mutations in those with Chronic Panc
29
What genetic mutations are most strongly associated with Chronic pancreatitis?
PRSS1 SPINK1 CFTR (cystic fibrosis)
30
Describe the pathophysiology of Chronic pancreatitis
**Duct obstruction** - Calculi (kidney stone), inflammation, protein plugs **Abnormal sphincter of Oddi function** –spasm: ­intrapancreatic pressure –relaxation: reflux of duodenal contents **Genetic polymorphisms** –Abnormal trypsin activation (just look this part up)
31
Describe the damage that takes place in the pancreatic ducts in chronic pancreatitis?
Pancreatic ducts blocked causing build up of pancreatic secretions This basically destroys the ducts - causing glandular atrophy & replacement by fibrous tissue Ducts become dilated, tortous & strictured - Inspissated secretions may calcify
32
How might nerves be exposed to damage in chronic pancreatitis?
Trapped Pancreatic juices may destroy perineural cells surrounding nerves This may cause them to become destroyed
33
How would chronic pancreatitis lead to portal hypertension?
Splenic , superior mesenteric & portal veins may thrombose This leads to portal hypertension
34
How does chronic pancreatitis tend to present?
**Abdominal pain** Weight loss Steatorhoea Diabetes (30%) Other: Jaundice, Portal hypertension, GI haemorrhage, pseudocysts & panc carcinoma
35
Why are symptoms like weight loss, Steatorrhoea and diabetes\* present in chronic pancreatitis? \*not a symptom but shut up
_Damage leads to **Exocrine insufficiency**_ **Fat malabsorption** =\> Steatorrhoea - Decreased fat soluble vitamins (ADEK) - Decreased Ca2+ & Mg 2+ **Protein malabsorption** =\> Weight loss **_Endocrine insufficiency_** =\> Diabetes in 30%
36
What investigations are done first line for chronic pancreatitis? *BMJ*
**Bloods:** Amylase, Glucose, Albumin, Vit B12 , Ca2+, Mg2+, LFT, Prothrombin time ## Footnote **CT scan** **AXR** **Abdo Utrasound**
37
What blood test results would indicate Chronic pancreatitis?
Serum amylase will increase **in Acute exacerbations** Albumin, Ca2+, Mg2+, Vit B12 will be **low** LFTs, prothrombin time (vit K), glucose will be **High**
38
What other investigations could be considered for Chronic pancreatitis?
EUS Pancreatic function tests: * Lundh * Pancreolauryl
39
Why is Abdominal ultrasound a useful imaging modality for Chronic pancreatitis?
Will identify: Pancreatic size, cysts, duct diameter, tumours
40
Why is Abdo X ray a useful imaging modality for chronic pancreatitis?
30% of CP patients have Calcification in their pancreas Xrays are good for picking this up
41
Pain control is a key part of the management of CP. Describe what is included in it?
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
42
How is the exocrine and endocrine aspect of CP managed?
**Diet** = Low fat (30-40 g/day) Pancreatic enzyme **supplements** (eg. Creon, Pancrex); may need acid suppression to prevent hydrolysis in stomach Vitamin supplements (usually not required) **Insulin for diabetes** mellitus (oral hypoglycaemics usually ineffective)
43
What is the prognosis for CP?
If they drink = 50% 10 year survival Abstinence = 80% 10 year survival
44
What are the main causes of death in those with Chronic pancreatitis?
Death from **complications of acute-on chronic attacks**, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
45
Describe the epidemiology of pancreatic carcinoma
11/100 000 pop/year (increasing) Males \> females 80% in 60-80 y/o age group More common in Western countries –highest rates in Maoris & Hawaiians
46
Where in the pancreas does the carcinoma tend to be?
**head 60%** body 13% tail 5% multiple sites 22%
47
What types of pancreatic carcinoma are there?
75% are duct cell mucinous adenocarcinoma carcinosarcoma cystadenocarcinoma (better prognosis) Acinar cell
48
What are the symptoms of pancreatic carcinoma?
**Upper abdominal pain** (75%) Jaundice (painless obstr. 25%) **Weight loss** (90%) Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
49
What are the signs **not on examination** of pancreatic cancer?
Tender subcutaneous **fat nodules** (like erythema nodosum) due to metastatic fat necrosis Thrombophlebitis migrans (shown below) Ascites Portal hypertension
50
What are the physical signs of pancreatic cancer? (ie signs on examination)
Hepatomegaly Jaundice Abdo mass Abdo tenderness Ascites, splenomegaly Supraclavicular lymphadenopathy Palpable gallbladder
51
How is pancreatic carcinoma firstly investigated?
1. Abdominal **US** ± **CT** scan ± **EUS**​ 2. (Mass identified): EUS/percutaneous needle biopsy 3. (if biopsy = carcinoma): CT scan/EUS/Laparoscopy/Laparotomy to see if operable
52
How is the investigative approach for pancreatic carcinoma different if there is jaundice?
ERCP ± Stent This is done as well as the other investigations
53
What is the general approach to managing pancreatic carcinoma?
\< 10% operable Management is usually **palliative**: * stent * palliative surgery - cholechoduodenostomy **Pain control** (opiates, coeliac plexus block, radiotherapy)
54
What is the approach to surgery with pancreatic cancer?
\< 10% operable If patient is Fit, the tumour is \< 3cm and there is no metastisis then a **pancreatoduodenectomy** (Whipple’s procedure) can be performed
55
Why is chemotherapy not available for treating pancreatic carcinoma?
It is only being used in controlled trials rn
56
Wha is the prognosis for pancreatic cancer?
Absolutely terrible _Inoperable_: * mean survival \< 6 months * 1% 5 year survival _Operable_: * 15% 5 year survival * Ampullary tumours 30-50% 5 year survival
57

Yr2 GI Joe (28 decks)

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