Pancreatic disorders Flashcards Preview

Phase II: Periop Pt1 > Pancreatic disorders > Flashcards

Flashcards in Pancreatic disorders Deck (38):
1

Name the 2 commonest causes of acute pancreatitis

Gallstone (60%)
Ethanol (30%)

2

Name 6 rare causes of acute pancreatitis

Trauma (1.5%)
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP (5%) and emboli
Drugs: azathioprine, oestrogen, thiazides, isoniazid, steroids, NSAIDs

10-30%: Pregnancy, neoplasia, idiopathic

3

How can acute pancreatitis be classified?

Oedematous (70%): simple or associated with phlegmon
Severe/necrotising (25%): sterile or infected necrosis, pseudocysts
Haemorrhagic (5%): Grey Turner's and Cullen's sign

4

Describe the clinical presentation of acute pancreatitis

Symptoms:
Gradual or sudden severe epigastric or central abdominal pain, that radiates to the back
Severe NaV

Signs:
Tachycardia
Fever
Jaundice
Shock
Ileus
Peritonism
Cullen's (periumbilical) or Grey Turner's sign (flank)

5

How is acute pancreatitis initially investigated?

Serum amylase >1000U/ml or 3x upper limit of normal
-note this does not correlate with severity of disease, and levels begin to fall within 24-48hr
Serum lipase: more sensitive and specific for pancreatitis

6

What imaging is used in suspected pancreatitis? What radiological findings may be seen with pancreatitis?

AXR (non-specific): sentinel loop, absent psoas shadows, colon cutoff sign, gallstones in CBD
CT: assess severity and complications
USS within 48hr admission: Gallstones in CBD

7

How is severe pancreatitis determined?

Glasgow-Imrie criteria:
3+ criteria within 48hr of admission ➔ ITU/HDU transfer
-PaO2 <8kPa
-Age >55
-Neutrophils/WCC >15,000 x10-9/L
-Corrected calcium <2mmol/L
-Raised blood urea >16mmol/L
-Enzymes AST >200U/L, LDH >600U/L
-Albumin <32g/L
-Sugar (BM) >10mmol/L (secondary diabetes)

8

Name 3 non-pancreatitis causes of raised serum amylase

Intestinal ischaemia
Leaking AAA
Perforated peptic ulcer
Acute cholecystitis
Acute appendicitis

Ectopic pregnancy
Pelvic inflammatory disease

Renal failure
Macroamylasaemia

DKA
Head injury

9

Describe the early treatment of acute pancreatitis

Urgent ERCP and stone extraction for proven bile duct stones causing obstruction and pancreatitis

10

Outline the definitive management of acute pancreatitis

Identify/prevent complications:
IV ABX - infected necrosis
CT scan - phlegmon, pseudocysts, haemorrhage
CT-guided pancreatic aspiration - infected necrosis
Enteral feeding - stress ulceration and sepsis

Treatment of early complications:
ITU/HDU transfer
Surgical debridement for infected necrosis
Drainage for very large acute pseudocysts

11

Name 2 early complications of acute pancreatitis

Shock
ARDS
Renal failure due to hypoperfusion
DIC
Sepsis
Hypocalcaemia due to saponification of fats
Hyperglycaemia

12

Name 3 late complications of acute pancreatitis

Pancreatic necrosis
Pseudocyst
Abscess
Bleeding
Thrombosis ➔ bowel ischaemia
Fistula
Oedematous pancreas ➔ obstructive jaundice
Pancreatic encephalopathy due to hypoperfusion

13

Describe the presentation of chronic pancreatitis

Recurrent/persistent epigastric pain radiating into back
-Relieved by sitting forward or hot water bottles
-Worse with food and alcohol
NaV
Anorexia
Exocrine insufficiency: Malabsorption with weight loss, diarrhoea, steatorrhoea, protein deficiency
Endocrine insufficiency: Brittle T1DM

14

What are the functions of the pancreas?

Endocrine: Insulin and glucagon production
Exocrine: Pancreatic protease (trypsin, chymotrypsin), amylase, lipase

15

What is seen on histology of chronic pancreatitis?

Glandular atrophy and duct ectasia
Microcalcification and intraductal stone formation

16

What sign may be seen as a result of conservative management of chronic pancreatitis?

Erythema ab igne (hot water bottle rash): chronic exposure to infrared radiation (heat) ➔ localised reticulated erythema and hyperpigmentation

17

List 3 causes of chronic pancreatitis

Recurrent acute pancreatitis esp. alcoholic pancreatitis
Secondary to pancreatic duct obstruction
-Pancreatic head tumours or cysts
-Pancreatic duct strictures: post-op, ERCP, parasites
-Congenital: pancreas divisum, annular pancreas
-Cystic fibrosis
Associated with primary biliary cirrhosis and primary sclerosing cholangitis
Congenital idiopathic chronic pancreatitis

18

What investigations should be used in chronic pancreatitis?

BM and HbA1c: Hyperglycaemia
AXR: Pancreatic calcifications
Abdo USS: Cystic changes and duct dilatation

Pancreatic CT: Pancreatic atrophy, disorganised ducts, altered acinar pattern with fibrosis, calcification
ERCP: Disorganised ducts, calcifications, dilated segments, cyst formation

19

Outline the initial treatment for chronic pancreatitis

Lifestyle: Alcohol and smoking cessation, antioxidant rich diet, dietary advice

Medical: Adequate analgesia, pancreatic enzyme supplements, insulin

20

What are the surgical indications for chronic pancreatitis?

Reversible cause
Severe intractable pain or multiple relapses
Complications: Pseudocysts, obstruction, fistula, infections, portal HTN

21

Name 3 complications of chronic pancreatitis

Pseudocysts
Obstruction
Fistula
Infection
Portal HTN
T1DM
Pancreatic carcinoma

22

What surgical management is initially available for chronic pancreatitis?

Options to remove causes or drain obstructed pancreas:
Pancreaticoduodenectomy (Whipple procedure)
Partial pancreatectomy of head or tail
Pancreaticojejunostomy (Puestow procedure)

23

What surgical management is used for severe retractable pain or multiple relapses?

Partial pancreatectomy of head or tail
Total pancreatectomy

24

Describe the epidemiology of pancreatic cancer

11th commonest cancer in UK
4th most common solid organ cancer in UK
5th most common cause of cancer death
Incidence continues to increase

80% occur in-between ages 60-70
Uncommon in under 40s

25

Describe the illness course of pancreatic cancer

Notoriously late presentation
Early metastases
Poor survival rates (<5%)

26

What types of pancreatic cancers exist?

Exocrine (majority)
-Adenocarcinomas (>80%)
-Cystic tumours
-Acinar cell cancer

Endocrine
-Gastrinoma e.g. ZE syndrome
-Insulinoma
-Somatostatinoma
-VIPoma
-Glucagonoma

27

Where do pancreatic cancers most commonly metastasise?

Liver
Peritoneum
Lungs

28

List 5 risk factors for pancreatic cancer

Increasing age
Smoking
Diet: red meat intake, low fruit and veg
Obesity
Alcohol
Diabetes
Chronic pancreatitis

FHx of pancreatic cancer
Occupational exposure to naphthylene and benzidine

29

Describe the presentation of carcinoma of the head of pancreas

Early symptoms are often vague and non-specific e.g. epigastric discomfort or dull backache

Obstructive jaundice (90%)
Pain (70%) in epigastric or LUQ - vague, radiates to back
Hepatomegaly ➔ metastases
Anorexia, NaV, fatigue, malaise, dyspepsia, pruritus
Acute pancreatitis
Thrombophlebitis migrans (10%) - splenic vein thrombosis

30

Describe the presentation of carcinoma of the body and tail

Usually asymptomatic in early stages
Weight loss and back pain (60%)
Epigastric mass
Jaundice ➔ spread to hepatic hilar LN or metastases
Thrombophlebitis migrans (7%)
Diabetes mellitus (15%)

31

Which investigations are used for pancreatic cancer?

FBC, LFTs, Serum glucose
Serum CA19-9: correlate with tumour volume

Transabdominal USS
Doppler USS of portal vein and superior mesenteric vessels
Abdominal CT
Fine needle aspiration cytology (FNAC)
ERCP - biliary drainage + cytology

32

Outline the curative treatment of pancreatic cancer

Radical surgical resection:
-Pancreatoduodenectomy (Whipple's) ➔ periampullary tumours, and carcinomas of pancreatic head
-Total pancreatectomy ➔ extensive tumour
-Distal pancreatectomy ➔ carcinomas of pancreatic tail

Adjuvant chemotherapy

33

Outline the palliative treatment of pancreatic cancer

Jaundice relief:
ERCP biliary stenting
Percutaneous biliary drainage and stenting or insertion of drainage catheter
Surgical biliary drainage

Duodenal obstruction relief:
Gastrojejunostomy

Pain relief:
Oral morphine
Chemical ablation of coeliac ganglia

34

What proportion of pancreatic cancers are suitable for surgical resection?

Only 5%

95% not suitable due to metastases, local invasion, LN involvement, age, or comorbidity

35

Outline the prognosis of pancreatic cancer

Poor, even in patients with resectable disease
5yr survival is 12%

36

Which drugs are particularly associated with acute pancreatitis?

NSAIDs
Steroids
Azathioprine
Thiazides
Isoniazid
Oestrogen

37

What investigation can be used to assess pancreatic function in chronic pancreatitis?

Faecal elastase - synthesised and excreted by pancreas

Low faecal elastase has high sensitivity and specificity for pancreatic compromise.

Specificity is compromised in Coeliac disease, Crohn's, and short bowel syndrome.

38

Name 2 pancreatic causes of raised serum amylase

Pancreatitis
Pancreatic trauma
Pancreatic carcinoma