Flashcards in Pancreatic disorders Deck (38):
Name the 2 commonest causes of acute pancreatitis
Name 6 rare causes of acute pancreatitis
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP (5%) and emboli
Drugs: azathioprine, oestrogen, thiazides, isoniazid, steroids, NSAIDs
10-30%: Pregnancy, neoplasia, idiopathic
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
Describe the clinical presentation of acute pancreatitis
Gradual or sudden severe epigastric or central abdominal pain, that radiates to the back
Cullen's (periumbilical) or Grey Turner's sign (flank)
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
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
How is severe pancreatitis determined?
3+ criteria within 48hr of admission ➔ ITU/HDU transfer
-Neutrophils/WCC >15,000 x10-9/L
-Corrected calcium <2mmol/L
-Raised blood urea >16mmol/L
-Enzymes AST >200U/L, LDH >600U/L
-Sugar (BM) >10mmol/L (secondary diabetes)
Name 3 non-pancreatitis causes of raised serum amylase
Perforated peptic ulcer
Pelvic inflammatory disease
Describe the early treatment of acute pancreatitis
Urgent ERCP and stone extraction for proven bile duct stones causing obstruction and pancreatitis
Outline the definitive management of acute pancreatitis
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:
Surgical debridement for infected necrosis
Drainage for very large acute pseudocysts
Name 2 early complications of acute pancreatitis
Renal failure due to hypoperfusion
Hypocalcaemia due to saponification of fats
Name 3 late complications of acute pancreatitis
Thrombosis ➔ bowel ischaemia
Oedematous pancreas ➔ obstructive jaundice
Pancreatic encephalopathy due to hypoperfusion
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
Exocrine insufficiency: Malabsorption with weight loss, diarrhoea, steatorrhoea, protein deficiency
Endocrine insufficiency: Brittle T1DM
What are the functions of the pancreas?
Endocrine: Insulin and glucagon production
Exocrine: Pancreatic protease (trypsin, chymotrypsin), amylase, lipase
What is seen on histology of chronic pancreatitis?
Glandular atrophy and duct ectasia
Microcalcification and intraductal stone formation
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
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
Associated with primary biliary cirrhosis and primary sclerosing cholangitis
Congenital idiopathic chronic pancreatitis
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
Outline the initial treatment for chronic pancreatitis
Lifestyle: Alcohol and smoking cessation, antioxidant rich diet, dietary advice
Medical: Adequate analgesia, pancreatic enzyme supplements, insulin
What are the surgical indications for chronic pancreatitis?
Severe intractable pain or multiple relapses
Complications: Pseudocysts, obstruction, fistula, infections, portal HTN
Name 3 complications of chronic pancreatitis
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)
What surgical management is used for severe retractable pain or multiple relapses?
Partial pancreatectomy of head or tail
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
Describe the illness course of pancreatic cancer
Notoriously late presentation
Poor survival rates (<5%)
What types of pancreatic cancers exist?
-Acinar cell cancer
-Gastrinoma e.g. ZE syndrome
Where do pancreatic cancers most commonly metastasise?
List 5 risk factors for pancreatic cancer
Diet: red meat intake, low fruit and veg
FHx of pancreatic cancer
Occupational exposure to naphthylene and benzidine
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
Thrombophlebitis migrans (10%) - splenic vein thrombosis
Describe the presentation of carcinoma of the body and tail
Usually asymptomatic in early stages
Weight loss and back pain (60%)
Jaundice ➔ spread to hepatic hilar LN or metastases
Thrombophlebitis migrans (7%)
Diabetes mellitus (15%)
Which investigations are used for pancreatic cancer?
FBC, LFTs, Serum glucose
Serum CA19-9: correlate with tumour volume
Doppler USS of portal vein and superior mesenteric vessels
Fine needle aspiration cytology (FNAC)
ERCP - biliary drainage + cytology
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
Outline the palliative treatment of pancreatic cancer
ERCP biliary stenting
Percutaneous biliary drainage and stenting or insertion of drainage catheter
Surgical biliary drainage
Duodenal obstruction relief:
Chemical ablation of coeliac ganglia
What proportion of pancreatic cancers are suitable for surgical resection?
95% not suitable due to metastases, local invasion, LN involvement, age, or comorbidity
Outline the prognosis of pancreatic cancer
Poor, even in patients with resectable disease
5yr survival is 12%
Which drugs are particularly associated with acute pancreatitis?
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.