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07. Year 2: Alimentary System > Surgery of Pancreatic Disorders > Flashcards

Surgery of Pancreatic Disorders Flashcards

1
Q

What are examples of pancreatic disorders?

A

Pancreatic cancer

Acute pancreatitis

Chronic pancreatitis

Intraductal papillary mucinous neoplasm (IPMN) and pancreatic cystic disease

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2
Q

What does IPMN stand for?

A

Intraductal papillary mucinous neoplasm

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3
Q

What is the incidence of pancreatic cancer in the UK?

A

10/100000

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4
Q

What age group is pancreatic cancer most common in?

A

60-80 years old

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5
Q

What is the male:female ratio of pancreatic cancer?

A

3:4

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6
Q

What is the 5 year survival rate of pancreatic cancer?

A

0.4%

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7
Q

What are risk factors for pancreatic cancer?

A

Smoking

Chronic pancreatitis

Adult onset of diabetes

Hereditary pancreatitis

Inherited predisposition

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8
Q

What is the presentation of pancreatic cancer?

A

Obstructive jaundice

Diabetes

Abdominal pain/back pain

Anorexia

Vomiting

Weight loss

Recurrent bouts pancreatitis

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9
Q

What investigations are done for pancreatic cancer?

A

Blood tests

Chest x-ray

Tumour markers (CA19-9)

Imaging/invasive investigations

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10
Q

What antigen is released by cancerous pancreatic cells that can be tested for?

A

CA19-9

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11
Q

What imaging/invasive tests can be done to investigate pancreatic cancer?

A

CXR

USS

CT

MRCP

Laparoscopic USS

Peritoneal cytology

Percutaneous needle biopsy

PET scan

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12
Q

What is considered when considering if a patient with pancreatic cancer is fit for pancreatic resection?

A

Basic history and examination

Chest x-ray and ECG

Respiratory function tests

Physiological scoring system

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13
Q

What types of surgery can be done for pancreatic cancer?

A

Kausch-Whipple

Pylorus-preserving pancreaticoduodenectomy (PPPD)

Palliative drainage

Metal stenting

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14
Q

What does PPPD stand for?

A

Pylorus-preserving pancreaticoduodenectomy

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15
Q

What is a pylorus-preserving pancreaticoduodenectomy

A

Similar to Whipples operation but none of the stomach is removed

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16
Q

What is Kausch-Whipple surgery?

A

Removes head of pancreas, bile duct, gallbladder and the duodenum

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17
Q

What is Kausch-Whipple surgery also known as?

A

Pancreaticoduodectomy

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18
Q

What is acute pancreatitis?

A

An acute inflammatory process of the pancreas with involvement of other regional tissues or remote organ systems

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19
Q

What are the different classifications of acute pancreatitis?

A

Mild AP

Severe AP

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20
Q

What is mild acute pancreatitis associated with?

A

Minimal organ dysfunction and uneventful recovery

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21
Q

What is severe acute pancreatitis associated with?

A

Organ failure or local complication

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22
Q

What are some local complications of acute pancreatitis?

A

Acute fluid collection

Pseudocyst

Pancreatic abscess

Pancreatic necrosis

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23
Q

What is the aetiology of acute pancreatitis?

A

Gallstones

Alcohol

Viral infections (CMV, mumps)

Tumours

Anatomical abnormalities

ERCP

Lipid abnormalities

Hypercalcaemia

Postoperative trauma

Ischaemia

Drugs

Scorpion venom

Idiopathic

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24
Q

What viral infections can cause acute pancreatitis?

A

CMV

Mumps

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25
Q

What does CMV stand for?

A

Cytomegalovirus

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26
Q

What is the pathophysiology of acute pancreatitis caused by alcohol?

A

Direct injury

Increased sensitivity to stimulation

Oxidation products (acetaldehyde)

Non-oxidative metabolism (fatty acid ethyl esters)

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27
Q

What is the pathophysiology of pancreatitis caused by gallstones?

A

Passage of gallstone is essential

Raised pancreatic ductal pressure

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28
Q

What is the pathophysiology of acute pancreatitis caused by ERCP?

A

Increased pancreatic duct pressure

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29
Q

What are some symptoms of acute pancreatitis?

A

Abdominal pain

Nausea, vomiting

Collapse

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30
Q

What are some signs of acute pancreatitis?

A

Pyrexia

Dehydration

Abdominal tenderness

Circulatory failure

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31
Q

What does the management of acute pancreatitis involve?

A

General supportive care (analgesia, IV fluids, cardiovascular, respiratory and renal support)

Monitoring (pulse, BP, urine output, CVP, arterial line, HDU/ITU)

Investigations

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32
Q

What should be monitored when managing acute pancreatitis?

A

Pulse, BP

Urine output

Central venous pressure (CVP)

Arterial line

HDU/ITU

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33
Q

What investigations should be done for acute pancreatitis?

A

U/E, glucose

Serum amylase

FBC, clotting

LFT ABG

Chest x-ray, abdomen x-ray

USS

CT scan

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34
Q

What critera does preducting severity of acute pancreatitis use?

A

Glasgow criteria

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35
Q

In the Glasgow criteria, what score inidcates severe acute pancreatitis?

A

3 or more

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36
Q

What does the Glasgow criteria check?

A

Glucose

Serum calcium

White cel count

Albumin

LDH

Urea

AST/ALT

Arterial pO2

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37
Q

What glucose level gives a score of 1 on the Glasgow criteria?

A

>10mmol/L

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38
Q

What serum calcium level gives a score of 1 on the Glasgow criteria?

A

<2mmol/L

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39
Q

What white cell count gives a score of 1 on the Glasgow criteria?

A

>1500/mm3

40
Q

What albumin level gives a score of 1 on the Glasgow criteria?

A

<32g/L

41
Q

What LDH level gives a score of 1 on the Glasgow criteria?

A

>700IU/L

42
Q

What urea level gives a score of 1 on the Glasgow criteria?

A

>16mmol/L

43
Q

What AST/ALT level gives a score of 1 on the Glasgow criteria?

A

>200IU/L

44
Q

What arterial pO2 level gives a score of 1 on the Glasgow criteria?

A

<60mmHg

45
Q

As well as the Glasgow criteria, what else can be used to predict the severity of acute pancreatitis?

A

Clinical assessment

CT scanning

Individual markers (CRP, IL-6)

46
Q

How is acute pancreatitis due to cholelithiasis managed?

A

ERCP and ES,

Cholecystectomy

47
Q

How is acute pancreatitis due to alcohol managed?

A

Abstinence

Counselling

48
Q

How is acute pancreatitis due to ischaemia managed?

A

Careful support

49
Q

How is acute pancreatitis due to malignancy managed?

A

Resection or bypass

50
Q

How is acute pancreatitis due to hyperlipidaemia managed?

A

Diet

Lipid lowering drugs

51
Q

How is acute pancreatitis due to anatomical abnormalities managed?

A

Correction if possible

52
Q

How is acute pancreatitis due to cholelithiasis managed?

A

Stop or change

53
Q

What are specific aspects of managing acute pancreatitis?

A

CT scanning

Antibiotics

Diagnosis of infection

ERCP in gallstone pancreatitis

Nutrition

Manipulation of inflammatory response

54
Q

What kind of complications from acute pancreatitis can be picked up by CT scanning?

A

Acute fluid collections

Abscess

Necrosis

Monitoring progress of disease

55
Q

What is used to diagnose infection with acute pancreatitis?

A

CT guided FNA or pancreatic necrosis

56
Q

What is CT guided FNA?

A

CT guided fine needle aspiration

57
Q

What is the definitive management of acute pancreatitis summarised?

A

Prevention of recurrent attacks

Fluid collection

Management of necrosis

Managment of complications

58
Q

What management is used to prevent further attacks of acute pancreatitis?

A

Management of gallstones

Investigations of non-gallstones pancreatitis

Alcohol abstinence

59
Q

How is necrosis due to acute pancreatitis managed?

A

Laparotomy

60
Q

What are examples of different kinds of necrosis due to acute pancreatitis?

A

Sterile necrosis

Infected necrosis

Abscess

61
Q

What are examples of different kinds of late complications due to acute pancreatitis?

A

Haemorrhage

Portal hypertension

Pancreatic duct stricture

62
Q

What is chronic pancreatitis?

A

Continuing chronic inflammatory process of the pancreas characterised by irreversible morphological changes leading to chronic pain and/or impairment of endocrine and exocrine function of the pancreas

63
Q

How does the incidence of males and females compare for chronic pancreatitis?

A

Males greater than females

64
Q

What are some causes of chronic pancreatitis?

A

Obstruction of the main pancreatic duct

Autoimmune

Toxin

Idiopathic

Genetic

Environmental

Recurrent injuries

65
Q

What are examples of things that can cause obstruction of the main pancreatic duct?

A

Tumour (adenocarcinoma, IPMT)

Sphincter of Oddi dysfunction

Pancreatic divisum

Duodenal obstruction (tumour, diverticulum)

Trauma

Stricture

66
Q

What is pancreatic divisum?

A

Congenital abnormality where a single pancreatic duct is not formed but remains as a ventral and dorsal duct

67
Q

What are examples of toxins that can cause chronic pancreatitis?

A

Ethanol

Smoking

Drugs

68
Q

What are examples of genetic causes of chronic pancreatitis?

A

Autosomal dominant (codon 29 and 122)

Autosomal ressesive (CFTR, SPINK1, codon A)

69
Q

What are examples of recurrent injuries that can cause chronic pancreatitis?

A

Biliary

Hyperlipidaemia

Hypercalcaemia

70
Q

What are clinical features of chronic pancreatitis?

A

Pain

Pancreatic exocrine insufficiency

Diabetes

Jaundice

Duodenal obstruction (uncommon)

Upper GI haemorrhage

71
Q

What investigations are done for chronic pancreatitis?

A

Appropriate imaging (CT scan, ERCP/MRCP)

Pancreatic exocrine function (used infrequently)

72
Q

What is done to look at pancreatic exocrine function?

A

Faecal/serum enzymes (elastase)

Pancreolauryl test (enzyme response to stimulus)

73
Q

What is the management of chronic pancreatitis?

A

Counselling

Abstinence from alcohol

Management of acute attacks

Analgesia

Avoid high fat, high protein diet

Surgery

74
Q

What are some possible complications of chronic pancreatitis that requires surgery to fix?

A

Pancreatic duct stenosis

Cyst/pseudocysts

Biliary tract obstruction

Splenic vein thrombosis/gastric varices

Portal vein compression/mesenteric vein thrombosis

Duodenal stenosis

Colonic stricture

75
Q

What interventional procedures can be done for treatment of chronic pancreatitis?

A

CBD stenting or bypass

Thoracoscopic splanchnectomy

Caeliac plexus block

76
Q

What procedures can be done for pancreatic duct stenosis and obstruction?

A

Endoscopic PD sphincterotomy, dilation and lithotripsy

77
Q

What are the different approaches for a caeliac plexus block?

A

Classic trans-crural

Trans-aortic

Anterior approach

78
Q

What are different ways of guiding a caeliac plexus block?

A

CT guided

EUS guided

Fluoroscopy guided

79
Q

What surgery can be done for drainage during chronic pancreatitis?

A

Pancreatic duct sphincteroplasty

Rochelle modification

80
Q

What surgery can be done for resection during chronic pancreatitis?

A

DPPHR

PPPD

Whipple’s pancreaticoduodectomy

Frey procedure

Spleen-preserving distal pancreatectomy

Central pancreatectomy

81
Q

What does DPPHR stand for?

A

Duodenal preserving pancreatic head resection

82
Q

What is mucinous cystic neoplasia of the pancreas?

A

Mucin producing and septated cyst forming epithelial neoplasia of the pancreas with distincive ovarian type stroma

83
Q

What is stroma?

A

Part of an organ or tissue with a structural or connective role

84
Q

What does MCN stand for?

A

Mucinous cystic neoplasia of the pancreas

85
Q

What is another condition similar to MCN?

A

Intraductal papillary mucinous neoplasm (IPMN)

86
Q

What does IPMN stand for?

A

Intraductal papillary mucinous neoplasm

87
Q

What are different kinds of IPMN?

A

MD-IPMN (main duct)

BD-IPMN (biliary duct)

88
Q

What are worrisome features of MD-IPMN?

A

Main pancreatic duct 5-9mm

Non-enhanced mural nodule

Abrupt change in main pancreatic duct

Lymph nodes involvement

89
Q

When is IPMN considered high risk?

A

MPD > 10mm

Enhanced solid component

90
Q

When is MCN considered high risk?

A

>1cm with enhanced solid component

Main pancreatic duct >1cm

91
Q

What are worrisome features of MCN?

A

>3cm

Enhanced cyst wall

Non-enhanced nodules

92
Q

What are indications for resection for MD-IPMN?

A

Always indicated

93
Q

What are indications for resection for BD-IPMN?

A

In elderly >3cm without high risk

In younger patients >2cm may be considered

94
Q

What are indications for resection for MCN?

A

All MCN in fit patients are indicated

95
Q

What are methods of IPMN and MCN resection?

A

Pancreatectomy

Focal and LN or spleen sparing (laparoscopic, robotic, multifocal BD-IPMN)

07. Year 2: Alimentary System (41 decks)

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