7.03- HPB Pancreas Flashcards
How is acute pancreatitis distinguished from chronic pancreatitis?
Limited damage to secretory function of the gland, with no gross structural damage developing.
Note repeated episodes of acute pancreatitis can result in chronic pancreatitis.
What are the causes of acute pancreatitis?
GET SMASHED:
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune disease (e.g. SLE)
Scorpion venom
Hypercalcaemia
Endoscopic retrograde cholangio-pancreatography (ERCP)
Drugs (e.g. NSAIDs, diuretics, Azathioprine)
What is the pathophysiology of acute pancreatitis?
GET SMASHED triggers will result in a premature and exaggerated activation of the digestive enzymes within the pancreas, resulting in a pancreatic inflammatory response that causes an increase in vascular permeability and subsequent fluid shifts (third spacing).
Enzymes are released from the pancreas result in autodigestion of fats and blood vessels. Fat necrosis can cause the release of free fatty acids, reacting with serum calcium to form chalky deposits and hypocalcaemia.
Severe end-stage pancreatitis results in necrosis.
What are the clinical features of acute pancreatitis?
- severe epigastric pain
- radiates to back
- nausea and vomiting
OE epigastric tenderness +/- guarding; haemodynamic instability; Cullen’s sign (bruising around umbilicus) and Grey Turner’s sign (bruising in the flanks) due to retroperitoneal haemorrhage; tetany due to hypocalcaemia.
What are the differential diagnoses for acute pancreatitis?
- abdominal aortic aneurysm
- renal calculi
- chronic pancreatitis
- aortic dissection
- peptic ulcer disease
How is acute pancreatitis investigated?
- serum amylase or serum lipase*
- LFTs to determine if gallstones underlying cause
*diagnostic of acute pancreatitis if 3x upper-limit of normal
What imaging is used to assess acute pancreatitis?
Abdominal ultrasound to identify any gallstones.
AXR reveal ‘sentinal loop sign’ - a dilated proximal small bowel loop adjacent to the pancreas, occurring secondary to localised inflammation.
CXR to assess for pleural effusion or ARDS.
CT CAP with contrast if investigations are inconclusive.
How is acute pancreatitis managed?
No curative management.
Treat underlying cause (e.g. urgent ERCP and sphincterectomy for gallstones).
Supportive treatment:
- IV fluid resuscitation
- Oxygen therapy as required
- Nasogastric tube if vomiting
- Catheterisation to monitor urine output (>0.5ml/kg/hr)
- Fluid balance chart (potential rapid third space losses)
- Opioid analgesia
- broad-spectrum antibiotic
UK guidelines state all patients with severe acute pancreatitis should be managed in ITU.
What are the complications of acute pancreatitis?
- disseminated intravascular coagulation (DIC)
- ARDS
- hypocalcaemia secondary to extensive fat necrosis
- hyperglycaemia secondary to destruction of islets of Langerhans
- pancreatic necrosis
- pancreatic cysts
What is chronic pancreatitis?
A chronic fibro-inflammatory disease of the pancreas, resulting in progressive and irreversible damage to the pancreatic parenchyma.
What are the causes of chronic pancreatitis?
- chronic alcohol abuse
- infection
- repeated acute pancreatitis
What are the clinical features of chronic pancreatitis?
- chronic epigastric / back pain
- nausea and vomiting
Due to damage to pancreatic parenchyma, there may be endocrine insufficiency resulting in hypergylcaemia / diabetes mellitus; may also be exocrine insufficiency resulting in malabsorption.
Malabsorption presents with weight loss, diarrhoea or steatorrhoea.
OE abdomen soft; tender epigastrium; significant cachexia
What are the differentials for chronic pancreatitis?
- peptic ulcer disease
- reflux disease
- abdominal aortic aneurysm
- biliary colic
- chronic mesenteric ischaemia
How is chronic pancreatitis investigated?
- urine dip
- serum amylase and lipase (not raised)
- blood glucose (?hyperglycaemia)
- LFTs (ensure no obstructive jaundice)
- faecal elastase (low)*
*faecal elastase is produced by acinar cells of the pancreas, and does not undergo any significant degradation during intestinal transit; any exocrine dysfunction presents with low faecal elastase levels.
What is the imaging of choice to investigate chronic pancreatitis?
- CT imaging
- MRCP
- EUS
- secretin stimulation test
How is chronic pancreatitis managed?
- treat underlying cause (e.g. alcohol cessation, statin therapy for hyperlipidaemia)
- analgesia (neuropathic medication)
- enzyme replacement (lipases)
- vitamin supplementation (A, D, E and K; fat soluble)
- insulin regimes and regular HbA1c if pncreatogenic diabetes
What is the most common type of pancreatic cancer?
Exocrine tumours more common, being ductal carcinoma.
Most commonly affects the head of the pancreas.
Why do pancreatic tumours affecting the body or tail have a worse prognosis than those affecting the pancreatic head?
Tumours affecting the pancreatic head are more likely to develop obstructive symptoms, therefore are more likely to be diagnosed at an earlier stage.
What are the risk factors for pancreatic cancer?
- smoking
- chronic pancreatitis
- family history
- obesity
What are the clinical features of pancreatic cancer?
- painless jaundice (compression of bile duct)
- weight loss (metabolic effects or secondary to exocrine dysfunction)
- abdominal pain (non-specific) due to invasion of coeliac plexus or secondary to pancreatitis
OE cachectic, malnourished, jaundiced, abdominal mass
What is Courvoisier’s Law?
Malignancy of the biliary tree or pancreas should be strongly suspected in the presence of jaundice and a palpable gallbladder.
What are the differentials for pancreatic cancer?
- gallstone disease
- cholangiocarcinoma
- gallstone disease
- peptic ulcer disease
- gastric cancer
- acute coronary syndrome
How is pancreatic cancer investigated?
- FBC (anaemia; thrombocytopenia)
- LFTs (raised bilirubin, ALP and GGT)
- CA19-9 to assess response to treatment
What is the imaging of choice to investigate pancreatic cancer?
Abdominal ultrasound first line.
CT imaging is gold standard for diagnosis; CT CAP for further investigation.
EUS and biopsy used for staging.
Outline the management of pancreatic cancer.
Curative radical resection rarely offered due to commonly advanced disease at time of presentation.
Non-resectable disease can undergo chemotherapy (gemcitabine), biliary stenting and enzyme replacements.
What are the surgical options for
a) head of pancreas tumour
b) body or tail of pancreas tumour
a) Whipple’s procedure with regional lymphadenectomy
b) distal pancreatectomy / splenectomy with regional lymphadenectomy
All patients should receive adjuvant chemotherapy, commonly gemcitabine.
What is Whipple’s procedure?
The removal of head of pancreas, antrum of stomach, proximal duodenum, common bile duct and gallbladder*.
Tail of pancreas and hepatic duct are attached to the jejenum; stomach is anastomosed with jejenum.
*All removed due to common arterial supply via gastroduodenal artery.
