7.03- HPB Pancreas

Question 1

How is acute pancreatitis distinguished from chronic pancreatitis?

Answer 1

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.

Question 2

What are the causes of acute pancreatitis?

Answer 2

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)

Question 3

What is the pathophysiology of acute pancreatitis?

Answer 3

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.

Question 4

What are the clinical features of acute pancreatitis?

Answer 4

• 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.

Question 5

What are the differential diagnoses for acute pancreatitis?

Answer 5

• abdominal aortic aneurysm
• renal calculi
• chronic pancreatitis
• aortic dissection
• peptic ulcer disease

Question 6

How is acute pancreatitis investigated?

Answer 6

• serum amylase or serum lipase*
• LFTs to determine if gallstones underlying cause

*diagnostic of acute pancreatitis if 3x upper-limit of normal

Question 7

What imaging is used to assess acute pancreatitis?

Answer 7

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.

Question 8

How is acute pancreatitis managed?

Answer 8

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.

Question 9

What are the complications of acute pancreatitis?

Answer 9

• disseminated intravascular coagulation (DIC)
• ARDS
• hypocalcaemia secondary to extensive fat necrosis
• hyperglycaemia secondary to destruction of islets of Langerhans
• pancreatic necrosis
• pancreatic cysts

Question 10

What is chronic pancreatitis?

Answer 10

A chronic fibro-inflammatory disease of the pancreas, resulting in progressive and irreversible damage to the pancreatic parenchyma.

Question 11

What are the causes of chronic pancreatitis?

Answer 11

• chronic alcohol abuse
• infection
• repeated acute pancreatitis

Question 12

What are the clinical features of chronic pancreatitis?

Answer 12

• 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

Question 13

What are the differentials for chronic pancreatitis?

Answer 13

• peptic ulcer disease
• reflux disease
• abdominal aortic aneurysm
• biliary colic
• chronic mesenteric ischaemia

Question 14

How is chronic pancreatitis investigated?

Answer 14

• 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.

Question 15

What is the imaging of choice to investigate chronic pancreatitis?

Answer 15

• CT imaging
• MRCP
• EUS
• secretin stimulation test

Question 16

How is chronic pancreatitis managed?

Answer 16

• 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

Question 17

What is the most common type of pancreatic cancer?

Answer 17

Exocrine tumours more common, being ductal carcinoma.

Most commonly affects the head of the pancreas.

Question 18

Why do pancreatic tumours affecting the body or tail have a worse prognosis than those affecting the pancreatic head?

Answer 18

Tumours affecting the pancreatic head are more likely to develop obstructive symptoms, therefore are more likely to be diagnosed at an earlier stage.

Question 19

What are the risk factors for pancreatic cancer?

Answer 19

• smoking
• chronic pancreatitis
• family history
• obesity

Question 20

What are the clinical features of pancreatic cancer?

Answer 20

• 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

Question 21

What is Courvoisier’s Law?

Answer 21

Malignancy of the biliary tree or pancreas should be strongly suspected in the presence of jaundice and a palpable gallbladder.

Question 22

What are the differentials for pancreatic cancer?

Answer 22

• gallstone disease
• cholangiocarcinoma
• gallstone disease
• peptic ulcer disease
• gastric cancer
• acute coronary syndrome

Question 23

How is pancreatic cancer investigated?

Answer 23

• FBC (anaemia; thrombocytopenia)
• LFTs (raised bilirubin, ALP and GGT)
• CA19-9 to assess response to treatment

Question 24

What is the imaging of choice to investigate pancreatic cancer?

Answer 24

Abdominal ultrasound first line.

CT imaging is gold standard for diagnosis; CT CAP for further investigation.

EUS and biopsy used for staging.

Question 25

Outline the management of pancreatic cancer.

Answer 25

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.

Question 26

What are the surgical options for

a) head of pancreas tumour

b) body or tail of pancreas tumour

Answer 26

a) Whipple’s procedure with regional lymphadenectomy

b) distal pancreatectomy / splenectomy with regional lymphadenectomy

All patients should receive adjuvant chemotherapy, commonly gemcitabine.

Question 27

What is Whipple’s procedure?

Answer 27

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.