*Biliary tract and pancreas disorders 3 (Lecture 11) Flashcards
What are the 3 main pancreatic diseases?
Acute pancreatitis
Chronic pancreatitis
Pancreatic tumours
What are the 5 parts of the pancreas?
Uncinate process Head Neck Body Tail
What do alpha islet cells release?
Glucagon
What do Beta islet cells release?
Insulin
What do Delta islet cells release?
somatostatin
What do PP cels release?
Pancreatic polypeptide
What are the 2 categories of acute pancreatitis?
Mild acute
Severe acute
What is the predominant feature of mild acute pancreatitis?
interstitial oedema of the gland
Associated with minimal organ dysfunction and an uneventful recovery
What is severe acute pancreatitis?
Associated with organ failure and/ or local complications such as necrosis (with infection), pseudocyst or abscess
What viral infections can cause acute pancreatitis?
Mumps
Coxsackie B (can cause hand foot and mouth disease)
Viral hepatitis
What other factor can cause acute pancreatitis apart from GET SMASHED?
Genetic factors
What genetic factors can cause acute pancreatitis?
Cationic trypsinogen gene
CF gene
What drugs can cause pancreatitis? (4)
Valproic acid
Azathioprine
L-asparaginase
Corticosteroids
What autoimmune disease can cause pancreatitis?
IgG4-related autoimmune disease
What causes necrosis of the pancreas during pancreatitis?
Inflammation of the parenchyma causing hypoperfusion
How is acute pancreatitis diagnosed?
History (e.g. gallstones, alcohol, drugs, trauma, infection, ERCP)
Examination
Blood tests
Imaging
What is peritonism?
having the clinical signs of shock and peritonitis
Possible examination findings for acute pancreatitis? (5)
Tenderness Peritonism Distension Bowel sounds Skin markings
Blood tests performed to look for acute percents?
FBC Clotting U&Es LFTs Amylase CRP Glucose Ca
Imaging for acute pancreatitis? (5)
CXR/AXR AUS CT pancreas MRI ERCP
Findings on AXR suggestive of possible AP? (2)
Pleural effusion
Sentinel loop
What is a sentinel loop?
dilatation of a segment of small intestine
What is the purpose of carrying out an US for AP?
To rule out biliary pancreatitis Look for: Gallstones Cholecystitis CBD diameter Free fluid
What is the purpose of carrying out a CT scan for acute pancreatitis?
Assess severity of pancreatitis
Decide on interventions and follow up
Look for complications (e.g. fluid collection, necrosis, ascites, bleeding, abscess)
Use of ERCP in AP?
Not as a diagnostic tool!
Used for treatment of CBD stones with obstruction cholangitis as an emergency procedure
Used for treatment of acute biliary pancreatitis (if no index cholecystectomy possible)
What is the glasgow prognostic score?
PaO2 less than 8kPa
Age greater than 55 years
Neutrophils greater than 15 X 10^9/L
Calcium less than 2mmol/L
Renal function: urea greater than 16mmol/L
Enzymes (AST/ ALT greater than 200 or LDH greater than 600)
Albumin less than 32 g/L
Sugar (glucose less than 10 mol/L)
*any 3 factors means acute severe pancreatitis
What Glasgow prognostic score = acute severe pancreatitis?
3
Apart form the Glasgow prognostic score, what is another scoring system that can be used to acute pancreatitis?
Ranson score (only for alcohol-induced pancreatitis) Balthazar score - used to assess percentage of necrosis and severity score from a CT scan (CT severity index)
Symptoms of acute pancreatitis? (7)
Epigastric/ diffuse abdominal pain +/- radiation to the back Nausea and vomiting Indigesiton Abdominal tenderness Loss of appetite +/- weight loss Temperature Jaundice (pain)
What type of acute pancreatitis are most pancreatitis?
Mild pancreatitis (85% - mortality = 1%)
How long does it take for all necrosis from pancreatitis to show up?
4 days
What are the local complications from Acute pancreatitis? (6)
Fluid collection Pseudocysts Abscess Necrosis +/- infection Ascites Pleural effusion
What are the systemic complications of acute pancreatitis? (8)
Pulmonary failure Renal failure Shock Sepsis Metabolic acidosis Hyperglycaemia Hypoglycaemia MODS (multi organ failure)
What problems can pseudocysts cause?
They can cause biliary and/ or gastric outlet obstruction
Symptoms of a pseudocyst? 95)
Pain nausea Vomiting Jaundice Weight loss
Treatment of pseudocysts?
Endoscopic drainage Surgical drainage (open/laparotomy) (cystgastrostomy or cystjejunostomy can be performed in order to drain the cyst into the stomach or jejunum)
Treatment of a pancreatic abscess?
CT/US guided retroperitoneal or transpirational drainage
drain abscess, control sepsis
Management of necrosis?
CT for assessment
Sterile or infected?
If sterile, it should be treated conservatively
May require drainage or necrosectomy and lavage if infected
What drugs have been shown to be beneficial for the treatment of acute pancreatitis?
no drug therapy has been shown to be beneficial
What is chronic pancreatitis?
Progressive and irreversible destruction of pancreatic tissue
Results in permanent loss of endocrine and exocrine function
What is pancreatic divisum?
congenital anomaly in the anatomy of the ducts of the pancreas in which a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts
What are the 5 main causes of chronic pancreatitis?
Familial Alcohol Hyperparathyroidism/ hypercalcaemia CF Alpha-antitrypsin deficiency Pancreatic duct obstruction (cholelithiasis, structure, tumour, pseudocyst, pancreas divisum) Tropical (deficient in methionine and trace elements) Autoimmune pancreatitis (IgG4 subclass)
How is autoimmune chronic pancreatitis treated?
Steroids
Diagnosis of chronic pancreatitis?
History Examination Blood tests Imagining *same as for acute pancreatitis except IgG4 and CA 19-9 pancreatic function tests are also performed
What are the 2 main imaging signs of chronic pancreatitis?
Extensie pancreatic calcification
Pancreatic duct dilation
Treatment of chronic pancreatitis?
Drugs e.g. analgesics, creon, vitamins, insulin
No alcohol and low fat diet may help
Surgery (pancreatectomy or pancreaticojejunostomy) if unremitting pain/ weight loss
What is another name for a pancreaticojejunostomy?
What does this involve?
Other 2 similar procedures?
Pustow procedure
Dilated pancreatic duct is filleted open and joined to the jejunum (which is also filleted open)
This allows pancreatic juice to enter the jejunum
(Frey procedure is the same as the pastor procedure although the head of the pancreas gets pulled out a bit more)
What type of procedure is used to treat chronic pancreatitis with inflammatory head tumour?
Beger procedure
Complications of chronic pancreatitis?
Splenic vein thrombosis Pseudoaneurysms Pancreatic cancer pseudocyst Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion
Treatment of a biliary obstruction?
Stent, bypass, resection
Treatment of a duodenal obstruction?
Stent, bypass, resection
What is the treatment for a pseudocyst?
Endoscopic drainage
Surgical drainage
Resection
What is the most common cause of chronic pancreatitis?
Alcohol (abstinence is associated with a more favourable prognosis)
Does stopping smoking have a higher chance of favourable outcomes for chronic pancreatitis?
Yes
What is the most common type of exocrine pancreatic tumour?
Adenocarcinoma (95% of exocrine pancreatic tumours)
What are the 5 possible types of endocrine pancreatic cancers?
Gastrinoma Insulinoma Glucagonoma (tends to be smaller and more easily treated than adenocarcinoma) Somatostatinoma Vipoma
Symptom of a gastroma?
Produces gastrin causing increased stomach acid = gastric/ duodenal ulcers
Symptom of an insulinoma?
Produces insulin, causing the body to store sugar rather than burn it = hypoglycaemia
Symptom of a glucagoma?
Produces glucagon, increasing blood sugar levels = hyperglycaemia
what are symptoms of somatostatinoma?
Diabetes
Steatorrhoea
Symptoms of vipoma?
Severe diarrhoea
Hypokalaemia
Achlorhydria
What is achlorhydria
Absence of HCl acid in gastric secretions
Symptoms of pancreatic cancer?
Jaundice (dark urine and light stools)
Back pain
Weight loss (anorexia, nausea, vomiting)
Risk factors for pancreatic cancer? (4)
Smoking
Diabetes
Familial pancreatitis
Obesity
How is pancreatic cancer diagnosed?
History
Examination (abdo exam probs won’t tell you anything unless they have metastases)
Blood tests
Imaging
How can you diagnose pancreatic cancer from ERCP?
Can take brushings = biopsy
Staging system for pancreatic cancer?
TNM
What is Tis for pancreatic cancer?
Very early stage, has not had the chance to spread 9carcinoma in situ
T1 for pancreatic cancer?
The size of the tumour in the pancreas is 2cm or less in any direction
T2 for pancreatic cancer?
The tumour is more than 2cm across in any direction
T3 for pancreatic cancer?
The cancer has started to grow into surrounding tissues around the pancreas, in the duodenum or bile duct
T4 for pancreatic cancer?
The cancer has grown further into the stomach, spleen, large bowel or nearby large blood vessels
N1 pancreatic cancer?
Has spread into lymph nodes (N0 = has not spread)
M1 pancreatic cancer?
Has spread to distant body parts (M0 = has not)
Stage 1 pancreatic cancer?
Cancer is confined to the pancreas
Stage 2 pancreatic cancer?
Cancer has spread beyond the pancreas to nearby tissues and organs and may have spread to the lymph nodes
Stage 3 pancreatic cancer?
Cancer has spread beyond the pancreas to the major blood vessels around the pancreas and may have spread to the lymph nodes
Stage 4 pancreatic cancer?
Cancer has spread to distant sites beyond the pancreas such as the liver, lungs and the peritoneum
Treatment for pancreatic cancer?
Surgery = only curative method
Chemotherapy
Radiotherapy
Combinations
Types of surgery for resectable pancreatic tumours? (4)
Whipple resection
Total pancreatectomy
Distal pancreatectomy
Midsegment pancratectomy
Types of surgery for non-resectable pancreatic tumours?
Biliary bypass
Gastric bypass
Double bypass
What is involved in Whipple’s operation?
Part of the stomach and the head of the pancreas are removed - remaining stomach and pancreas are joined separately to the small intestines
Distal pancreatectomy?
Body and tail of the pancreas and usually the spleen are removed
Biliary bypass?
Rerouting the flow of bile from the common bile duct into the intestine bypassing the pancreas
Gastric bypass?
Pancreatic tumour can block the duodenum - surgery directly joins the stomach and the small intestine
