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GI/Liver > Clinical Aspects of Pancreatico-Biliary Disease > Flashcards

Clinical Aspects of Pancreatico-Biliary Disease Flashcards

1
Q

Briefly describe the exocrine function of the pancreas.

A 
Ductal cells release alkaline fluid in response to secretin
Acinar cells secrete digestive enzymes in response to secretaogues (CCK, secretin, substance P, VIP, ACh and bombesin)
- Amylase
- Chemotryospin
- Trypsinogen
- Lipase
- Phospholipase
- Cholesterol Esterase
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2
Q

What are the cells within the islets of Langerhans?

A

Beta-cells = insulin
Alpha-cells = glucagon
Delta-cell = somatostatin
PP or Gamma-cells = pancreatic polypeptide

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3
Q

How are gallstones detected?

A

Ultrasound
- over 90% of gallstones
Endoscopic Ultrasound
- can detect microlithiasis

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4
Q

What is biliary colic?

A

Consant pain that occurs when a gallstone temporarily blocks the gallbladder neck or cystic duct
Typically in the right upper quadrant, and lasts 4-6 hours
- pain is releived when the stone disimpacts and moves on
Usually the presenting feature of gallstones

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5
Q

How often is acute cholecystitis due to gallstones?

A

90% of the time

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6
Q

What are the risk factors for gallstones/acute cholecystitis?

A 
Female
Fat
Forty
Fair
Fertile
Hormonal therapy 
Rapid weight loss
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7
Q

What are the signs and symptoms of acute cholecystitis?

A 
Biliary colic - may radiate out to right shoulder (Murphy's sign)
Fever
Nausea
Deranged LFTs
- elevated ALT, AST, ALP
- mildly elevated bilirubin and amylase
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8
Q

What symptoms are associated with biliary sepsis (cholangitis)?

A 
Charcots triad
- fever
- jaundice
- RUQ pain
Reynolds pentad
- fever
- jaundice
- RUQ pain
- mental confusion
- spetic shock
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9
Q

What are some of the causes of cholangitis?

A 
Gallstones - main
Biliary manipulation
Hepatobiliary malignancy
- pancreas
- bile duct
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10
Q

What blood results would you expect to see with cholangitis associated biliary sepsis?

A 
Obstructive LFTs
Raised bilirubin
Raised amylase (maybe)
Positive blood cultures (50%)
- E.Coli
- Klebsiella
- Enterococcus
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11
Q

How is cholangitis associated biliary sepsis treated?

A

Broad spectrum antibiotics

ERCP/PTC

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12
Q

Describe the presentation of acute pancreatitis.

A 
Acute, severe upper abdominal pain
- 50% radiates to the back
Partially relived by bending forward
Severe
- multi-organ failure
- pleural effusion
- asites
5-10% painless
Jaundice (if gallstone disease)
3% of patients
- Cullen's sign or Grey Turner sign
- non-specific
- represents reteroperitoneal bleeding in pancreatic necrosis
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13
Q

How is acute pancreatitis diagnosed?

A

Elevated serum amylase (>3x ULN)
- rises within 6-12 hours and has a short half-life
- beware of normal amylase in late presenters
- may be lower in alcoholic pancreatitis and hypertriglyceridaemia pancreatitis
Serum lipase elevated
CT

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14
Q

What are the possible causes of acute pancreatitis?

A 
I GET SMASHED
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - scorpion sting
M - mumps/malignancy
A - autoimmune
S - steriods
H - hyperlipidaemia
E -  ERCP
D - drugs
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15
Q

How can acute pancreatitis be classified?

A

Interstitial oedematous acute pancreatitis
Necrotising acute pancreatitis
Mild acute pancreatitis (no organ failure or complications)
Moderately severe pancreatitis (organ failure <48hrs and/or local complications)
Severe acute pancreatitis (persistant organ failure >48hrs)

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16
Q

How is acute pancreatitis managed?

A

Supportive in mild cases
- fluid replacement
- pain control
- PO/enteral nutrition
- antibiotics if they are septic
Treat the underlying cause (e.g. stop drinking)
Persistance symptomatic fluid collections >4 weeks need drainage

17
Q

What is chronic pancreatitis?

A

Inflammatory condition
Parenchyma replaces with fibrous tissue
Acute pancreatitis/recurrent pancreatitis/chronic pancreatitis progression

18
Q

What are the symptoms of chronic pancreatitis?

A

Pain
Malnutrition
Diabetes
Increased risk of pancreatic cancer

19
Q

What are the possible causes/risk factors of chronic pancreatitis?

A 
TIGAR-O
T - toxic
I - idiopathic
G - genetic (PRSS1, CFTR)
A - autoimmune
R - RAP/SAP associated
O - obstructive (e.g. tumour)
20
Q

How is chronic pancreatitis diagnosed?

A

Cacification on imaging
Aspiration of duodenal secretions at ERCP
- post-secretin/CCK
MRCP
EUS
Labelled carbon breath test (for PEI)
Wedge biopsy or section of resected pancreas

21
Q

What is the treatment of chronic pancreatitis?

A 
Potent analgesia (opiates)
Duct drainage
Address exocrine and endocrine needs
Smoking cessation
Alcohol cessation
Surgery - pancreaticojejunostomy/distal pancreatectomy
22
Q

What are the possible mechanisms of pancreatic exocrine insufficiency?

A

Reduced secretion of exocrine fluid due to pancreatic disease
Low CCK release due to duodenal disease
Acidic duodenal pH due to gastric hypersecretion or low bicarbonate secretion
Abnormal aboral transit due to surgery

23
Q

Name some possible causes of PEI.

A 
Acute pancreatitis
Chronic pancreatitis
Cystic fibrosis
- thick mucous in pancreas blocks ducts
Pancreatic cancer
Diabetes mellitus
- trophic effect of insulin
- autonomic neuropathy 
Pancreatectomy 
Gastrectomy
- strech receptors that allow pancreatic juice release aren't activated 
Coelaic disease
IBD
Zollinger-Ellison syndrome
- increased gastrin secretion
24
Q

What are the clinical consequences of PEI?

A 
Malnutrition and not diarrhoea
- steatorrhoea
Deficient nutritional status associated with
- pain episodes
- hospitalisation
- CV events
- fracture risk (osteoporosis)
- infection risk
25
Q

How is PEI diagnosed in clinical practice?

A

Don’t always need confirmation tests
Direct/indirect faecal elastase
Morphological evaluation of the pancreas in chronic pancreatitis patients
A trial of PERT in suspected patients

26
Q

What is the aim of therapy for PEI?

A

Avoidance of steatorrhoea, weight loss and maldigestion-related symptoms
Toe ensure normal nutritional status

27
Q

How is PEI managed?

A

Enteric coated pancreatin mini-microspheres (Creon 25,000 units, 2 caps per meal, 1 cap for snacks)
If that isn’t enough
- add a PPI and increase enzyme dose
If that isn’t enough
- check for other causes of malabsorption and treat

28
Q

Why is the mortality rate for pancreatic carcinoma so high?

A 
Late presentation
Systemic disease at presentation
Nihilistic attitude of the medical profession
- 'brought it upon themselves' 
Inappropriate selection for treatment 
Correct access for treatment
29
Q

What are the clinical features of pancreatic carcinoma?

A 
Jaundice (if CBD obstruction) or mets
Abdominal/back pain
Weight loss
Recent diagnosis of diabetes (<2 years)
Acute pancreatitis
Migratory thrombophlebitis 
- inflamed vein near skin surface
Double duct sign
30
Q

What are the risk factors for pancreatic carcinoma?

A 
Smoking
Male
Alcohol 
Chronic pancreatitis 
BMI
Family history
Genetic
- HNPCC
- FAP
- BRCA2
31
Q

How is pancreatic cancer diagnosed?

A

CT or MRI

32
Q

How is pancreatic cancer treated?

A 
Whipple's Resection 
Oncology
Palliative care
- chemotherapy (folfirinox, gem, gem-cap, gem-abraxane)
- coealic axis neurolysis
- stenting (for jaundice)
- PERT to minimise weight loss
- thoracoscopic splanchnicectomy

GI/Liver (12 decks)

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