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4th Year GI > Diseases of the pancreas > Flashcards

Diseases of the pancreas Flashcards

1
Q

Definition of acute pancreatitis

A

A medical and surgical condition characterised by acute inflammation of the exocrine pancreas as a result of an acute insult.

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2
Q

Acute pancreatitis varied widely in its severity, from mild oedema to extensive necrosis. It is potentially life threatening. What is its mortality rate?

A

10%

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3
Q

Aetiology of acute pancreatitis

A

Gallstone disease and alcohol account for the majority of cases (80-90%)

GET SMASHED

Gallstones

Ethanol

Truama

Steroids

Mumps and infections (eg Coxsackie B)

Autoimmune

Scorpian venom

Hyperlipidaemia

ERCP induced

Drugs - azathioprine, diuretics, valproate

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4
Q

Pathophysiology of acute pancreatitis

A
  • Premature intra-pancreatic activation of digestive enzymes (trypsinogen in particular) remains the central mechanism of pathogenesis
  • This ultimately leads to autodigestion of the pancreas itself
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5
Q

Clinical features of acute pancreatitis

A
  • Severe epigastric pain is the most common initial symptom
  • Patients often describe pain radiating/penetrating through the back and occasionally as a tight band like pain encircling the upper abdomen
  • Nausea and vomiting are commonly associated symptoms
  • Patients are often unwell, presenting with tachycardia, pyrexia and hypoxia
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6
Q

Which signs may be seen in severe acute pancreatitis?

What do these signs indicate?

A

The Cullen sign (peri-umbilical discolouration) and the Grey Turner sign (flank discolouration).

This is indicative of pancreatic necrosis.

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7
Q

Investigations for acute pancreatitis

A
  1. Blood tests including amylase and lipase
    • ​​elevated amylase or lipase (usually 3 x the upper limit)
    • FBC (elevated WCC), CRP (daily to monitor progress)
    • U&Es, glucose, calcium and albumin
    • LFTs (cholestatic picture secondary to gallstones)
    • ABG (may show hypoxia secondary to ARDS/effusions)
  2. Radiological imaging
    • Erect abdominal film to rule out any evidence of perforation, may reveal pancreatic calcification
    • Abdominal USS - may be diagnostic in early disease and useful to screen for gallstone as a possible cause (in later stated it may be more difficult to visualise the pancreas due to swelling
    • CT abdomen with contrast - usually performed at least 72 hours after admission to assess the extent of necrosis
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8
Q

Which score is used to assess the severity and prognosis of acute pancreatitis?

A

Glasgow score

PANCREAS

PAO2 <8.0kPa

Age >55 years

Neutrophils >15x109/L

Calcium <2.0mmol/L

Renal function - urea >16mmol/L

Enzymes - AST >200 or LDH >600

Albumin <32g/L

Sugar - glucose >10mmol/L

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9
Q

Management of acute pancreatitis

A
  • All patients should be made nil by mouth (consider NG tube)
  • Appropriate analgesia and anti-emetics should be given
  • Aggressive IV fluid replacement is the single most important medical therapy
    • Isotonic crystalloid fluids are favoured
  • Strict fluid balance with hourly volumes
  • VTE prophylaxis should be considered (patients with pancreatitis are pro-coagulopathic)
  • Oxygen it low PaO2
  • Blood capillary glucose should be monitored (and hyperglycaemia corrected with insulin)
  • Enteral feeding should be considered in the event of prolonged fasting
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10
Q

Interventional management of gallstone pancreatitis

A
  • Emergency ERCP with stone extraction and sphincterotomy (within 24 hours in severe disease)
  • Routine MRCP or EUS in the first instance (to look for residual stone in less severe cases, followed by ERCP)
  • Urgent laparoscopic cholecystectomy with intra-operative cholangiogram
    • should be performed within 2 weeks of the acute event
    • If left untreated, recurrence rates are up to 80%
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11
Q

Early complications of acute pancreatitis

A

Systemic inflammatory response that occurs as a result of pancreatitis is responsible for most of the early complications. They usually occur in the first 7 days and include:

  • Respiratory - ARDS, pleural effusions
  • Cardiovascular - hypovolaemic shock
  • Disseminated intravascular coagulopathy
  • Renal failure
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12
Q

What is chronic pancreatitis?

A

Chronic inflammation of the pancreas characterised by recurrent abdominal pain and progressive destruction of the exocrine pancreas.

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13
Q

Aetiology of chronic pancreatitis

A
  • Alcohol abuse (80%)
  • Idiopathic
  • Genetic - hereditary pancreatitis, cystic fibrosis
  • Autoimmune
  • Associated with malnutrition, dietary toxins
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14
Q

Late complications of acute pancreatitis

A
  • Pancreatic necrosis (urgent necrosectomy is required)
  • Pancreatic abscess
  • Rupture of the pancreatic duct and accumulation of fluid may develop in the adjacent lesser sac
  • Pancreatic pseudo cyst (fluid collection in the lesser sac encapsulated by granulation/fibrotic tissue)
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15
Q

Clinical features of chronic pancreatitis

A
  • Intermittent upper abdominal pain radiating to the back
  • Associated nausea and vomiting
  • Malabsorption symptoms due to exocrine pancreatic insufficiency
    • ​​​steatorrhoea or diarrhoea
    • decreaesed appetite
    • weight loss
  • Glycaemic dysfunction secondary to endocrine pancreatic insufficiency
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16
Q

Management of chronic pancreatitis

A
  • Alcohol cessation and low fat diet
  • Provide analgesia (NSAIDs good first line option, opiates often required in the later stages)
  • Offer enzyme and vitamin supplements (Creon tablets, vitamins A, D, E and K)
  • Consider PPI therapy to reduce malabsorption
  • Glycaemic control
17
Q

Definition of pancreatic cancer

A

Pancreastic cancer primarily refers to a Ducati adenocarcinoma affecting the exocrine gland of the pancreas. This represents 90% of all pancreatic tumours.

18
Q

Epidemiology of pancreatic cancer

A
  • Fifth most common cause of cancer deaths in the UK
  • Male preponderance of 2:1
  • Peak incidence in the seventh decade
19
Q

Clinical features of pancreatic cancer

A
  • Initial symptoms are often vague - epigastric/simple back pain and unexplained weight loss
  • Painless jaundice and a palpable gallbladder may be present in tumours involving the head of the pancreas
20
Q

Risk factors for pancreatic cancer

A
  • Smoking
  • Chronic pancreatitis
  • Alcohol
  • Diabetes mellitus
  • Genetic predisposition
21
Q

Investigations for pancreatic cancer

A
  • Abdominal ultrasound
    • looking for benign biliary pathology
    • duct dilation, liver mets, head of pancreas mass may be seen
  • Contrast enhanced CT
    • allows TNM staging and surgical assessment
22
Q

Management of pancreatic cancer

A
  1. Respectable disease (5-10%)
    • Whipple procedure with adjuvant chemotherapy
  2. Palliative chemotherapy in metastatic disease
    • NICE recommends paclitaxel or gemcitabine
  3. Palliative stent insertion and symptomatic control

4th Year GI (15 decks)

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