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GI AND SURGERY > DISORDERS OF EXOCRINE PANCREAS > Flashcards

DISORDERS OF EXOCRINE PANCREAS Flashcards

1
Q

What is acute pancreatitis?

A

an acute inflammatory process of the pancreas with varying involvement of local tissues or more remote organ systems

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2
Q

What is mild, moderately severe and severe acute pancreatitis?

A

Mild - absence of local/systemic complications or organ failure. Usually has an uneventful recovery and resolves in the first week
Moderately severe - local complications and/or transient organ failure which resolves within 48 hours
Severe - persistent single or multi-organ failure for >48 hours

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3
Q

What is recurrent acute pancreatitis?

A

acute pancreatitis which occurs on more than one occasion, with full recovery between episodes

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4
Q

What are the risk factors for acute pancreatitis?

A

Gallstones
Alcohol use
Post-endoscopic procedures
Blunt abdominal trauma
Surgery near pancreas
Hypertrigyceridaemia and hypercalcaemia
Infections - mumps, coxsackie B4 virus and mycoplasma pneumonia infections
Drugs - thiazide diuretics, ACEi, statins, fenofibrate, azathioprine, tetracyclines, oestrogens, corticosteroids, valproic acid and DPP 4 inhibitors
Chronic pancreatitis
Microlithiasis
Anatomical or functional disorders of pancreas
Autoimmune conditions e.g. SLE or Sjögren’s syndrome
Pancreatic adenocarcinoma, cholangiocarcinoma or peri-ampullaray tumous

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5
Q

What are the 3 most common causes of acute pancreatitis?

A

50% of all cases are caused by gall stones
25% of cases are caused by alcohol misuse

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6
Q

How do gallstones cause acute pancreatitis?

A

Obstruction of the pancreatic duct initiates the activation of pancreatic enzymes, which cause auto-digestion of pancreatic tissue, stimulating a local inflammatory response

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7
Q

How does alcohol cause acute pancreatitis?

A

The mechanism of pancreatic injury is poorly understood, and may include alcohol acting as a direct toxin to the pancreatic cells causing inflammation and cell destruction, or increased ductal pressures caused by protein deposition causing retrograde flow and intra-pancreatic enzymatic activation

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8
Q

What proportion of those with acute pancreatitis will have a mild self-limiting disease? And what’s the mortality rate?

A

80-85%
1-3% mortality rate

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9
Q

What proportion of those with acute pancreatitis will have a moderate-severe disease? And what’s the mortality rate?

A

20%
13-35% mortality rate

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10
Q

What are complications of acute pancreatitis?

A

Pancreatic necrosis
Pseudocyst
Pancreatic abscess
Fistulae
Vascular - pre-hepatic portal hypertension or erosion of veins/arteries
Multi-organ failure
Sepsis
AKI
ARDS
DIC

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11
Q

How does acute pancreatitis present?

A

Acute upper or generalised abdominal pain that radiates through to the back
Nausea and vomiting
Systemically unwell - low grade fever and tachycardia
Cullen’s sign and grey turner sign

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12
Q

How should you investigate a person with suspected acute pancreatitis?

A

Bloods - FBC, calcium, ABG, lipase, amylase, LFT, renal function, CRP

Imagin - USS (looking for gallstones(, CT abdomen
Assitional - MRCP or ERCP if underlying cause is unknown

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13
Q

Whats the popular mnemonic for remembering the causes of pancreatitis?

A

I GET SMASHED

I – Idiopathic
G – Gallstones
E – Ethanol
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting
H – Hyperlipidaemia
E – ERCP
D – Drugs (furosemide, thiazide diuretics and azathioprine)

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14
Q

What scoring tool is used for measuring the severity of pancreatitis?

A

The Glashow score

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15
Q

Outline how the Glasgow score works?

A

P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)

Criteria all score 1 point each
0-1 mild
2- moderate
3 or more - severe

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16
Q

How do we manage acute pancreatitis?

A

Arrange emergency hospital admission and management should occur in HDU or ICU
IV fluids, oxygen, IV analgesia, IV antibiotics (only for any infection e.g. infected pancreatic necrosis), early nutritional support
ERCP or cholecystectomy to treat gallstones
Percutaneous or endoscopic drainage of pancreatic collections and potential surgical management of other complications

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17
Q

What is purtscher-like retinopathy?

A

A rare but serious potential complication of acute pancreatitis

present with a sudden-onset painless visual decline in both eyes within two days of trauma.

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18
Q

Whats better to measure, serum amylase or lipase?

A

Serum amylase is raised in 75% of pt and is typically >3 times the upper limit of Normal. Note that the levels dont correlate with disease severity. Specificity is around 90%
Serum lipase is more sensitive and specific. It has a longer half life and may be useful for late presentations e.g. >24 hours

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19
Q

What can raise serum amylase?

A

Pancreatitis
pancreatic pseudocyst
mesenteric infarct
Choledocholithiasis
Pancreatic ascites
Pancreatic trauma
perforated viscus
acute cholecystitis
diabetic ketoacidosis

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20
Q

What is chronic pancreatitis?

A

a chronic, irreversible, inflammation and/or fibrosis of the pancreas, often characterized by severe pain and progressive endocrine and exocrine insufficiency

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21
Q

How does chronic pancreatitis usually present?

A

It usually begins as recurrent acute pancreatitis where recurrent episodes of pancreatic inflammation of variable intensity and length lead to fibrosis of pancreatic tissue, and dilatation and calcification of the pancreatic duct and branches.

22
Q

What are risk factors for chronic pancreatitis?

A

70-80% of cases are caused by alcohol
Smoking
Hyperttiglyceridaemia
Hypercalcaemia
Autoimmune disease
Genetic abnormalities e.g. CF and haemochromatosis
Drugs - thiazide diuretics, azathioprine, tetracyclines, oestrogens, valproic acid, cimetidine, DPP4 inhibitors
Obstructive causes - gallstones, structures, carcinoma
Recurrent acute pancreatitis

23
Q

What are the complications of chronic pancreatitis?

A

Maldigestion and malabsorption
Malnutrition
Diabetes mellitus
Chronic pain
Oesteoporosis, osteopenia and fracture risk
Pancreatic cancer
Pancreatic calcification, pancreatic duct stones and structure, fistulae
Pseudocyst formation
Pseudoanerysms
Splenic or portal vein thrombosis

24
Q

Why can chronic pancreatitis cause maldigestion and malabsorption?

A

The destruction of pancreatic ductal and acinar cells reduces the ability of the pancreas to produce the digestive enzymes amylase, lipase, and protease. Also damage and structures to the duct system result in obstruction in excretion of pancreatic juice and bile. This results in maldigestion and malabsorption.

25
Q

What is pancreatogenic diabetes/type 3c diabetes?

A

Diabetes mellitus secondary to pancreatic disease
Has an increased risk of hypoglycaemia compared to type 1 and type 2
Progressive fibrosis of exocrine tissue leads to worsening insulin deficiency

26
Q

Whats the prognosis of chronic pancreatitis?

A

70% survival at 10 years
45% at 20 years

Older people and those with alcohol-related disease had a worse prognosis.

27
Q

Whats the natural history of chronic pancreatitis?

A

Episodes of acute pancreatitis, pain, hospitalizations, and surgical interventions in the first 5 years.
Stricture of the main biliary duct, chronic pseudocysts, pancreatic calcifications, and progressive pancreatic insufficiencies after 5–10 years.
Progressive pancreatic endocrine and exocrine insufficiency after 10 years onwards.

28
Q

Who should you suspect chronic pancreatitis in?

A

Recurrent or persistent upper/generalised abdominal pain, particularly if Hx or clinical features of alcohol misuse
Pain is typically worse 15-30 mins following a meal
Steatorrhoea (usually 5-25 years after onset of pain) - sign of pancreatic insufficiency
Diabetes mellitus (typically >20 years after symptoms onset)

29
Q

What should you ask about when taking a history on chronic pancreatitis?

A

The duration and characteristics of abdominal pain.
Nausea and vomiting
Symptoms of pancreatic exocrine insufficiency -steatorrhoea, anaemia, bone disease from vit D deficiency, bleeding disorders, weight loss, fatigue
Symptoms of diabetes mellitus - polyuria, polydypsia, weight loss
FHx chronic pancreatitis

30
Q

What investigations should be done for suspected chronic pancreatitis?

A

LFTs
Serum HbA1c
Faecal elastase (low conc found in those with exocrine pancreatic insufficiency)
Abdominal USS identify gallstones and signs of chronic pancreatitis e.g. pancreatic calcifications
Abdominal X-ray shows pancreatic calcifications in 30% of cases but CT is more sensitive

31
Q

How should you manage chronic pancreatitis?

A

Abstinence from alcohol and smoking
Analgesia
Replacing pancreatic enzymes (creon)
Subcutaneous insulin to treat diabetes
ERCP with stenting to treat strictures and obstructions to biliary system and pancreatic duct
?Surgery to treat severe chronic pain, obstructions, Pseudocyst, abscesses

32
Q

What type of cancers are most pancreatic cancers?

A

Adenocarcinomas

33
Q

Which part of the pancreas do most pancreatic cancers occur in?

A

The head of the pancreas

34
Q

Why does pancreatic cancer have such a poor prognosis?

A

Often diagnosed late
Spread and metastasise early

35
Q

Whats the average survival when diagnosed with advanced disease of pancreatic cancer?

A

6 months
(Even when caught early, the 5 year survival is still <25%)

36
Q

How does pancreatic cancer present?

A

Painless obstructive jaundice - yellow skin and sclera, pale stools, dark urine, pruritus
Non-specific upper abdo/back pain
Unintentional weight loss
Palpable mass in epigastric region
Change in bowel habit
Nausea/vomiting
New onset diabetes or rapid worsening of type 2 diabetes

37
Q

What are the referral guidelines for suspected pancreatic cancer?

A

Over 40 with jaundice – referred on a 2 week wait referral
Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen

Additional symptoms - diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, new-onset diabetes

38
Q

What is Courvoisier’s law?

A

a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

39
Q

What is trousseau’s sign of malignancy?

A

a paraneoplastic process of recurrent, migratory thrombophlebitis associated with underlying, often occult, carcinoma. Particularly pancreatic adenocarcinoma

(I.e. blood vessels become inflamed with an associated thrombus and reoccurs in different locations over time0

40
Q

What are risk factors for pancreatic cancer?

A

increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation

41
Q

How do we investigate pancreatic cancer?

A

LFTs may show cholestatic picture
High resolution CT scan is investigation of choice
Biopsy
Staging CT can be a CT TAP
CA 19-9
MRCP to assess biliary system in detail
ERCP to put a stent in and relieve obstruction, and also take a biopsy from the tumour

42
Q

What would be seen on CT for pancreatic cancer?

A

Double duct sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts (represents a maligannt cause until proven otherwise)

43
Q

How is pancreatic cancer managed?

A

Surgery can be considered with small tumours isolated in the head of the pancreas (typically <20% of cases)

Palliative treatment - stents to relieve biliary obstruction, surgery to improve symptoms e.g. bypassing biliary obstructive, palliative chemotherapy or radiotherapy, EOL care with symptom control

44
Q

What surgical options are there for pancreatic cancer?

A

Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
Radical pancreaticoduodenectomy (Whipple procedure)

45
Q

What is a Whipple procedure?

A

A pancreaticoduodenectomy
Removes head of pancreas, pylorus of stomach, duodenum, gallbladder, bile duct and relevant lymph nodes

It’s a huge surgery so pt need to be in good baseline health

46
Q

In what proportion of acute pancreatitis cases does peripancreatic fluid collections occur?

A

25% of cases

47
Q

What is a peripancreatic fluid collection?

A

Fluid collection in or near the pancreas and lack a wall of granulation/fibrous tissue
Occurs within 4 weeks of acute pancreatitis
May resolve or develop into a pseudocyst or abscess
Aspiration and drainage is best avoided as it may preciptate infection

48
Q

What is a pseudocyst?

A

A complication of acute pancreatitis
Results from peripancreatic fluid collection which becomes walled by fibrous/granulation tissue
Typically occurs 4 weeks or more after an acute pancreatitis attack
Most are retrogastric
75% are associated with persistent mild elevation of amylase
Treated with endoscopic or surgical cystograstrostomy or aspiration

49
Q

Whats the most common complication of ERCP?

A

Pancreatitis

50
Q

How can calcium be used in pancreatitis diagnoses?

A

Hypercalcaemia can cause pancreatitis
Hypocalcaemia is an indicator of pancreatitis severity (its part of the Glasgow scale of pancreatitis severity)

51
Q

What is seen on imaging in chronic pancreatitis?

A

Pancreatic calcification

GI AND SURGERY (31 decks)

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