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Stage 3 > Gastroenterology: Pancreas > Flashcards

Gastroenterology: Pancreas Flashcards

1
Q

What are the causes of acute pancreatitis?

A

GET SMASHED
1) Gallstones (most common worldwide)
2) Ethanol (most common cause in Europe)
3) Trauma
4) Steroids
5) Mumps
6) Autoimmune disease (Polyarteritis Nodosa/SLE)
7) Scorpion bite
8) Hypercalcaemia, hypertriglyceridaemia, hypothermia
9) ERCP
10) Drugs

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2
Q

Which autoimmune diseases can cause acute pancreatitis?

A

Polyarteritis nodosa, SLE

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3
Q

What is an iatrogenic cause of acute pancreatitis?

A

ERCP

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4
Q

What are causes of acute drug-induced pancreatitis?

A

FATSHEEP
1) Furosemide
2) Azathioprine/Asparaginase
3) Thiazides/Tetracycline
4) Statins/Sulfonamides/Sodium Valproate
5) Hydrochlorothiazide
6) Estrogens
7) Ethanol
8) Protease inhibitors and NRTIs

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5
Q

What are some examples of sulphonamides that can cause acute pancreatitis?

A

1) Thiazides
2) Furosemide
3) Some HIV drugs (protease inhibitors and non-nucleoside reverse transcriptase inhibitors)
4) Sulfasalazine
5) Gliclazide

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6
Q

What are some important drugs to remember that can cause acute pancreatitis?

A

1) Furosemide
2) Thiazides
3) Tetracycline
4) Sulfasalazine
5) Azathioprine
6) HIV drugs
7) Statins
8) Sodium valproate

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7
Q

What are the symptoms of acute pancreatitis?

A

1) Stabbing-like epigastric pain which radiates to the back - relieved by sitting forward or lying in the fetal position
2) Vomiting
3) PMH - recent alcohol binge, gallstones

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8
Q

What are the signs of acute pancreatitis?

A

1) Hypovolaemia - tachycardia, dry mucous membranes
2) Fever (only if complicated with infection)
3) Epigastric guarding
4) Grey-Turner’s sign - bruising along the flanks
5) Cullen’s sign - bruising around the peri-umbilical area

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9
Q

What is pancreatitis?

A

Inflammation of pancreas (not necessarily infection)

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10
Q

What two signs are highly associated with acute pancreatitis?

A

1) Grey-Turner’s sign - bruising along the flanks
2) Cullen’s sign - bruising around the peri-umbilical area

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11
Q

What does Grey-Turner’s sign indicate?

A

Retroperitoneal bleeding - highly associated with haemorrhagic acute pancreatitis

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12
Q

What are some complications of acute pancreatitis?

A

1) ARDS (acute respiratory distress syndrome)
2) Pleural effusions
3) Hypovolaemia (causing AKI)

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13
Q

How does acute pancreatitis lead to lung and kidney complications?

A

1) Third space fluid sequestration in pancreatitis is the result of a combination of inflammatory mediators, vasoactive mediators and tissues
2) This leads to vascular injury, vasoconstriction and increased capillary permeability leading to extravasation of fluid into the third space
3) Leads to ARDS, pleural effusions and hypovolaemia (causing AKI)

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14
Q

What blood tests are done in acute pancreatitis?

A

1) FBC
2) U&E
3) LFTs
4) Amylase ± lipase

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15
Q

What does leucocytosis indicate in pancreatitis?

A

Necrotising pancreatitis

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16
Q

Why might LFTs be abnormal in pancreatitis?

A

If there is gallstone disease

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17
Q

Which test is more sensitive and specific marker of pancreatitis and should be used if available but not readily available in UK?

A

Lipase

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18
Q

How is amylase used to diagnose pancreatitis?

A

1) Amylase 3x the upper limit of normal - v suggestive of acute pancreatitis
2) The degree of elevation of amylase is not related to the severity of the disease

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19
Q

What are other causes of an elevated amylase (although to a lesser extent)?

A

Perforated duodenal ulcer, cholecystitis and mesenteric infarction

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20
Q

How is imaging used in pancreatitis?

A

Imaging tests are not useful for diagnosing pancreatitis but may be useful to identify the cause

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21
Q

What imaging investigations can be done in acute pancreatitis to look for the cause?

A

1) Ultrasound abdomen can look for gallstones
2) MRCP can be used to look for obstructive pancreatitis
3) ERCP is often preferred in these cases compared to MRCP and can be therapeutic
4) CT scan can be performed to at a later stage if complications of pancreatitis are suspected such as pseudocysts or necrotising pancreatitis

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22
Q

Which criteria is used to predict the severity of pancreatitis?

A

Modified Glasgow criteria

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23
Q

What are the components of the modified Glasgow score for acute pancreatitis severity?

A

PANCREAS
1) PaO2 < 8kPa
2) Age > 55 years
3) Neutrophils - WBC > 15
4) Calcium < 2
5) Renal function - Urea > 16
6) Enzymes - AST/ALT > 200 or LDH > 600
7) Albumin < 32
8) Sugar - Glucose > 10

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24
Q

How is the modified Glasgow criteria interpreted and used in acute pancreatitis?

A

1) Used to predict the severity of pancreatitis
2) In practice this is usually done at admission and after 48h of admission
3) The true score is performed after 48h
4) A score of 3 or more positive factors indicates transfer to ITU/HDU for intensive monitoring and aggressive fluid resuscitation
5) These indicators are based on the degree of potential complications arising from pancreatitis, such as necrosis of surrounding tissue and therefore saponification, reduced hormone output (insulin) and ARDS

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25
Q

A modified Glasgow score of what indicates transfer to ITU/HDU for intensive monitoring and aggressive fluid resus?

A

3 or more

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26
Q

How do you manage acute pancreatitis?

A

Supportive
1) Aggressive fluid resuscitation with crystalloids
2) Catheter
3) Opioid analgesia
4) Anti-emetics
5) Calcium if hypocalcaemia
6) Insulin if hyperglycaemia, due to damaged pancreas reducing release of insulin
7) IV abx only in necrotising pancreatitis

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27
Q

What is necrotising pancreatitis?

A

1) Complication of severe pancreatitis representing inadequate fluid resuscitation during initial management
2) It is usually diagnosed by CT scan

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28
Q

What causes chronic pancreatitis?

A

Chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas

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29
Q

What is the most common cause of chronic pancreatitis?

A

Chronic alcohol excess (80% of patients)

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30
Q

What are less common causes of chronic pancreatitis?

A

1) Cystic fibrosis (genetic)
2) Pancreatic cancer (obstructive)
3) Raised triacylglycerides (metabolic)
4) Idiopathic (15-20%)

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31
Q

How does chronic pancreatitis present?

A

1) Epigastric pain - worse after eating fatty food and relieved by sitting forward
2) Exocrine dysfunction e.g. malabsorption and steatorrhoea
3) Endocrine dysfunction - type 1 diabetes (thirst and polyuria)

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32
Q

What are examination findings in chronic pancreatitis?

A

1) Epigastric tenderness
2) Signs of chronic liver disease - suggests alcohol as a cause

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33
Q

What structural investigations are done in chronic pancreatitis?

A

1) AXR - looking for calcifications
2) CT scan - shows pancreatic calcification

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34
Q

What would you see on CT scan (and AXR) in chronic pancreatitis?

A

Pancreatic calcification

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35
Q

What is the aim of functional investigations done in chronic pancreatitis?

A

Detecting exocrine and endocrine dysfunction

36
Q

What functional investigations can be done in chronic pancreatitis?

A

1) Faecal elastase - exocrine dysfunction
2) Fasting glucose/OGTT - endocrine dysfunction

37
Q

How do you differentiate between acute and chronic pancreatitis?

A

Serum amylase and lipase are NOT raised in chronic pancreatitis + steatorrhoea in chronic pancreatitis (from exocrine dysfunction)

38
Q

How is chronic pancreatitis managed?

A

1) Conservative measures - ethanol abstinence + good diet
2) Medical measures - analgesia, insulin, pancreatic enzyme replacement
3) If above measures fail intensive interventions may be considered e.g. coeliac plexus block, pancreatectomy

39
Q

What are conservative measures for chronic pancreatitis management?

A

1) Ethanol abstinence
2) Good diet

40
Q

What is used for medical management of chronic pancreatitis?

A

1) Analgesia (for pain control)
2) Insulin - endocrine dysfunction
3) Pancreatic enzyme replacement - exocrine dysfunction

41
Q

How is endocrine dysfunction managed in chronic pancreatitis?

A

Insulin

42
Q

How is exocrine dysfunction managed in chronic pancreatitis?

A

Pancreatic enzyme replacement

43
Q

What invasive interventions can be considered if conservative and medical management options fail in chronic pancreatitis?

A

1) Coeliac plexus block
2) Pancreatectomy

44
Q

What are potential complications of chronic pancreatitis?

A

1) Local - pseudocyst, pancreatic cancer
2) Systemic - endocrine dysfunction (diabetes), or exocrine dysfunction (malabsorption and steatorrhoea)

45
Q

Is chronic pancreatitis a risk factor for pancreatic cancer?

A

Yes

46
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma (ductal)

47
Q

What is the 5 year survival rate of pancreatic cancer?

A

< 5 %

48
Q

Why does pancreatic cancer often present late?

A

Bc of its non-specific early symptoms

49
Q

How does early pancreatic cancer present?

A

Generalised symptoms
1) Malaise
2) Abdominal pain
3) Nausea
4) Weight loss

50
Q

How does advanced pancreatic cancer present?

A

1) Obstructive jaundice + painless palpable gallbladder
2) Diabetes
3) Unexplained pancreatitis
4) Pancreatic exocrine dysfunction with steatorrhoea
5) Trousseau’s syndrome
6) Disseminated intravascular coagulation (DIC)
7) Hypercalcaemia
8) Epigastric mass

51
Q

What type of jaundice occurs in pancreatic cancer?

A

Obstructive

52
Q

What causes obstructive jaundice in pancreatic cancer?

A

Blockage of the common bile duct from a tumour in the pancreatic head

53
Q

Tumour in which part of the pancreas leads to obstructive jaundice?

A

Pancreatic head

54
Q

What sign is relevant to pancreatic cancer?

A

Courvoisier’s sign

55
Q

What is Courvoisier’s sign?

A

Painless palpable gallbladder + jaundice

56
Q

When should you suspect a tumour in the body or tail of the pancreas?

A

Elderly + newly diagnosed diabetes + weight loss

57
Q

Diabetes is a presentation of pancreatic cancer in which part of the pancreas?

A

Body or tail

58
Q

What does infiltration of pancreatic cancer into the pancreas lead to?

A

1) Unexplained pancreatitis
2) Pancreatic exocrine dysfunction - steatorrhoea

59
Q

What does steatorrhoea indicate (pancreas)?

A

Chronic pancreatitis ± pancreatic cancer

60
Q

What paraneoplastic syndrome occurs in pancreatic cancer?

A

Trousseau’s syndrome

61
Q

What is Trousseau’s syndrome?

A

Migratory thrombophlebitis affecting the extremities of the body e.g. an arm vein becomes swollen and red, then a leg vein

62
Q

What should you suspect in a patient presenting with migratory thrombophlebitis affecting the extremities of the body?

A

Pancreatic cancer (Trousseau’s syndrome)

63
Q

What is a complication of pancreatic cancer?

A

Disseminated intravascular coagulation (DIC)

64
Q

Where does pancreatic cancer metastasise to (early)?

A

Lung, liver + bowel

65
Q

How can pancreatic metastases present?

A

1) Haemoptysis (lung)
2) Jaundice (lung)
3) Constipation (bowel)

66
Q

What is the key red flag symptom of pancreatic cancer and should be investigated urgently?

A

Painless obstructive jaundice

67
Q

What blood tests results are shown in painless obstructive jaundice?

A

Raised bilirubin + ALP

68
Q

What is the diagnostic test for pancreatic cancer?

A

CT abdomen + pelvis

69
Q

What imaging investigation can be used to initially assess for pancreatic cancer (if not high clinical suspicion?

A

Abdominal ultrasound - can detect tumours > 2cm, liver metastases + dilation of common bile duct (good for tumours in head of pancreas, bad for tumours in body/tail and early disease)

70
Q

Does a normal abdominal ultrasound rule out pancreatic cancer?

A

No

71
Q

Why is CT abdomen/pelvis the diagnostic investigation of choice for pancreatic cancer esp. when there is high clinical suspicion?

A

1) Highly specific
2) Can predict whether surgical resection is a possibility
3) Allows disease staging

72
Q

Which imaging investigations are potential adjuncts to CT abdo pelvis in pancreatic cancer?

A

PET-FDG + MRI

73
Q

What can be used to give information about the biliary ducts but can’t show extension of the tumour in pancreatic cancer?

A

MRCP

74
Q

What is endoscopic ultrasound (invasive test) used for in pancreatic cancer?

A

1) Detect very small lesions (2-3mm)
2) Biopsy of a lesion (ERCP can also be used)

75
Q

What is the only potentially curative treatment for pancreatic cancer?

A

Resection of the pancreatic tumour

76
Q

What % of patients present with resectable pancreatic cancer?

A

15-20% (disease often presents v late)

77
Q

What are criteria for pancreatic cancer resection?

A

1) No evidence of involvement of the superior mesenteric artery or coeliac arteries
2) No evidence of distant metastases

78
Q

What is the most common surgical procedure used to resect a tumour in the head of the pancreas?

A

Radical pancreaticoduodenectomy (Whipple procedure) - removes pancreatic head, duodenum, bile duct and gallbladder

79
Q

What treatment can be offered to patients after surgery if they have recovered well?

A

Adjuvant chemotherapy

80
Q

What is the management for pancreatic cancer which is locally advanced or metastatic?

A

Palliative care

81
Q

What are the components of palliative care in pancreatic cancer?

A

1) Endoscopic stent insertion into the common bile duct
2) Palliative surgery if endoscopic stent insertion fails
3) Chemotherapy
4) Radiotherapy (only for localised advanced disease)
Important for patients to refer to palliative care for pain management + mental/emotional support

82
Q

What tumour marker is used for diagnosis, prognosis, monitoring treatment and detecting recurrence in pancreatic cancer?

A

Ca 19-9

83
Q

What are risk factors for pancreatic cancer?

A

1) Smoking
2) Alcohol
3) Carcinogens
4) Diabetes
5) Chronic pancreatitis
6) High waist circumference
7) Male > 60 years

84
Q

What are rarer types of pancreatic cancer?

A

1) Ampullary tumour - arises in the ampulla of Vater
2) Pancreatic islet cell tumours - insulinomas, gastrinoma, glucagonomas, somatostatinomas, VIPomas

85
Q

Which genetic mutation is associated with pancreatic cancer?

A

KRAS2 gene (~95% have mutation in this)

86
Q

What is the most accurate imaging modality for diagnosis and staging?

A

EUS (endoscopic sonography)

Stage 3 (61 decks)

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