Gen Surg: pancreatitis and pancreatic cancer

Question 1

What can serum calcium be helpful for looking at/diagnosing?

Answer 1

Acute pancreatitis, Clotting, cardiac function

Question 2

What is painless jaundice a sign of?

Answer 2

Pancreatic cancer until proven otherwise

Question 3

A man is 60 years old and has a recent diagnosis of DM. He has lost a stone and has a yellow tinge to his skin. What may he have a diagnosis of?

Answer 3

Pancreatic cancer - recent onset of DM over age of 60. Painless jaundice is a clue too.

Question 4

What are the features of chronic pancreatitis?

Answer 4

Epigastric pain that radiates through to the back (exacerbated by fatty food/alcohol and relieved by sitting back), steatorrhoea, weight loss and diabetes mellitus.

Question 5

What is the most sensitive blood test for diagnosis of acute pancreatitis?

Answer 5

Lipase! NOT amylase - as can rise and fall quickly, so can lead to false -ve.

Question 6

Whats the most common type of tumour is in pancreatic cancer?

Answer 6

ductal carcinoma, which is from the exocrine part of the pancreas

Question 7

Where do pancreatic tumours arise from?

Answer 7

Head- 60-70%
Body and tail - 20-25%
Diffuse- 10-20%

Body and tail tumours more likely to be diagnosed at advance stages compared to head

Question 8

What are the risk factors for pancreatic tumours?

Answer 8

Smoking
Chronic pancreatitis
Poor diet- high red meat and low fruit and veg
late onset DM
Fhx

Question 9

What is the presentation of pancreatic cancer?

Answer 9

Usually non-specific
Can get:
obstructive jaundice
weight loss
non-specific abdo pain

Question 10

How does a patient with pancreatic cancer appear on examination?

Answer 10

Cachexia
jaundiced
malnourished
courvoisiers law applies

Question 11

How is acute pancreatitis managed?

Answer 11

Treat underlying cause if appropriate - urgent ERCP and cholecystectomy.
Supportive measures - IV fluid resus, NG tube if vomiting, catheterise, opined analgesia

QM:
* A-E assessment as these are patients who can be, or become very unwell very quickly.
* Aggressive fluid resuscitation with crystalloids to maintain urine output > 30 mL/hour.
* Catheterisation.
* Analgesia: Strong opioids are often necessary.
* Anti-emetics.
* calcium may be administered if hypocalcaemia is detected.
* Insulin due to impaired pancreatic hormone release.

Question 12

What are some complications of ERCP?

Answer 12

Haemorrhage
Perforation
Acute Pancreatitis
Aspiration pneumonia
Ascending cholangitis

Question 13

What is Courvoisier’s law?

What can you infer about the diagnosis from this?

Answer 13

Courvoisier’s law = Painless jaundice with a palpable gallbladder means the diagnosis is unlikely to be stones

Conclusion: Will need to be obscuring the common bile duct (e.g. stricture / pancreatic mass) to cause jaundice. Can often cause fever and pain too

Question 14

Give an example of when you might use an MRCP and another example of when an ERCP would be more appropriate

Answer 14

MRCP - diagnostic tool e.g. suspect gall stone blocking CBD

ERCP - investigation + intervention. e.g. carcinoma of head of pancreas - place stent to open up duct

Question 15

causes pancreatitis?

Answer 15

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridaemia
ERCP
Drugs

Question 16

Presentation of pancreatitis?

Answer 16

Severe epigastric pain radiating to back, relieved when leaning forward
Vomiting
Abdo tenderness
Systemically unwell

Question 17

Investigations in pancreatitis?

Answer 17

FBC- to see WCC
U&Es- urea
LFTs- albumin and transaminases
CRP
Calcium
VBG for PaO2 and blood glucose
Amylase- 3x upper limit of normal

From Quesmed:
Key diagnostic investigations include:

• FBC and U+E Elevated white blood cell count (leukocytosis) can suggest necrotizing pancreatitis.
• LFT: Abnormalities may be seen in gallstone-related pancreatitis.
• Lipase and Amylase - lipase is more sensitive
• US abdo: Useful for detecting gallstones.
• MRCP: Detects obstructive pancreatitis.
• ERCP: Not only diagnostic but also therapeutic.
• CT pancreas scan: Performed later to identify complications like pseudocysts or necrotizing pancreatitis and is the gold standard for identifying severity and complications.

Question 18

Complications of pancreatitis?

Answer 18

Pseudocyst
Pancreatic necrosis
Abscess formation
chronic pancreatitis

Question 19

Pancreatic cancer lab investigations?

Answer 19

FBC- anaemia or thrombocytopenia and LFTs- raised bilirubin, raised ALP, gamma GT
CA19-9 to assess response to treatment

Question 20

Imaging used for pancreatic cancer?

Answer 20

Abdo USS- may show pancreatic mass or dilated biliary tress

CT- gold standard preliminary diagnosis

CT TAP- good for staging

Biopsy

Question 21

contraindications to laprascopic surgery

Answer 21

Absolute contraindications:
- haemodynamic instability/shock
- raised intracranial pressure
- acute intestinal obstruction (i.e. dilated bowel loops (e.g. > 4 cm)
- uncorrected coagulopathy

Relative contraindications:
- cardiac or respiratory failure
- recent laparotomy (within 4-6 weeks)
- abdominal aortic aneurysm (increased risk of vascular rupture)
- pregnancy (risk of injury to uterus)
- extensive adhesions from previous bowel surgery

Question 22

complications of laprascopic surgery

Answer 22

include:

• general risks of anaesthetic
• vasovagal reaction (e.g. bradycardia) in response to abdominal distension
• extra-peritoneal gas insufflation: surgical emphysema
• injury to gastro-intestinal tract
• injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

Question 23

How is severity of pancreatitis measured?

Answer 23

modified glasgow criteria - use PANCREAS:

PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L

Question 24

What are ddx for acute pancreatitis?

Answer 24

Acute MI
Perf peptic ulcer
AAA
Cholecystitis
Acute appendiciti - starts diffuse periumbilical pain
DKA
Pyelonephritis
Intestinal obstruction
Hepatitis

Question 25

What drugs can induce acute pancreatitis?

Answer 25

Drug-induced pancreatitis can be recalled using the mnemonic FATSHEEP, denoting:

Furosemide
Azathioprine/Asparaginase
Thiazides/Tetracycline
Statins/Sulfonamides/Sodium Valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors and NRTIs

Question 26

Describe pathophysiology of acute pancreatitis?

Answer 26

• begins with inflammation of the pancreas, triggering the activation of digestive enzymes within the pancreas itself.
• These enzymes then auto-digest the pancreatic tissue, setting off a cycle of inflammation and damage.
• This process can lead sepsis