Gen Surg: pancreatitis and pancreatic cancer Flashcards
What can serum calcium be helpful for looking at/diagnosing?
Acute pancreatitis, Clotting, cardiac function
What is painless jaundice a sign of?
Pancreatic cancer until proven otherwise
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?
Pancreatic cancer - recent onset of DM over age of 60. Painless jaundice is a clue too.
What are the features of chronic pancreatitis?
Epigastric pain that radiates through to the back (exacerbated by fatty food/alcohol and relieved by sitting back), steatorrhoea, weight loss and diabetes mellitus.
What is the most sensitive blood test for diagnosis of acute pancreatitis?
Lipase! NOT amylase - as can rise and fall quickly, so can lead to false -ve.
Whats the most common type of tumour is in pancreatic cancer?
ductal carcinoma, which is from the exocrine part of the pancreas
Where do pancreatic tumours arise from?
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
What are the risk factors for pancreatic tumours?
Smoking
Chronic pancreatitis
Poor diet- high red meat and low fruit and veg
late onset DM
Fhx
What is the presentation of pancreatic cancer?
Usually non-specific
Can get:
obstructive jaundice
weight loss
non-specific abdo pain
How does a patient with pancreatic cancer appear on examination?
Cachexia
jaundiced
malnourished
courvoisiers law applies
How is acute pancreatitis managed?
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.
What are some complications of ERCP?
Haemorrhage
Perforation
Acute Pancreatitis
Aspiration pneumonia
Ascending cholangitis
What is Courvoisier’s law?
What can you infer about the diagnosis from this?
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
Give an example of when you might use an MRCP and another example of when an ERCP would be more appropriate
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
causes pancreatitis?
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridaemia
ERCP
Drugs
Presentation of pancreatitis?
Severe epigastric pain radiating to back, relieved when leaning forward
Vomiting
Abdo tenderness
Systemically unwell
Investigations in pancreatitis?
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.
Complications of pancreatitis?
Pseudocyst
Pancreatic necrosis
Abscess formation
chronic pancreatitis
Pancreatic cancer lab investigations?
FBC- anaemia or thrombocytopenia and LFTs- raised bilirubin, raised ALP, gamma GT
CA19-9 to assess response to treatment
Imaging used for pancreatic cancer?
Abdo USS- may show pancreatic mass or dilated biliary tress
CT- gold standard preliminary diagnosis
CT TAP- good for staging
Biopsy
contraindications to laprascopic surgery
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
complications of laprascopic surgery
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
How is severity of pancreatitis measured?
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
What are ddx for acute pancreatitis?
Acute MI
Perf peptic ulcer
AAA
Cholecystitis
Acute appendiciti - starts diffuse periumbilical pain
DKA
Pyelonephritis
Intestinal obstruction
Hepatitis
