HPB - Pancreas and Spleen Flashcards
How can acute pancreatitis be distinguished from chronic pancreatitis?
Limited damage to the secretory function of the pancreas - no gross structural damage develops
What are the two most common causes of acute pancreatitis?
Gallstones
Excess alcohol consumption
List the common causes of acute pancreatitis
GET SMASHED: Gallstones Ethanol Trauma Steroids Mumps Autoimmune disease (eg. SLE) Scorpion venom Hypercalcaemia ERCP Drugs (eg. Azothioprine, NSAIDs, Diuretics)
Describe the pathogenesis of acute pancreatitis
Premature and exaggerated activation of digestive enzymes within the pancreas leads to a pancreatic inflammatory response
This causes an increase in vascular permeability and so subsequent 3rd space fluid losses
Why may hypocalcaemia occur in pancreatitis?
Release of pancreatic enzymes into systemic circulation causes auto digestion of fats –> fat necrosis
This can cause release of free fatty acids which react with serum Ca2+ to form chalky deposits
What is the typical clinical features of acute pancreatitis?
- Severe epigastric pain (can radiate to the back)
- N+V
- Hypovolaemic shock possible
- Epigastric tenderness but soft abdomen
What signs might be seen in acute pancreatitis? Why do these occur?
Grey Turner’s (flank bruising)
Cullen’s sign (umbilical bruising)
–> Caused by retroperitoneal haemorrhage
What are the main DDx of abdominal pain radiating to the back?
Symptomatic/ruptured AAA
Pancreatitis (acute or chronic)
Aortic dissection
Duodenal ulcer
What is the diagnostic test for acute pancreatitis?
Serum amylase
>3x upper limit of normal
What conditions cause raised serum amylase?
Acute pancreatitis Bowel perforation Ectopic pregnancy Mesenteric ischaemia DKA
What is the rationale behind doing LFTs in acute pancreatitis?
Assess for any concurrent cholestatic element
ALT >150U/L indicates 85% of gallstones as the underlying cause
What scoring criteria can be used to assess the severity of acute pancreatitis? What score is considered as sever?
Modified Glasgow criteria (within first 48hrs)
Score ≥3 –> HDU
What are the criteria in the modified Glasgow criteria?
PANCREAS: pO2<8kPa Age >55 Neutrophils >15x10^9/L Calcium <2mmol/L Renal function (urea) >16mmol/L Enzymes (LDH>600 or AST>200) Albumin <32g/L Sugar >10mmol/L
What imaging may be indicated in a case of acute pancreatitis?
Abdominal USS - helps to identify underlying cause
What might be seen on an AXR in acute pancreatitis?
Sentinel loop sign - dilated proximal bowel loop adjacent to pancreas
Why might a CXR be done in acute pancreatitis?
Assess for pleural effusion or signs of ARDS
What might a contrast enhanced CT scan show in acute pancreatitis 48hrs post presentation?
Pancreatic oedema
If it no longer enhances this can suggest a necrosing pancreas
What is the supportive treatment for acute pancreatitis?
High flow O2 IV fluid resuscitation NG tube (if profuse vomiting) Catheterisation Opioid analgesia
What extra intervention may be prescribed in pancreatic necrosis?
Broad spectrum antibiotic eg. imipenem
What are the systemic complications of acute pancreatitis?
DIC ARDS Hypocalcaemia Hyperglycaemia Hypovolaemic shock Multiorgan failure
What local complications are there of acute pancreatitis?
Pancreatic necrosis
Pancreatic pseudocyst
What is a pancreatic pseudocyst?
Collection of fluid containing pancreatic enzymes, blood and necrotic tissue
Tends to occur in the lesser sac
Why is a pancreatic pseudocyst named this way?
It lacks an epithelial lining - has a vascular and fibrotic wall surrounding the collection instead
When should pancreatic necrosis be considered?
In patients with evidence of persistent systemic inflammation for >7-10days after onset of pancreatitis
What definitive management is there for pancreatic necrosis?
Necrosectomy
What difference in lab findings may be seen between acute and chronic pancreatitis?
Amylase and lipase levels are typically lower in chronic pancreatitis than in acute
What blood vessels supply the spleen?
The splenic artery and short gastric arteries
What are the common causes of splenic rupture?
- Haematological disease (eg. CML, myelofibrosis)
- Thromboembolism
- Vasculitis
- Trauma
What is Kehr’s sign?
Left upper quadrant abdominal pain radiating to the left shoulder
How do patients with splenic infarct present?
- Often asymptomatic
- LUQ pain
- Fever
- N+V
What common differentials are there to exclude in LUQ pain?
- Peptic ulcer disease
- Pyelonephritis
- Left sided basal pneumonia
What is the gold standard investigation for splenic infarct?
CT abdo with IV contrast
What is seen on imaging of splenic infarct?
Hypoattenuated segmental wedge (as IV contrast cannot reach infarcted area) - tends to point at the hilum of the spleen
What treatment is indicated for splenic infarct?
Management of the underlying cause and ensuring sufficient antimicrobial prophylaxis against encapsulated bacteria
What long term management can be given in splenic infarct if necessary?
Splenectomy - avoid due to risk of OPSI syndrome
What are the most common complications of splenic infarction?
- Splenic rupture
- Splenic abscess
- Pseudo cyst formation
When do splenic abscesses tend to form?
When underlying cause of infarct was a non sterile embolus
How is a diagnosis of splenic abscess made?
CT scan but confirmed by explorative surgery
What is auto splenectomy?
Where repeated splenic infarctions result in progressive fibrosis and atrophy of the spleen –> complete spleen atrophy
What is themes common cause of auto splenectomy?
Sickle cell anaemia
What are the common causes of splenic rupture?
- Abdominal trauma
- Iatrogenic
- Underlying splenomegaly
What clinical features will patients with splenic rupture often have?
- LUQ pain + Kehr’s sign
- ## Features of hypovolaemic shock
What immediate management is needed for haemodynamically unstable patients with peritoneum following trauma? Why?
Immediate laparotomy - abdominally bleeding until proven otherwise
What imaging is needed for suspected abdominal injury?
Urgent CT chest-abdo-pelvis with IV contrast
What scan can be done to assess for free fluid?
FAST scan
What can be used to grade the level of injury in splenic rupture?
AAST splenic injury scale
scale of 1-5
What conservative management is there for splenic rupture?
If haemodynamically stable:
- Permissive hypotension
- HDU for observation
- Prophylactic vaccinations at discharge
When is a repeat CT scan indicated in splenic rupture?
1 week post injury
When is embolisation indicated in splenic injury?
Vascular abnormalities or higher grade injury
What are the main complications of conservative treatment of embolisation in splenic injury?
- Ongoing bleeding
- Splenic necrosis
- Splenic abscess or cyst formation
- Thrombocytosis
What prophylactic vaccinations and ABx are needed post splenectomy?
Pneumococcus, Meningococcus + H influenzae
+ Penicillin V ABx
What types of pancreatic cancer are there?
- Ductal carcinoma ***
- Cystic tumours
- Ampullary cell tumours
- Islet cell tumours
What age group does pancreatic cancer tend to affect?
60-80yrs
Which other organs may be affected by direct invasion in the spread of pancreatic cancer?
Spleen, transverse colon + adrenal glands
Where does pancreatic cancer commonly metastasise to and how?
Lymphatically –> regional lymph nodes, liver, lungs and peritoneum
What are the risk factors for pancreatic carcinomas?
- Smoking
- Chronic pancreatitis
- Recent onset of T2DM
- ?FHx
- Late onset diabetes (>50yrs 8x higher)
What is the classic combination of symptoms seen in cancer of the head of the pancreas?
- Obstructive jaundice
- Abdo pain radiating to the back
- Weight loss
What is thrombophlebitis migrans?
Recurrent migratory superficial thrombophlebitis caused by a paraneoplastic hypercoagulable state
What is Courvoisier’s law?
Jaundice + palpable gallbladder –> strong suspicion of malignancy of biliary tree or pancreas
Why is there abdominal pain radiating to the back in pancreatic carcinoma?
Invasion of the coeliac plexus or secondary to pancreatitis
What is the tumour marker for pancreatic cancer?
CA19-9
What investigation should be used for pancreatic cancer? Why is it useful?
Pancreatic protocol CT scan - can also stage disease progression
What is the curative management for pancreatic cancer?
Radical resection
- Head of pancreas –> pancreaticduodenectomy (Whipples)
- Body/tail –> distal pancreatectomy
What contraindications are there for surgery in pancreatic cancer?
Metastasis to the perineum, liver and distant sites
What specific complications are there post surgery in pancreatic cancer?
- Pancreatic fistula
- Delayed gastric emptying
- Pancreatic insufficiency
What adjuvant chemotherapy is used in pancreatic cancer?
5-Flourouracil post surgery
What is the FLOFIRINOX regime?
- Folinic acid
- 5-Flourouracil
- Irinotecan
- Oxaliplatin
What palliative therapy is there for pancreatic cancer?
- Biliary stent to relieve obstructive jaundice
- Enzyme replacements (eg. creon) to reduce malabsorption effects
- Palliative chemo
What is the prognosis of pancreatic cancer?
5 year survival less than 5% –> high metastatic capacity
What does MEN1 typically consist of?
- Hyperparathyroidism
- Endocrine pancreatic tumours
- Pituitary tumours (often prolactinomas)
What types of endocrine tumours are there of the pancreas?
- Gastrinoma
- Glucagonoma
- Insulinoma
- Somatostatinoma
- VIPoma
What does Verner-Morrison syndrome consist of?
Prolonged profuse watery diarrhoea, severe hypokalaemia and dehydration
What is involved in a Whipple’s procedure?
Removal of the head of the pancreas, antrum of the stomach, D1+D2, CBD + gallbladder
–> Tail of pancreas, hepatic duct + stomach attached with jejunum
What is the gold standard imaging technique for an insulinoma?
Upper endoscopic ultrasound
What are the types of high risk pancreatic cyst?
- Intraductal papillary mutinous neoplasm
- Mucinous cystic neoplasm
- Solid pseudopapillary neoplasm
- Cystic pancreatic neuroendocrine tumour
What are the low risk types of pancreatic cyst?
- Serous cystic adenoma
- Simple cyst
- Mucinous non-neoplastic cyst
- Lymphoepithelial cyst
How to the majority of pancreatic cysts present?
Asymptomatic, found incidentally on imaging
What symptoms may be associated with pancreatic cysts?
- Abdominal pain
- Back pain
- Post obstructive jaundice
- Vomiting
What is a pancreatic pseudocyst?
Collection of fluid within the pancreatic tissue (usually after pancreatitis) - inflammatory reaction produces necrotic space in pancreas that fills with pancreatic fluid
Why is a pancreatic pseudocyst termed this way?
It lacks epithelial or endothelial cells lining the collection of fluid
What imaging is used for further evaluation of pancreatic cysts?
- Pancreatic protocol CT scan
- MRCP
What are low risk features of pancreatic cysts?
- Cyst diameter <3cm
- Cystic morphology with central classification
- Asymptomatic
What are high risk features of pancreatic cysts?
- Cyst diameter >3cm
- Main pancreatic duct dilation >10mm
- Enhancing solid component
- Non-enhancing mural nodule
How is a biopsy obtained from a pancreatic cyst?
Endoscopic US scan with fine needle aspiration
What is first line treatment for high risk pancreatic cysts?
Resection with a follow up MRI scan every 2 years
What is recommended in low risk pancreatic cysts?
Surveillance with MRI scan every 5 years
What are the causes of chronic pancreatitis?
- Chronic alcohol abuse***
- Idiopathic
- Hyperlipidaemia
- Hypercalcaemia
- Virus eg. HIV, mumps, coxsackie
- Bacterial eg. Echinococcus
- Cystic fibrosis
- Autoimmune (AIP)
- SLE
- Obstruction of pancreatic duct
- Pancreas divisum
- Annular pancreas
What is meant by small duct disease in chronic pancreatitis?
Associated with normal imaging + no pancreatic calcification - difficult to diagnose
What is meant by large duct disease in chronic pancreatitis?
- Dilatation + dysfunction of large pancreatic ducts
- Pancreatic fluid changes and allows for deposition of precursors to calcium carbonate stones –> diffuse pancreatic calcification
Describe a typical clinical presentation of chronic pancreatitis
- Chronic epigastric pain radiating to the back
- Pain eased on leaning forward
- N+V
- Symptoms secondary to endocrine dysfunction eg. DM
- Symptoms secondary to exocrine dysfunction eg. steatorrhoea
What DDx should be considered in a case of chronic pancreatitis?
- Acute cholecystitis
- Peptic ulcer disease
- Acute hepatitis
- Sphincter of Oddi dysfunction
What specific bloods should be looked at in chronic pancreatitis and why?
- BM - raised glucose from endocrine dysfunction
- Serum calcium - hypercalcaemia
- LFTs - may be deranged (especially if hepatic aetiology)
What is a good sensitive test for chronic pancreatitis?
Faecal elastase - low
What is the first line imaging for suspected chronic pancreatitis?
Abdominal USS
What is the use of a CT scan in chronic pancreatitis?
Confirmation of diagnosis + Look for pancreatic calcification or pseudocyst
What can be used with MRCP/ERCP to visualise pancreatic duct strictures? How?
IV secretin
—> Stimulates the pancreas to produce a bicarbonate rich fluid
What is involved in the definitive management of chronic pancreatitis?
- Avoidance of precipitating factor
- Management of chronic pain
- Nutritional support
What surgical treatment can be used for chronic pancreatitis?
- ERCP
- Endoscopic ultrasound
- Endoscopic pancreatic sphincterotomy
What are the complications of chronic pancreatitis?
- Pseudocyst
- Steatorrhoea + malabsorption
- Diabetes mellitus
- Ascites + Pleural effusion
- Pancreatic malignancy
