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Surgery Block > HPB - Pancreas and Spleen > Flashcards

HPB - Pancreas and Spleen Flashcards

1
Q

How can acute pancreatitis be distinguished from chronic pancreatitis?

A

Limited damage to the secretory function of the pancreas - no gross structural damage develops

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2
Q

What are the two most common causes of acute pancreatitis?

A

Gallstones

Excess alcohol consumption

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3
Q

List the common causes of acute pancreatitis

A 
GET SMASHED: 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease (eg. SLE)
Scorpion venom
Hypercalcaemia
ERCP
Drugs (eg. Azothioprine, NSAIDs, Diuretics)
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4
Q

Describe the pathogenesis of acute pancreatitis

A

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

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5
Q

Why may hypocalcaemia occur in pancreatitis?

A

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

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6
Q

What is the typical clinical features of acute pancreatitis?

A
  • Severe epigastric pain (can radiate to the back)
  • N+V
  • Hypovolaemic shock possible
  • Epigastric tenderness but soft abdomen
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7
Q

What signs might be seen in acute pancreatitis? Why do these occur?

A

Grey Turner’s (flank bruising)
Cullen’s sign (umbilical bruising)
–> Caused by retroperitoneal haemorrhage

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8
Q

What are the main DDx of abdominal pain radiating to the back?

A

Symptomatic/ruptured AAA
Pancreatitis (acute or chronic)
Aortic dissection
Duodenal ulcer

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9
Q

What is the diagnostic test for acute pancreatitis?

A

Serum amylase

>3x upper limit of normal

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10
Q

What conditions cause raised serum amylase?

A 
Acute pancreatitis
Bowel perforation
Ectopic pregnancy
Mesenteric ischaemia
DKA
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11
Q

What is the rationale behind doing LFTs in acute pancreatitis?

A

Assess for any concurrent cholestatic element

ALT >150U/L indicates 85% of gallstones as the underlying cause

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12
Q

What scoring criteria can be used to assess the severity of acute pancreatitis? What score is considered as sever?

A

Modified Glasgow criteria (within first 48hrs)

Score ≥3 –> HDU

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13
Q

What are the criteria in the modified Glasgow criteria?

A 
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
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14
Q

What imaging may be indicated in a case of acute pancreatitis?

A

Abdominal USS - helps to identify underlying cause

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15
Q

What might be seen on an AXR in acute pancreatitis?

A

Sentinel loop sign - dilated proximal bowel loop adjacent to pancreas

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16
Q

Why might a CXR be done in acute pancreatitis?

A

Assess for pleural effusion or signs of ARDS

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17
Q

What might a contrast enhanced CT scan show in acute pancreatitis 48hrs post presentation?

A

Pancreatic oedema

If it no longer enhances this can suggest a necrosing pancreas

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18
Q

What is the supportive treatment for acute pancreatitis?

A 
High flow O2
IV fluid resuscitation 
NG tube (if profuse vomiting)
Catheterisation
Opioid analgesia
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19
Q

What extra intervention may be prescribed in pancreatic necrosis?

A

Broad spectrum antibiotic eg. imipenem

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20
Q

What are the systemic complications of acute pancreatitis?

A 
DIC
ARDS
Hypocalcaemia
Hyperglycaemia
Hypovolaemic shock
Multiorgan failure
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21
Q

What local complications are there of acute pancreatitis?

A

Pancreatic necrosis

Pancreatic pseudocyst

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22
Q

What is a pancreatic pseudocyst?

A

Collection of fluid containing pancreatic enzymes, blood and necrotic tissue
Tends to occur in the lesser sac

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23
Q

Why is a pancreatic pseudocyst named this way?

A

It lacks an epithelial lining - has a vascular and fibrotic wall surrounding the collection instead

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24
Q

When should pancreatic necrosis be considered?

A

In patients with evidence of persistent systemic inflammation for >7-10days after onset of pancreatitis

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25
Q

What definitive management is there for pancreatic necrosis?

A

Necrosectomy

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26
Q

What difference in lab findings may be seen between acute and chronic pancreatitis?

A

Amylase and lipase levels are typically lower in chronic pancreatitis than in acute

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27
Q

What blood vessels supply the spleen?

A

The splenic artery and short gastric arteries

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28
Q

What are the common causes of splenic rupture?

A
  • Haematological disease (eg. CML, myelofibrosis)
  • Thromboembolism
  • Vasculitis
  • Trauma
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29
Q

What is Kehr’s sign?

A

Left upper quadrant abdominal pain radiating to the left shoulder

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30
Q

How do patients with splenic infarct present?

A
  • Often asymptomatic
  • LUQ pain
  • Fever
  • N+V
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31
Q

What common differentials are there to exclude in LUQ pain?

A
  • Peptic ulcer disease
  • Pyelonephritis
  • Left sided basal pneumonia
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32
Q

What is the gold standard investigation for splenic infarct?

A

CT abdo with IV contrast

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33
Q

What is seen on imaging of splenic infarct?

A

Hypoattenuated segmental wedge (as IV contrast cannot reach infarcted area) - tends to point at the hilum of the spleen

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34
Q

What treatment is indicated for splenic infarct?

A

Management of the underlying cause and ensuring sufficient antimicrobial prophylaxis against encapsulated bacteria

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35
Q

What long term management can be given in splenic infarct if necessary?

A

Splenectomy - avoid due to risk of OPSI syndrome

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36
Q

What are the most common complications of splenic infarction?

A
  • Splenic rupture
  • Splenic abscess
  • Pseudo cyst formation
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37
Q

When do splenic abscesses tend to form?

A

When underlying cause of infarct was a non sterile embolus

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38
Q

How is a diagnosis of splenic abscess made?

A

CT scan but confirmed by explorative surgery

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39
Q

What is auto splenectomy?

A

Where repeated splenic infarctions result in progressive fibrosis and atrophy of the spleen –> complete spleen atrophy

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40
Q

What is themes common cause of auto splenectomy?

A

Sickle cell anaemia

41
Q

What are the common causes of splenic rupture?

A
  • Abdominal trauma
  • Iatrogenic
  • Underlying splenomegaly
42
Q

What clinical features will patients with splenic rupture often have?

A
  • LUQ pain + Kehr’s sign
  • ## Features of hypovolaemic shock
43
Q

What immediate management is needed for haemodynamically unstable patients with peritoneum following trauma? Why?

A

Immediate laparotomy - abdominally bleeding until proven otherwise

44
Q

What imaging is needed for suspected abdominal injury?

A

Urgent CT chest-abdo-pelvis with IV contrast

45
Q

What scan can be done to assess for free fluid?

A

FAST scan

46
Q

What can be used to grade the level of injury in splenic rupture?

A

AAST splenic injury scale

scale of 1-5

47
Q

What conservative management is there for splenic rupture?

A

If haemodynamically stable:

  • Permissive hypotension
  • HDU for observation
  • Prophylactic vaccinations at discharge
48
Q

When is a repeat CT scan indicated in splenic rupture?

A

1 week post injury

49
Q

When is embolisation indicated in splenic injury?

A

Vascular abnormalities or higher grade injury

50
Q

What are the main complications of conservative treatment of embolisation in splenic injury?

A
  • Ongoing bleeding
  • Splenic necrosis
  • Splenic abscess or cyst formation
  • Thrombocytosis
51
Q

What prophylactic vaccinations and ABx are needed post splenectomy?

A

Pneumococcus, Meningococcus + H influenzae

+ Penicillin V ABx

52
Q

What types of pancreatic cancer are there?

A
  • Ductal carcinoma ***
  • Cystic tumours
  • Ampullary cell tumours
  • Islet cell tumours
53
Q

What age group does pancreatic cancer tend to affect?

A

60-80yrs

54
Q

Which other organs may be affected by direct invasion in the spread of pancreatic cancer?

A

Spleen, transverse colon + adrenal glands

55
Q

Where does pancreatic cancer commonly metastasise to and how?

A

Lymphatically –> regional lymph nodes, liver, lungs and peritoneum

56
Q

What are the risk factors for pancreatic carcinomas?

A
  • Smoking
  • Chronic pancreatitis
  • Recent onset of T2DM
  • ?FHx
  • Late onset diabetes (>50yrs 8x higher)
57
Q

What is the classic combination of symptoms seen in cancer of the head of the pancreas?

A
  • Obstructive jaundice
  • Abdo pain radiating to the back
  • Weight loss
58
Q

What is thrombophlebitis migrans?

A

Recurrent migratory superficial thrombophlebitis caused by a paraneoplastic hypercoagulable state

59
Q

What is Courvoisier’s law?

A

Jaundice + palpable gallbladder –> strong suspicion of malignancy of biliary tree or pancreas

60
Q

Why is there abdominal pain radiating to the back in pancreatic carcinoma?

A

Invasion of the coeliac plexus or secondary to pancreatitis

61
Q

What is the tumour marker for pancreatic cancer?

A

CA19-9

62
Q

What investigation should be used for pancreatic cancer? Why is it useful?

A

Pancreatic protocol CT scan - can also stage disease progression

63
Q

What is the curative management for pancreatic cancer?

A

Radical resection

  • Head of pancreas –> pancreaticduodenectomy (Whipples)
  • Body/tail –> distal pancreatectomy
64
Q

What contraindications are there for surgery in pancreatic cancer?

A

Metastasis to the perineum, liver and distant sites

65
Q

What specific complications are there post surgery in pancreatic cancer?

A
  • Pancreatic fistula
  • Delayed gastric emptying
  • Pancreatic insufficiency
66
Q

What adjuvant chemotherapy is used in pancreatic cancer?

A

5-Flourouracil post surgery

67
Q

What is the FLOFIRINOX regime?

A
  • Folinic acid
  • 5-Flourouracil
  • Irinotecan
  • Oxaliplatin
68
Q

What palliative therapy is there for pancreatic cancer?

A
  • Biliary stent to relieve obstructive jaundice
  • Enzyme replacements (eg. creon) to reduce malabsorption effects
  • Palliative chemo
69
Q

What is the prognosis of pancreatic cancer?

A

5 year survival less than 5% –> high metastatic capacity

70
Q

What does MEN1 typically consist of?

A
  • Hyperparathyroidism
  • Endocrine pancreatic tumours
  • Pituitary tumours (often prolactinomas)
71
Q

What types of endocrine tumours are there of the pancreas?

A
  • Gastrinoma
  • Glucagonoma
  • Insulinoma
  • Somatostatinoma
  • VIPoma
72
Q

What does Verner-Morrison syndrome consist of?

A

Prolonged profuse watery diarrhoea, severe hypokalaemia and dehydration

73
Q

What is involved in a Whipple’s procedure?

A

Removal of the head of the pancreas, antrum of the stomach, D1+D2, CBD + gallbladder
–> Tail of pancreas, hepatic duct + stomach attached with jejunum

74
Q

What is the gold standard imaging technique for an insulinoma?

A

Upper endoscopic ultrasound

75
Q

What are the types of high risk pancreatic cyst?

A
  • Intraductal papillary mutinous neoplasm
  • Mucinous cystic neoplasm
  • Solid pseudopapillary neoplasm
  • Cystic pancreatic neuroendocrine tumour
76
Q

What are the low risk types of pancreatic cyst?

A
  • Serous cystic adenoma
  • Simple cyst
  • Mucinous non-neoplastic cyst
  • Lymphoepithelial cyst
77
Q

How to the majority of pancreatic cysts present?

A

Asymptomatic, found incidentally on imaging

78
Q

What symptoms may be associated with pancreatic cysts?

A
  • Abdominal pain
  • Back pain
  • Post obstructive jaundice
  • Vomiting
79
Q

What is a pancreatic pseudocyst?

A

Collection of fluid within the pancreatic tissue (usually after pancreatitis) - inflammatory reaction produces necrotic space in pancreas that fills with pancreatic fluid

80
Q

Why is a pancreatic pseudocyst termed this way?

A

It lacks epithelial or endothelial cells lining the collection of fluid

81
Q

What imaging is used for further evaluation of pancreatic cysts?

A
  • Pancreatic protocol CT scan

- MRCP

82
Q

What are low risk features of pancreatic cysts?

A
  • Cyst diameter <3cm
  • Cystic morphology with central classification
  • Asymptomatic
83
Q

What are high risk features of pancreatic cysts?

A
  • Cyst diameter >3cm
  • Main pancreatic duct dilation >10mm
  • Enhancing solid component
  • Non-enhancing mural nodule
84
Q

How is a biopsy obtained from a pancreatic cyst?

A

Endoscopic US scan with fine needle aspiration

85
Q

What is first line treatment for high risk pancreatic cysts?

A

Resection with a follow up MRI scan every 2 years

86
Q

What is recommended in low risk pancreatic cysts?

A

Surveillance with MRI scan every 5 years

87
Q

What are the causes of chronic pancreatitis?

A
  • 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
88
Q

What is meant by small duct disease in chronic pancreatitis?

A

Associated with normal imaging + no pancreatic calcification - difficult to diagnose

89
Q

What is meant by large duct disease in chronic pancreatitis?

A
  • Dilatation + dysfunction of large pancreatic ducts
  • Pancreatic fluid changes and allows for deposition of precursors to calcium carbonate stones –> diffuse pancreatic calcification
90
Q

Describe a typical clinical presentation of chronic pancreatitis

A
  • 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
91
Q

What DDx should be considered in a case of chronic pancreatitis?

A
  • Acute cholecystitis
  • Peptic ulcer disease
  • Acute hepatitis
  • Sphincter of Oddi dysfunction
92
Q

What specific bloods should be looked at in chronic pancreatitis and why?

A
  • BM - raised glucose from endocrine dysfunction
  • Serum calcium - hypercalcaemia
  • LFTs - may be deranged (especially if hepatic aetiology)
93
Q

What is a good sensitive test for chronic pancreatitis?

A

Faecal elastase - low

94
Q

What is the first line imaging for suspected chronic pancreatitis?

A

Abdominal USS

95
Q

What is the use of a CT scan in chronic pancreatitis?

A

Confirmation of diagnosis + Look for pancreatic calcification or pseudocyst

96
Q

What can be used with MRCP/ERCP to visualise pancreatic duct strictures? How?

A

IV secretin

—> Stimulates the pancreas to produce a bicarbonate rich fluid

97
Q

What is involved in the definitive management of chronic pancreatitis?

A
  • Avoidance of precipitating factor
  • Management of chronic pain
  • Nutritional support
98
Q

What surgical treatment can be used for chronic pancreatitis?

A
  • ERCP
  • Endoscopic ultrasound
  • Endoscopic pancreatic sphincterotomy
99
Q

What are the complications of chronic pancreatitis?

A
  • Pseudocyst
  • Steatorrhoea + malabsorption
  • Diabetes mellitus
  • Ascites + Pleural effusion
  • Pancreatic malignancy

Surgery Block (12 decks)

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