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CP3 SURGERY > HPB - The Pancreas > Flashcards

HPB - The Pancreas Flashcards

1
Q

Sx acute pancreatitis (SOCRATES)

A 
S - epigastric pain 
O - sudden (if cause = gallstones), gradual if b./c alcohol 
R - back 
A - N+V (prominent) 
T - pain incr for hrs, then plateaus for a few days 
E.- coughing/deep breathing 
R - sitting forward + up 
S - severe
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2
Q

Signs acute pancreatitis

A 
TachyC + sweaty 
Tachypnoea 
Fever
Ileus 
Jaundice 
Rigid abdomen 
Cullen's sign 
Grey-Turners sign
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3
Q

What is Cullens sign

A

Periumbilical discoloration due to haemorrhage into peritoneal space (in acute pancreatitis)

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4
Q

What is Grey-Turners sign

A

Discoloration of the flanks in acute pancreatitis

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5
Q

If brusing signs occur in an individual w/ acute pancreatitis, what does this signify

A

A worse prognosis

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6
Q

Aetiology acute pancreatitis (I GET SMASHED)

A 
Idiopathic 
Gallstones (/ other duct obstruction) 
Ethanol 
Trauma 
Steroids (direct acinar damage) 
Mumps 
Autoimmune 
Scorpion venom 
Hyper - lipidaemia/thyroid. Hypothermia 
ERCP
Dx - thiazides/sulphonamides/ACEi/NSAIDs
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7
Q

Pathology of acute pancreatitis

A

Insult to pancreas –> marked elevation intracellular Ca –> leakage enzymes –> acute inflamm.
Liberation digestive enzymes –> extensive tissue necrosis esp fat

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8
Q

What is periductal necrosis

A

Necrosis of acinal cells adjacent to ducts

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9
Q

What is periductal necrosis generally due to

A

Obstruction ie gallstones

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10
Q

What is panlobular necrosis

A

Necrosis of whole acinar lobule

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11
Q

/ What is panlobular necrosis generally due to

A

Dx/toxins/virus/metabolic insults

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12
Q

What is perilobular necrosis

A

Necrosis of peripheries of lobules

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13
Q

What is perilobular necrosis generally due to

A

Poor vascular perfusion ie. shock/hypothermia

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14
Q

Acute Mx of pancreatitis

A 
A-E + supportive Tx 
Aggressive fl resus , catheter + CVP monitor 
Hrly: pulse, BP, U/O + bloods 
Analgesia (STRONG)
NBM
PPI 
Anticoag 
Consider ITU
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15
Q

Why should a patient being treated for acute pancreatitis be kept NBM?

A

to rest the pancreas

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16
Q

further Mx of acute pancreatitis is gallstones suspected

A

ERCP

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17
Q

further Mx of acute pancreatitis if abscess or necrosis on CT

A

laparotomy + debridment

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18
Q

what % of pt w/ acute pancreatitis req ITU

A

15%

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19
Q

What % of ITU admissions with pancreatitis end in death

A

50%

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20
Q

Early complications pancreatitis (6)

A 
Shock (hypoV/septic) 
ARDS
Renal failure 
DIC
Hypocalcaemia 
Hyperglycaemia
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21
Q

Late complications pancreatitis (5(

A 
Pancreatiic pseudocyst 
Abscess 
Bleeding from elastase erodign through major vessel 
Thrombosis of aa --> bowel necrosis 
Fistulae
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22
Q

What is a pancreatic pseudocyst?

A

Collections of pancreatic fl and tissue debris around the pancreas

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23
Q

When does a pancreatic pseudocyst occur

A

4-6 weeks after acute pancreatits

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24
Q

Features of pancreatic pseudocyst

A

N+V
Epigastric pain
Elevated amylase

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25
Q

Ix acute pancreatitis - bloods

A 
FBC
CRP 
U+E
LFT 
Glucose 
Ca
Coagulation 
Lactate
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26
Q

Why do CRP when Ix acute pancreatitis

A

Indication of severity and prognosis

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27
Q

Why do lactate when Ix acute pancreatits

A

Indication of progression

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28
Q

When to repeat bloods in acute pancreatitis to assess severity

A

24+48h

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29
Q

When is serum amylase a sensitive marker of acute pancreatitis

A

If measured within 24hrs

And if > 3x norm

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30
Q

Which other conditions can also raise amylase (3)

A

Cholecystitis
GI perforations
Mesenteric infarcton

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31
Q

Which marker is moer sensitive and specific than amylase in acute pancreatitis>

A

lipase

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32
Q

How long is lipase elevated for in acute pancreatitis

A

72hr

33
Q

Imaging to Ix acute pancreatitis

A 
AXR  = mandatory 
Erect CXR 
CT
MRCO
USS
Endoscopic USS
34
Q

What are you looking for on AXR to diagnose acute pancreatitis (3)

A

Sentinel loop
Small bowel ileus
Calcification of the pancreas

35
Q

Why do an erect CXR when Ix acute pancreatitis

A

Assess for perforation

36
Q

Why do a CT when Ix acute pancreatitis

A

For ID abscess, necrosis, pseudocyst

If repeated at 72hr can assess severity necrosis

37
Q

When is MRCP particularly useful in acute pancreatitis

A

When ddx between l + s inflamm mass

38
Q

What scoring system best predicts the prognosis of acute pancreatitis

A

The Modified Glasgow criteria

39
Q

What score on the Glasgow Criteria prompts admission to ITU

A

3 or >

40
Q

The Glasgow Criteria (8) (PANCREAS)

A 
PaO2 <8 
Age >55 
Neutrophils - WCC >15 
Ca <2
Enzymes: LDH >600 + AST >200 
Albumin <32
Sugar - glucose   >10 `
41
Q

What does the APACHE II do

A

Allocations of points for assessment of
A = clinical parameters
B age
C = co-morbidities

42
Q

What APACHE II score indicates severe acute pancreatitis

A

> 9

43
Q

What is the Ranson criteria

A

Includes age + lab scores on admission, then clinical findings at 48hrs to give mortality risk figure

44
Q

Metabolic complications acute pancreatitis (5)

A 
Hyperglycaemia 
Hypocalcaemia 
Hypermagnesia 
Reduced Se albumin 
Malabsoprtion vit ADEK
45
Q

Def pseudocyst

A

Localised fluid collection rich in pancreatic enzymes, with a non-epithelialized wall containing fibrous/granulation tissue

46
Q

From when do pseudocysts occur

A

day 10 after pancreatitis

47
Q

PS pseudocyst (6)

A 
Deep persistent abdominal pain 
ABdo pain 
Anorexia
jaundice 
sepsis 
pleural effusion
48
Q

Ix pseudocyst (5)

A 
Amylase +/- elevation 
LFTs may be abnormal 
Abdo CT = gold standard
MRI (DDx from necrosis) 
ERCP
49
Q

Complications of pseudocyst

A

Bleeding
Infection
GI obstruction
Ruputre

50
Q

Mx pseudocysts

A

Most req supporive care + reg monitoring

Some req drainage

51
Q

Indications for drainage of pseudocyst (3)

A

Complications
Relief of Sx
Concerns RE malignancy

52
Q

Age - pancreatic carcinoma

A

Pt >60

53
Q

RF pancreatic carcinoma (4)

A

Smoking
Alcohol
DM
Chronic pancreatitis

54
Q

PS carcinoma of head of pancreas

A

PS earlier
Painless jaundice
May develop pain as progresses

55
Q

O/E carcinoma head of the pancreas (4)

A

Signs related to obstructive janducie
HSmegaly/ascites
Palpable abdo mass
Courvoisiers sign

56
Q

Sx carcinoma of body/tail pancreas

A

PS later
Dull abdo pain R to back
Partially relieved by leaning forwards
Non-specific B Sx = common

57
Q

What can either pancreatitc cancers PS with

A

Acute pancreaitis

DM

58
Q

Trousseau’s syndrome

A

Thrombosis of superficial/deep leg vv related to pancreatic carcinoma

59
Q

Ix pancreatic cancer - bloods (6)

A 
FBC
U_E
LFT
CA 19.9 or CEA
Amylase (rarely elevated)
60
Q

Imaging Ix pancreatic cancer (4)

A

USS - confirm obstruction + duct dilatation
CT
EUS +/- biopsy - location, spread of tumour + LN involv
Staging lapraoscopy

61
Q

What type of cancers are the majority of pancreatic cancers

A

Ductal adenocarcinomas

62
Q

% of pancreatic carcinomas by location

A

60% head
25% body
15% tail

63
Q

What % of pancreatic tumours are islet cell tumours

A

<2%

64
Q

What syndrome can islet cell tumours occur w/

A

MEN syndrome

65
Q

Sx of insulinoma

A

Sx hypoglycaemic events

Gross weight gain

66
Q

Are the majority of insulinomas malignant or benign

A

Benign

67
Q

PS glucagonoma

A

Often asymp

Or 2’ DM

68
Q

PS gastrinoma (4)

A

Zollinger-Ellison syndrome
w/ oesophagitis
GI ulcers
Diarrhoea

69
Q

PS somatostatinoma

A

DM (insulin release inhib)
Achlorrhydria (gastrin release inhib)
Gall stones (CCK release inhib)

70
Q

Sx VIPoma

A

Profound diarrhoea

71
Q

What % of pancreatic tumours are resectable

A

15%

72
Q

Name of surgery pancreatic tumours

A

WHipples procedure

Pancreatoduodenectomy

73
Q

What post surgery improves pancreatic cancer survival

A

chemotherapy

74
Q

Is palliative surgery used in panc cancer

A

No

no benefit

75
Q

Palliative Mx pancr tumour

A

ERCP/stent

to help jaundice + anorexia

76
Q

Med survival pancreatic cancer

A

<6m

77
Q

5y survival pancreatic cancer without whipples procedure

A

<2%

78
Q

5 y survival pancreatic cancer with Whipples procedure

A

10-15%

CP3 SURGERY (19 decks)

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