HPB - The Pancreas Flashcards
Sx acute pancreatitis (SOCRATES)
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
Signs acute pancreatitis
TachyC + sweaty Tachypnoea Fever Ileus Jaundice Rigid abdomen Cullen's sign Grey-Turners sign
What is Cullens sign
Periumbilical discoloration due to haemorrhage into peritoneal space (in acute pancreatitis)
What is Grey-Turners sign
Discoloration of the flanks in acute pancreatitis
If brusing signs occur in an individual w/ acute pancreatitis, what does this signify
A worse prognosis
Aetiology acute pancreatitis (I GET SMASHED)
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
Pathology of acute pancreatitis
Insult to pancreas –> marked elevation intracellular Ca –> leakage enzymes –> acute inflamm.
Liberation digestive enzymes –> extensive tissue necrosis esp fat
What is periductal necrosis
Necrosis of acinal cells adjacent to ducts
What is periductal necrosis generally due to
Obstruction ie gallstones
What is panlobular necrosis
Necrosis of whole acinar lobule
/ What is panlobular necrosis generally due to
Dx/toxins/virus/metabolic insults
What is perilobular necrosis
Necrosis of peripheries of lobules
What is perilobular necrosis generally due to
Poor vascular perfusion ie. shock/hypothermia
Acute Mx of pancreatitis
A-E + supportive Tx Aggressive fl resus , catheter + CVP monitor Hrly: pulse, BP, U/O + bloods Analgesia (STRONG) NBM PPI Anticoag Consider ITU
Why should a patient being treated for acute pancreatitis be kept NBM?
to rest the pancreas
further Mx of acute pancreatitis is gallstones suspected
ERCP
further Mx of acute pancreatitis if abscess or necrosis on CT
laparotomy + debridment
what % of pt w/ acute pancreatitis req ITU
15%
What % of ITU admissions with pancreatitis end in death
50%
Early complications pancreatitis (6)
Shock (hypoV/septic) ARDS Renal failure DIC Hypocalcaemia Hyperglycaemia
Late complications pancreatitis (5(
Pancreatiic pseudocyst Abscess Bleeding from elastase erodign through major vessel Thrombosis of aa --> bowel necrosis Fistulae
What is a pancreatic pseudocyst?
Collections of pancreatic fl and tissue debris around the pancreas
When does a pancreatic pseudocyst occur
4-6 weeks after acute pancreatits
Features of pancreatic pseudocyst
N+V
Epigastric pain
Elevated amylase
Ix acute pancreatitis - bloods
FBC CRP U+E LFT Glucose Ca Coagulation Lactate
Why do CRP when Ix acute pancreatitis
Indication of severity and prognosis
Why do lactate when Ix acute pancreatits
Indication of progression
When to repeat bloods in acute pancreatitis to assess severity
24+48h
When is serum amylase a sensitive marker of acute pancreatitis
If measured within 24hrs
And if > 3x norm
Which other conditions can also raise amylase (3)
Cholecystitis
GI perforations
Mesenteric infarcton
Which marker is moer sensitive and specific than amylase in acute pancreatitis>
lipase
How long is lipase elevated for in acute pancreatitis
72hr
Imaging to Ix acute pancreatitis
AXR = mandatory Erect CXR CT MRCO USS Endoscopic USS
What are you looking for on AXR to diagnose acute pancreatitis (3)
Sentinel loop
Small bowel ileus
Calcification of the pancreas
Why do an erect CXR when Ix acute pancreatitis
Assess for perforation
Why do a CT when Ix acute pancreatitis
For ID abscess, necrosis, pseudocyst
If repeated at 72hr can assess severity necrosis
When is MRCP particularly useful in acute pancreatitis
When ddx between l + s inflamm mass
What scoring system best predicts the prognosis of acute pancreatitis
The Modified Glasgow criteria
What score on the Glasgow Criteria prompts admission to ITU
3 or >
The Glasgow Criteria (8) (PANCREAS)
PaO2 <8 Age >55 Neutrophils - WCC >15 Ca <2 Enzymes: LDH >600 + AST >200 Albumin <32 Sugar - glucose >10 `
What does the APACHE II do
Allocations of points for assessment of
A = clinical parameters
B age
C = co-morbidities
What APACHE II score indicates severe acute pancreatitis
> 9
What is the Ranson criteria
Includes age + lab scores on admission, then clinical findings at 48hrs to give mortality risk figure
Metabolic complications acute pancreatitis (5)
Hyperglycaemia Hypocalcaemia Hypermagnesia Reduced Se albumin Malabsoprtion vit ADEK
Def pseudocyst
Localised fluid collection rich in pancreatic enzymes, with a non-epithelialized wall containing fibrous/granulation tissue
From when do pseudocysts occur
day 10 after pancreatitis
PS pseudocyst (6)
Deep persistent abdominal pain ABdo pain Anorexia jaundice sepsis pleural effusion
Ix pseudocyst (5)
Amylase +/- elevation LFTs may be abnormal Abdo CT = gold standard MRI (DDx from necrosis) ERCP
Complications of pseudocyst
Bleeding
Infection
GI obstruction
Ruputre
Mx pseudocysts
Most req supporive care + reg monitoring
Some req drainage
Indications for drainage of pseudocyst (3)
Complications
Relief of Sx
Concerns RE malignancy
Age - pancreatic carcinoma
Pt >60
RF pancreatic carcinoma (4)
Smoking
Alcohol
DM
Chronic pancreatitis
PS carcinoma of head of pancreas
PS earlier
Painless jaundice
May develop pain as progresses
O/E carcinoma head of the pancreas (4)
Signs related to obstructive janducie
HSmegaly/ascites
Palpable abdo mass
Courvoisiers sign
Sx carcinoma of body/tail pancreas
PS later
Dull abdo pain R to back
Partially relieved by leaning forwards
Non-specific B Sx = common
What can either pancreatitc cancers PS with
Acute pancreaitis
DM
Trousseau’s syndrome
Thrombosis of superficial/deep leg vv related to pancreatic carcinoma
Ix pancreatic cancer - bloods (6)
FBC U_E LFT CA 19.9 or CEA Amylase (rarely elevated)
Imaging Ix pancreatic cancer (4)
USS - confirm obstruction + duct dilatation
CT
EUS +/- biopsy - location, spread of tumour + LN involv
Staging lapraoscopy
What type of cancers are the majority of pancreatic cancers
Ductal adenocarcinomas
% of pancreatic carcinomas by location
60% head
25% body
15% tail
What % of pancreatic tumours are islet cell tumours
<2%
What syndrome can islet cell tumours occur w/
MEN syndrome
Sx of insulinoma
Sx hypoglycaemic events
Gross weight gain
Are the majority of insulinomas malignant or benign
Benign
PS glucagonoma
Often asymp
Or 2’ DM
PS gastrinoma (4)
Zollinger-Ellison syndrome
w/ oesophagitis
GI ulcers
Diarrhoea
PS somatostatinoma
DM (insulin release inhib)
Achlorrhydria (gastrin release inhib)
Gall stones (CCK release inhib)
Sx VIPoma
Profound diarrhoea
What % of pancreatic tumours are resectable
15%
Name of surgery pancreatic tumours
WHipples procedure
Pancreatoduodenectomy
What post surgery improves pancreatic cancer survival
chemotherapy
Is palliative surgery used in panc cancer
No
no benefit
Palliative Mx pancr tumour
ERCP/stent
to help jaundice + anorexia
Med survival pancreatic cancer
<6m
5y survival pancreatic cancer without whipples procedure
<2%
5 y survival pancreatic cancer with Whipples procedure
10-15%
