Inflammation and Tumours of the Pancreas Flashcards
4 pancreatic hormones?
Glucagon
Insulin
Somatostatin
Pancreatic polypeptide
What is acute pancreatitis?
Acute inflammatory process of the pancreas, with variable innolvement of other regional tissues or remote organ systems
Two types of acute pancreatitis?
Mild acute pancreatitis - assoc. with minimal organ dysfunction; predominant feature is interstitial oedema of the gland
Severe acute pancreatitis - assoc. with organ failure and/or local complications, such as necrosis (with infection), pseudocysts and abscesses
3 main causes of pancreatitis?
Obstructive factors, e.g: biliary disease (gallstones), benign pancreatic duct stricture and tumours of the ampulla/pancreas
Toxic factors, e.g: alcohol and viral infections
Metabolic factors (hyperparathyroidism and hyperlipoproteinaemia)
Other causes of pancreatitis?
Genetic defects, e.g: CF
Trauma
Iatrogenic causes
Drug-induced acute pancreatitis
Inflammatory - IgG4-related autoimmune disease
Mnemonic for pancreatitis causes?
Iatrogenic
Gallstones
Ethanol
Trauma
Scorpions Mumps Autoimmune Steroids Hyperlipidaemia / hypercalcaemia / hyperparathyroidism (metabolic disorders) ERCP Drugs
Pathophysiology of acute pancreatitis?
Causative factors cause pancreatic acinar cell damage; trypsin and lipase become activated
Trypsin causes the activation of other enzymes, which mediate inflammation, vascular damage, haemorrhage and coagulation necrosis; lipase causes fat necrosis
Obstruction of pancreatic duct and inflammation of the parenchyma causes hypoperfusion (necrosis and infection) and pseudocysts
Why do psudocysts form as a result of inflammation of the parenchyma?
Peri-pancreatic exudation or pancreatic ductal leakage causes cysts
Blood tests for acute pancreatitis?
FBC, U&Es, LFTs, CRP
Amylase (most important measure)
Clotting, glucose and Ca
Imaging for acute pancreatitis?
CXR/AXR
AUS - rule out biliary pancreatitis; check for gallstones, cholecystitis, CBD diameter and free fluid
CT pancreas
MRI
ERCP is not a diagnostic tool but is form of treatment for CBD stones with obstructions
What will be found on CXR/AXR with acute pancreatitis?
Pleural effusion
Sentinel loop (distended bowel loop specifically due to pancreatitis)
Complications of pancreatitis?
Fluid collections
Pancreatic/peri-pancreatic necrosis
Ascites
Bleeding
Abscess
Glasgow prognostic score (1 point for each)?
Age >55 years
PaO2 15x10(9) / L
Serum calcium 16 mmol/l
LDH >600 iu/l or AST/ALT >200 iu/l
Albumin 10 mmol/l
Any 3 factors indicated acute severe pancreatitis
Grade of pancreatitis?
Grade A - normal gland (0 points)
Grade B - focal or diffuse oedema (1 points)
Grade C - peri-pancreatic inflammation (2 points)
Grade D - single fluid collection (3 points)
Grade E - 2 or more colelctions and/or gas in/adjacent to the pancreas (4 points)
This is added to scores for necrosis:
No necrosis = 0
30% or less =
Symptoms of acute pancreatitis?
Epigastric/diffuse abdominal pain +/- radiation to the back (retroperitoneal)
Nausea and vomiting
Indigestion
Abdominal tenderness
Loss of appetite +/- weight loss
Temperature
Jaundice (pain) if there is an obstructive cause
Local complications of acute pancreatitis?
Fluid collection Pseudocysts and abscess Necrosis +/- infection Ascites Pleural effusion
Systemic complications of acute pancreatitis?
Pulmonary failure Renal failure Shock Sepsis Metabolic acidosis Hyperglycaemia Hypocalcaemia MODs (maturity-onset diabetes)
Prognosis of acute pancreatitis?
Prognosis worsens as you move down the list:
Mild pancreatitis
Severe pancreatitis:
Sterile necrosis
Infected necrosis
Severe necrotising pancreatitis (signs of necrosis)
What is a pseudocyst?
Cystic lesion that may appear as a cyst on scans but lacks epithelial/endothelial cells; can cause biliary obstruction and gastric outlet obstruction
Symptoms of pseudocyst?
Pain
Nausea and vomiting
Jaundice
Weight loss
Treatment of pseudocysts?
Endoscopic drainage
Surgical drainage, depends on location of pseudocyst:
Cystgastrostomy
Cystjejunostomy
Treatment of pancreatic abscesses?
CT scan/ultrasound retroperitoneal drainage; sepsis is controlled and
Treatment of necrosis?
CT for assessment and determination of whether it is sterile or infected
Interventional drainage
Necrosectomy and lavage
What is chronic pancreatitis?
Progressive and irreversible destruction of pancreatic tissue; results in permanent loss of endocrine and exocrine function
Main causes of chronic pancreatitis?
Alcohol abuse
Idiopathic
Pancreatic duct obstruction:
Acquired - stone, stricture, tumour or pseudocyst
Congenital - pancreas divisum
Tropical causes
Autoimmune pancreatitis - increased IgG4 sub-class levels; treatment with steroids
Hereditary chronic pancreatitis
Miscellaneous - hypercalcaemia in hyperparathyroidism and renal failure
Blood tests for chronic pancreatitis?
FBC, U&ES, LFTs
Clotting and CRP
Glucose and Ca
Amylase
IgG4
Pancreatic function tests
AXR and CT scan findings on chronic pancreatitis?
Extensive pacreatic calcification
Pancreatic duct dilatation
Intra-pancreatic fluid collection
Treatments for chronic pancreatitis?
Pustow procedure:
- Dilated pancreatic duct is “filleted open”
- Jejunum divided
- Opened pancreatic duct is anastamosed to the jejunum (pancreaticojejunostomy)
- Jejuno-jejunostomy restores continuity of the GI tract
Frey procedure
Beger procedure - duodenum preserving pancreatic
Head resection with reconstruction
Complications of chronic pancreatitis?
Splenic vein thrombosis
Pseudoaneuryms
Pancreatic cancer
Pseudocyst
Bile duct (oedema due to acute flare-up, calcification or fibrosis and pancreatic head tumour) or duodenal obstruction
Pancreatic ascites
Pleural effusion
Treatment of bile duct or duodenal obstruction, due to chronic pancreatitis?
Stent, bypass and resection
Treatment of pseudocysts?
Endoscopic drainage
Surgical drainage
Resection
Types of pancreatic cancers?
Exocrine pancreatic cancers:
Adenocarcinoma are the majority
Endocrine pancreatic cancer:
Gastrinoma - produces gastrin causing increased stomach acid, leading to gastric/duodenal ulcers
Insulinoma - produces insulin and causes hypoglycemia
Glucagonoma - produces glucagon which causes hyperglycemia
Somatostatinoma
Vipoma
How is pancreatic cancer related to age?
Incidence increases with age
Symptoms of pancreatic cancer?
Jaundice - dark urine and light stools
Back pain and abdominal pain
Weight loss along with anorexia, nausea and vomiting
Risk factors for pancreatic cancer?
Smoking
Charred meat
Obesity and physical inactivity
Diabetes type I and II
Staging pancreatic cancer?
TNM staging
Treatment of pancreatic cancer?
Chemotherapy
Radiotherapy
Combinations
Can be curative or palliative
What types of surgery are done for pancreatic cancer?
For resectable tumours: Whipple resection Total Pancreatectomy Distal Pancreatectomy Midsegment Pancreatectomy
For non-resectable tumours:
Biliary bypass
Gastric bypass
Double bypass
