Inflammation and Tumours of the Pancreas Flashcards by Aliya Hussain

4 pancreatic hormones?

Glucagon
Insulin
Somatostatin
Pancreatic polypeptide

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What is acute pancreatitis?

Acute inflammatory process of the pancreas, with variable innolvement of other regional tissues or remote organ systems

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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

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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)

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Other causes of pancreatitis?

Genetic defects, e.g: CF

Trauma

Iatrogenic causes

Drug-induced acute pancreatitis

Inflammatory - IgG4-related autoimmune disease

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Mnemonic for pancreatitis causes?

Iatrogenic

Gallstones
Ethanol
Trauma

Scorpions
Mumps
Autoimmune
Steroids
Hyperlipidaemia / hypercalcaemia / hyperparathyroidism (metabolic disorders)
ERCP
Drugs

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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

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Why do psudocysts form as a result of inflammation of the parenchyma?

Peri-pancreatic exudation or pancreatic ductal leakage causes cysts

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Blood tests for acute pancreatitis?

FBC, U&Es, LFTs, CRP

Amylase (most important measure)

Clotting, glucose and Ca

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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

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What will be found on CXR/AXR with acute pancreatitis?

Pleural effusion

Sentinel loop (distended bowel loop specifically due to pancreatitis)

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Complications of pancreatitis?

Fluid collections

Pancreatic/peri-pancreatic necrosis

Ascites

Bleeding

Abscess

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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

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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 =

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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

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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: 1. Dilated pancreatic duct is "filleted open" 2. Jejunum divided 3. Opened pancreatic duct is anastamosed to the jejunum (pancreaticojejunostomy) 4. 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