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Surgery > Pancreas > Flashcards

Pancreas Flashcards

1
Q

Diagnosis acute pancreatitis? (6)

A

Revised Atlanta classification and definitions: 2 of 3
• abdominal pain - persistent, severe epigastric pain which radiates to back
• serum lipase (preferred- more specific)/amylase activity of at least 3x greater than the upper limit of normal
• characteristic finings acute pancreatitis on CECT or MRI or trans abdominal US

• CT if:
- abdominal pain strongly suggest acute pancreatitis but amylase/lipase not high enough (may be the case in late presentation) to confirm diagnosis
-Local or late complications
- not responding to treatment so exclude other cause acute abdomen

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2
Q

Cause of mortality in acute pancreatitis? (2)

A

• Early phase: mods secondary to inflammatory cascade triggered by pancreatic parenchyma inflammation
• late phase > 2 weeks: secondary to septic complications ( infected necrosis)

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3
Q

Etiology acute pancreatitis? (12)

A

I get smashed
Idiopathic (3rd most common 15-25%)
Gallstones (most common 38%)
Ethanol (2nd most common 36%)
Trauma
Steroids
Mumps and other infections (CMV, mycoplasma, vzv)
Autoimmune: SLE, Sjogren’s syndrome (dry eyes dry mouth)
Scorpion toxin and other toxins
Hypercalcaemia, hypertriglycieridemia (metabolic causes)
Ercp (2-5%) -post ercp (endoscopic retrograde cholangiopancreatography)
Drugs (1-2 %): steroids, NSAIDs, diuretics, arvs esp stavudine
Rare causes: neoplasm (pancreatic or ampullary tumour), congenital (pancreatic divisum), genetics.

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4
Q

Treatment pancreatic pseudocyst as complication of acute pancreatitis?

A

Only treat if symptomatic- endoscopic cyst gastrostomy

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5
Q

Name 3 early local complications of severe acute pancreatitis

A

< 4 weeks after acute pancreatitis

• Acute peri-pancreatic fluid collection
• acute necrotic collection
• infected pancreatic necrosis (leading cause mortality)

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6
Q

Name 2 late local complications of severe acute pancreatitis

A

> 4 weeks after acute pancreatitis

• Pancreatic pseudocyst
• Walled-off necrosis

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7
Q

Treatment infected necrosis as complication of acute pancreatitis? (7)

A

• Empiric antibiotics known to penetrate pancreatic necrosis: carbapenems or quinolones (ciprofloxacin) and metronidazole
•step up approach necessary for lower complications:
1. Percutaneous radiologic guided drainage catheter
2. Catheter irrigated and upsized as needed
3. If no improvement in 72 hours- minimally invasive retroperitoneal approach video assisted retroperitoneal debridement VARD
4 endoscopic
5. Laparoscopic necrosectomy
6. Open surgical necrosectomy last resort

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8
Q

Treatment sterile necrosis as complication of acute pancreatitis? (4)

A

• Discontinue antibiotics and continue conservative treatment for 4-6 weeks

Only radiological/endoscopic/surgical if:
• ongoing gastric outlet, intestinal or biliary obstruction due to mass effect 4-8 weeks after onset acute pancreatitis
• persistent symptoms (eg abdominal pain, nausea, vomiting, anorexia) >8 weeks after onset
• disconnected duct syndrome (full transection pancreatic duct) with persisting symptomatic collections with necrosis (eg pain, obstruction ) >8 weeks after onset

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9
Q

Define chronic pancreatitis (4)

A

Irreversible, progressive disease with recurrent inflammatory episodes resulting in replacement of pancreatic parenchyma by fibrous connective tissue and ducal metaplasia.
This leads to progressive exocrine ( diarrhoea, steatorrhea) and endocrine (diabetes mellitus) pancreatic insufficiency

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10
Q

Imaging and features for Diagnosis chronic pancreatitis? (3)

A

• Early: endoscopic ultrasound - specific parenchymal and ductal features scored with rosemont criteria
. Calcifications = pathognomonic
• strictures main pancreatic duct : chain of lakes

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11
Q

Pathophysiology acute pancreatitis?

A

Unregulated activation trypsin within pancreatic acinar cells, activating pro-enzymes leading to auto digestion and inflammatory response. Can → sirs

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12
Q

How do gallstones cause acute pancreatitis? (2)

A

2 theories:
• obstructive theory - increased pressure pancreatic duct due to continuous secretion pancreatic juice in presence of pancreatic duct obstruction
. Reflux theory: stones impacted in ampulla of vater. Common channel forms that allows reflux bile salts into pancreas. Bile salts cause direct acinar cell destruction and necrosis.

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13
Q

How does alcohol cause pancreatitis? (4)

A

Triggers pro-inflammatory pathway pancreas
• increased expression and activity caspases (proteases that mediate apoptosis)
• decreased perfusion of pancreas
• sphincter of oddi spasm
• obstructs pancreatic ducts by precipitation of protein inside ducts

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14
Q

Symptoms acute pancreatitis? (5)

A

• Cardinal= epigastric and or peri-umbilical pain that radiates to back
• associated nausea and vomiting that doesn’t relieve pain
• dehydration, poor skin turgor, tachycardia, hypotension, dry mucous membranes common

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15
Q

Clinical presentation acute pancreatitis? (6)

A

• Mild pancreatitis: mild epigastric tender (but can have severe pancreatitis with mild findings)
. Severe pancreatitis: typically significant distention with generalised rebound tender and abdominal rigidity
• rarely: Grey turner sign (flank ecchymosis) and Cullen sign (peri-umbilical ecchymosis) - retroperitoneal bleeding associated with severe pancreatitis
• May have jaundice: concomitant choledocholithiasis or significant Edema of head of pancreas.
• May have dullness to percussion and decreased air entry in L (less commonly R) hemithorax. Pleural effusion secondary to acute pancreatitis.

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16
Q

Which sign is demonstrated by flank ecchymosis and may indicate severe acute necrotising pancreatitis?

A

Grey turner sign

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17
Q

Which sign is demonstrated by peri-umbilical ecchymosis and may indicate haemorrhagic pancreatitis?

A

Cullen sign

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18
Q

Name the 2 types acute pancreatitis

A

• Interstitial edematous pancreatitis: most patients. Diffuse enlargement secondary to inflammation and oedema. Clinical symptoms usually resolve within first week.

• necrotising pancreatitis:5-10% develop necrosis of pancreatic parenchyma or peri-pancreatic tissue or both. Variable history - may be solid or liquefy, sterile or infected, persist or disappear.

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19
Q

Severity Classification and differences Acute pancreatitis? (3)

A

1 mild acute pancreatitis
• absence organ failure, local/systemic complications
• can usually be discharged in early phase, low mortality
• don’t need imaging

  1. Moderately severe acute pancreatitis
    • transient organ failure <48 hours
    . Local or systemic complications without persistent organ failure
    • May resolve without intervention or may need prolonged specialist care, mortality far less than severe
  2. Severe acute pancreatitis
    • persistent organ failure > 48 hours single or multiple, organ failure that develops during early phase due to sirs. If sirs present, increased risk of persistent organ failure so treat as severe,
    • also local complications
    • mortality 36 -50%, if infected necrosis mortality very high
20
Q

Criteria for sirs? (4)

A

2 or more:
• hr > 90
• temp <36 or >38,3
• wcc <4000 or > 12 ooo
. Rr > 20 or pco2 <32

21
Q

Name 4 risk factors for severe pancreatitis

A

• Age >60
• comorbid illness
• history chronic alcohol consumption
• obesity

22
Q

CT features of acute peri-pancreatic fluid collection?

A

• no well-defined wall
• homogenous
• confined by normal fascial planes in retroperitoneum, may be multiple

23
Q

Treatment acute peri-pancreatic fluid collection?

A

Most remain sterile and resolve spontaneously. Doesn’t need treatment if it resolves in 4 weeks or is asymptomatic

24
Q

Complication acute peri-pancreatic fluid collection?

A

It persist more than 4 weeks, will likely develop into pancreatic pseudocyst

25
Q

Diagnosis infected pancreatic necrosis? (2)

A

• Extraluminal gas bubbles in pancreatic or peri-pancreatic tissue on CT!
• percutaneous image guided FNA is positive for bacteria/fungi on MCS

Early complication of acute pancreatitis <4 weeks

26
Q

Name 3 other local. complications acute pancreatitis of colon and blood supply

A

• Gastric outlet obstruction
• splenic/portal vein thrombosis
• colonic necrosis

27
Q

Name systemic complications acute pancreatitis

A

Exacerbation of pre-existing comorbidity eg COPD, cad, ccf precipitated by acute pancreatitis (not new onset organ failure)

28
Q

Which score is used to classify organ dysfunction for severity of acute pancreatitis? Describe. (3)

A

Modified Marshall score.
• Respiratory pa02 if ventilated:0 (>400) → 4 (≤101).
• renal creatinine: 0 (≤134 )→4 (>439)
• cardiovascular SBP: 0 (>90),1 (<90, fluid responsive), 3 (<90, ph < 7,3) →4 (<90, ph < 7,2)

Score 2 or more in any system = organ failure

29
Q

Imaging in acute pancreatitis? (3)

A

• CT: early stage confirm diagnosis when its unclear ; after a week to evaluate for local complications (sterile or infected necrosis, )
• MRI: distinguish pseudocyst from walled off necrosis.
Mrcp useful to identify retained CBD stones, can reduce use of ercp for diagnosis (less complications)
• endoscopic ultrasound: sensitive in detecting cholelithiasis and choledocholithiasis; useful for image guided FNA or interventions like cystgastrostomy and endoscopic necrosectomy; contrast enhanced can accurately differentiate pseudocyst or walled off necrosis from cystic neoplasm of the pancreas.

30
Q

Initial management acute pancreatitis? (4)

A

• Analgesia: PCA pump with opioids
• aggressive fluid resuscitation otherwise risk pancreatic necrosis and mortality (over-resuscitation → pulmonary oedema)
- ringers bolus 20 ml /kg
-continuous infusion 3 ml/kg/hour
-Reassess end points of resuscitation every 6-8 hours. (Base deficit aim < 4; cardiac output; urine output not accurate due to associated underlying renal or organ dysfunction )
• early enteral feeding or TPN within 24-48 hours to decrease risk infection. Patient will continue eating when symptoms resolve, usually few days after presentation
• only give antibiotics if confirmed sepsis! - gas seen in pancreatic necrosis on CT, FNA positive, clinical deterioration (spiking temp)

31
Q

Name 6 indications for ICU admission in acute pancreatitis

A

• Respiratory failure
• hypotension not responding to fluids
• mods
• persistent sirs
• increased urea, creatinine or haematocrit
• underlying cardiac or pulmonary illness

32
Q

Which microbials are responsible for infected necrosis as a complication of acute pancreatitis?

A

Gut derived: E. coli, pseudomonas, klebsiella, enterococcus

33
Q

Etiology chronic pancreatitis? (6)

A

Tigar-o
• Toxic metabolic: alcohol and tobacco 80-90%
• idiopathic (do genetic testing in all these patients), tropical India South America
• genetics: early onset <20. Cationic trypsinogen gene (prss1), cystic fibrosis transmembrane conductance regulator (cftr), serine protease inhibitor Kazal I gene (spinki) mutation
• autoimmune
• recurrent and severe acute pancreatitis
• obstructive (pancreatic divisum, sphincter of oddi dysfunctions)

34
Q

Name 7 local complications chronic pancreatitis?

A

• Inflammatory ductal changes and intraductal calculus (pancreatolithiasis) → multiple ductal stones and dilatations
• inflammatory mass head of pancreas
• duodenal obstruction (inflammatory mass) → gastric outlet obstruction
• thrombosis splenic, SMV, portal veins → portal HT
• Pancreatic pseudocyst
• Vascular erosion (rare) → obscure gi bleed ( haemosuccus pancreaticus)
• 4 times higher risk pancreas cancer

35
Q

Radiological investigations chronic pancreatitis? (4)

A

• Ercp gold standard: calcifications pathognomonic, often accompanied by strictures in main pancreatic duct: “chain of lakes” - 3-7 % Risk of causing acute pancreatitis
• endoscopic ultrasound: early chronic pancreatitis using rosemont criteria (better than MRI and ct)
• AXR: incidental calcifications in region pancreas.
• Pancreatic protocol CT scan (triphasic ctap CT during arterial portography with oral contrast immediately prior to ct): better visualisation parenchyma calcifications and to plan surgery

36
Q

Laboratory investigations chronic pancreatitis? (9)

A

• Pancreatic secretin stimulation test: gold standard but invasive. Give iv secretin and aspirate pancreatic secretions into duodenum with suction, analyse over 2 hours
• Pancreatic endocrine function: glucose tolerance test, Hba1c
• 72 hour fecal collection to estimate daily fecal fat (steatorhea)
• fecal elastase will be low due to exocrine insufficiency steatorrhoea (<200 micrograms/gram)
• UCE: dehydration and renal function for CT
•Fbc: chronic anaemia, iron deficiency
• LFT: nutrition (albumin), GGT alp for distal CBD strictures
• INR: clotting abnormal, vit K deficiency
• CMP (comprehensive metabolic panel): vit D deficiency

Serum amylase and lipase not useful in chronic, pancreas “burned out”

37
Q

Symptoms chronic pancreatitis? (4)

A

• Pain 90%: intermittent epigastric, radiate to back, worse after meals, relieved by sit upright or lean forward. Assessed using visual analogue scale
• 20% exocrine or endocrine insufficiency but no pain
• change bowel habits (diarrhea) followed by steatorrhea (exocrine insufficiency)
• newly diagnosed diabetes 30% (endocrine) - late symptom
• weight loss: anorexia and malabsorption

38
Q

Clinical findings chronic hepatitis? (6)

A

• Loss weight: anorexia and malabsorption
. Epigastric tender
• epigastric mass: pseudocyst or head of pancreas inflammatory mass
• obstructive jaundice: CBD stricture or head pancreas mass
• splenomegaly: thrombosis of splenic vein
• pancreatic ascites: pancreatic peritoneal fistula

39
Q

Management chronic pancreatitis? (6)

A

• Reduce risk factors, stop smoking and alcohol
• exocrine insufficiency: pancreatic enzyme replacement therapy (pencrealipase creon )and nutritional supplements
• endocrine (diabetes): insulin usually needed
• pain therapy according to WHO pain ladder
• corticosteroids for autoimmune cp

• endoscopy or surgery only if complications

40
Q

Name 2 endoscopic therapeutic drainage interventions for chronic pancreatitis

A

• Internal drainage: endoscopic cyst gastrostomy|cystduodenostomy. Problem with recurrence and catheter dislocation.
• endoscopic ductal drainage: stenting, stone extraction or lithotripsy
If endoscopic drainage not possible, do percutaneous: temporary treatment for abscess, infected pseudocyst followed by definitive surgery

41
Q

Surgical aims and indications in chronic pancreatitis (4)

A

To decompress pancreatic parenchyma compartments, main pancreatic duct and address complications eg CBD strictures, gastric outlet obstructions. Indications:
• failed pain Management
• extra-pancreatic complications including obstructive jaundice, gastric outlet obstruction
• suspicion of malignancy

42
Q

Name 5 surgical techniques for chronic pancreatitis drainage, resection or pain relief

A

• Drainage procedures: cystojejunostomy, lateral pancreaticojejunostomy
• duct drainage and resection: Frey procedure (roux-en-y drainage of head pancreas with pancreaticojejunostomy ), Bern procedure
. Resection: Whipple procedure, beger procedure
• coeliac plexus Nerve block: inject sclerosing agent, but pain may come back worse.
• total pancreatectomy in some cases - last resort (also remove gallbladder, CBD, portions small intestine and stomach, spleen)

43
Q

Name 10 risk factors pancreatic cancer

A

Host
. Family history: including chronic pancreatitis, BRCA 2, etc
• elderly
• male
• black
• non-0 blood group

Lifestyle
A smoking!
• obesity
• diet: high fat, high meat, low veg and folate
Alcohol

Occupational: chlorinated hydrocarbon solvents, nickel

Medical surgical conditions
• diabetes
• H pylori
A periodontal disease
Liver cirrhosis (alcohol)

44
Q

Head pancreas tumour symptoms and presentation? (7)

A

• Obstructive jaundice!: palpable gallbladder (Courvoisier’s sign! - nontended unlike gallstones), may have cholangitis
. Gastric outlet obstruction: nausea vomiting
• weight loss
• pancreatic duct obstruction → maldigestion, recurrent pancreatitis
• diabetes
• UGI bleed
• panniculitis (inflam subcutaneous fat), depression
Midepigastric pain radiate to mid or lower back, worse when lying flat
Troussaeu sign of malignancy: blood clots felt as small lumps under skin!
Steattorhea

45
Q

Prognostic marker for pancreatic cancer?

A

CA 19-9

46
Q

Pancreatic cancer tumour staging?

A

1) less than 2 cm
2) more than 2 cm
3) grow into neighbouring tissue
4) metastatic through blood and lymph

Surgery (40 decks)

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