Pancreas Flashcards
What is acute pancreatitis?
Refers to sudden inflammation of the pancreas.
Pathophysiology of acute pancreatitis?
Inflammation of the pancreas triggers the activation of digestive enzymes within the pancreas itself.
These enzymes auto-digest the pancreatic tissue, setting off a cycle of inflammation and damage.
Leads to a pro-inflammatory systemic response akin to Systemic Inflammatory Response Syndrome (SIRS)
Causes of acute pancreatitis?
GET SMASHED
Gallstones (most common)
Ethanol (most common)
Trauma
Steroids
Mumps
Autoimmune disease (e.g., Polyarteritis Nodosa/SLE)
Scorpion bite
Hypercalcaemia, hypertriglycerideaemia, hypothermia
ERCP
Drugs (detailed below)
FATSHEEP (to remember drugs)
Furosemide
Azathioprine/Asparaginase
Thiazides/Tetracycline
Statins/Sulfonamides/Sodium Valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors and NRTIs
Presentation of acute pancreatitis?
- stabbing-like, epigastric pain
- pain radiates to the back
- pain is relieved by sitting forward or adopting a foetal position
- vomiting
PMHx:
- gallstones
- alcohol consumption
- hypovolaemia (tachycardia, dry mucous membranes)
- fever
- guarding
- positive Grey-Turner’s sign (haemorrhagic pancreatitis; bruising along the flanks)
- positive Cullen’s sign (bruising around the peri-umbilical area)
How is acute pancreatitis diagnosed?
Clinical history
Elevated lipase (3 times time the upper limit of normal)
US
What investigations would you do for acute pancreatitis
Key diagnostic IVx:
- FBC (raised WCC -necrotizing pancreatitis)
- U&Es
- LFTs
- lipase and amylase (lipase is more sensitive and specific)
- US abdomen (detect gallstones)
- MRCP (Magnetic Resonance Cholangiopancreatograph; detects obstructive pancreatitis)
- ERCP (Endoscopic Retrograde Cholangiopancreatography)
- CT pancreas scan (identify complications e.g. pseudocysts or necrotizing pancreatitis)
What is the modified Glasgow criteria? What factors are considered?
Predicts the severity of pancreatitis.
Usually done at admission and after 48 hours of admission (true score).
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
≥3 – severe pancreatitis
PANCREAS
PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L
Management of acute pancreatitis?
A-E assessment (pt can become very unwell very quickly)
Supportive care:
- IV fluids
- Analgesia
- Anti-emetics
- Nutritional support
- Abx if infection is evident (e.g. infection of necrotising pancreatitis)
- Insulin (hyperglycaemia due to impaired pancreatic hormone release)
Close monitoring of observations/blood results.
Prognosis of acute pancreatitis?
Potentially life-threatening with high mortality, so recognition and prompt management is vital.
Mild cases have a favourable outlook with proper care, including fluid resuscitation, pain management, and nutrition support.
Severe acute pancreatitis carries a guarded prognosis due to potential complications like pancreatic necrosis, abscesses, or multi-organ failure. Higher risk of mortality.
What is chronic pancreatitis?
Refers to long-term condition characterised by progressive inflammation and fibrosis of the pancreas.
Leads to irreversible destruction of the exocrine and endocrine functions of the pancreas.
Causes of chronic pancreatitis?
Excess alcohol (common)
Genetic factors (e.g. cystic fibrosis)
Hyperparathyroidism
Elevated triacylglycerides
Obstruction of the pancreatic duct (stones or pancreatic cancer)
Pathophysiology of chronic pancreatitis?
Progressive inflammation and the development of fibrotic tissue in the pancreas leads to loss of exocrine function (lipase, amylase) and endocrine function (insulin).
Leads to malabsorption and impaired blood glucose control.
Presentation of chronic pancreatitis?
- epigastric pain, tenderness
- exacerbated after eating fatty food
- relieved by sitting forward (15-30 mins after eating)
- bloating
- wt loss
- malabsorption
- steatorrhoea (fat in stool)
- vitamin deficiencies
- diabetes mellitus, polyuria, thirst (due to endocrine dysfunction)
- signs of chronic liver disease (e.g. jaundice, itchy skin, libido, spider naevi, clubbing, oedema, nausea, gynecomastia, confusion, wt loss)
Investigations for chronic pancreatitis?
Blood glucose
Faecal elastate (low = exocrine insufficiency)
Serum amylase and lipase (not typically raised in chronic pancreatitis, but raised in acute pancreatitis)
Abdominal x-ray (detects calcifications)
CT scan (shows pancreatic calcification)
When would you suspect chronic pancreatitis?
Recurrent or persistent upper or generalised abdominal pain with RFs e.g. alcohol misuse.
Management of chronic pancreatitis?
Conservative:
Stop alcohol
Maintain healthy and balanced diet
Medical:
Analgesia
Insulin (for endocrine dysfunction)
Pancreatic enzyme replacement therapy e.g. Creon (brand name; contains mixtures of amylase, lipase, and protease)
Surgical (if above tx fails):
- coeliac plexus block
- pancreatectomy
Complications of chronic pancreatitis?
Pseudocyst
Pancreatic cancer
Diabetes mellitus (due to endocrine dysfunction)
Malabsorption (due to exocrine dysfunction)
Steatorrhoea (due to exocrine dysfunction)
What is pancreatic cancer?
Refers to a malignant neoplasm originating from the pancreatic tissue.
Most common type: pancreatic adenocarcinoma (originates from the head of the pancreas).
Causes of pancreatic cancer?
Older age
Smoking
Obesity
Diabetes
Chronic pancreatitis
FHx
Genetic syndromes (BRCA2, Lynch syndrome, familial atypical mole, melanoma (FAMMM) syndrome)
Presentation of pancreatic cancer?
Early stage pancreatic cancer:
Malaise
Abdominal pain
Nausea
Weight loss
Painless jaundice
Courvoisier’s sign (painless jaundice with a palpable gallbladder -indicates pancreatic or gallbladder malignancy)
Advanced disease can present with complications:
- obstructive jaundice (due to blockage of the common bile duct by a tumour in the pancreatic head)
- diabetes mellitus
- pancreatic infiltration
- paraneoplastic syndromes (Trousseau’s syndrome, marantic endocarditis)
- disseminated intravascular coagulation (DIC)
- can metastasise early to the lung, liver, and bowel.
Investigations for pancreatic cancer?
Abdominal US (detect tumours >2cm, liver metastases, dilation of the common bile duct)
CT abdomen/pelvis (for high clinical suspicion, predicts surgical resectability and disease staging)
Magnetic resonance cholangiopancreatography (MRCP; details about biliary ducts)
Endoscopy US (detect small lesions 2-3mm, biopsy)
PET-FDG and MRI as adjuncts.
Management of suspected pancreatic cancer?
Refer using suspected cancer pathway referral 2ww if:
Pancreatic cancer + age ≥40 + jaundice
Urgent CT scan or US performed within 2 weeks if:
Pancreatic cancer + age ≥60 + wt loss + any of the following (diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes)
Treatment for pancreatic cancer?
Criteria for resection include:
- No evidence of superior mesenteric artery (SMA) or coeliac arteries involvement.
- No evidence of distant metastases
Surgical procedure of for tumours in the head of the pancreas:
Kausch-Whipple procedure (radical pancreaticoduodenectomy)
Chemotherapy (for post-surgery if pt has recovered well)
Palliative therapy (if locally advanced or metastatic disease):
- Endoscopic stent insertion into the common bile duct.
- Palliative surgery if endoscopic stent insertion fails.
- Chemotherapy.
- Radiotherapy (only for localised advanced disease).
Crucial to refer pts to palliative care services for pain management and psychological support.
