Pancreas Flashcards
What % of all malignancy is carcinoma of the pancreas?
Typical prevalence for carcinoma of pancreas
> 60 and 60% male (oxford handbook say more female)
Risk factors for pancreatic carcinoma
Smoking
Alcohol
High adiposity - central obesity
Family Hx
Carcinogens
DM
Chronic pancreatitis
Possibly high fat/red meat/processed meat diet
What type of carcinoma is common?
Ductal adenocarcinoma
Metastasise early and present late
Location of pancreatic cancer normally
60% in head
25% in body
15% in tail
A few in ampulla of vater or pancreatic islet cells
Oncogene usually involved in pancreatic cancer
95% have KRAS2 activation
Features of pancreatic head cancer
Painless obstructive jaundice
Obstruction of pancreatic duct can lead to pancreatic damage causing abnormalities in glucose homeostasis and therefore diabetes
Features of body or tail of pancreas carcinoma
Abdominal/epigastric pain - radiates to back and relieved on leaning forward
Also non-specific symptoms such as anorexia, weight loss
Investigations in pancreatic cancer
Transabdominal ultrasound - less reliable for body or tail cancers because of overlying bowel gas
CEA and Ca 19-9 can be elevated
Contrast CT scan
ERCP - usually for palliative treatment but can be good for cytology if diagnosis is in question
Rarer features of pancreatic cancer
Thrombophlebitis migrans
Non-bacterial thrombotic endocarditis
Portal hypertension - splenic vein thrombosis
Signs of cancer of head of pancreas
Jaundice and pruritus
Gall bladder may be palpable - Courvoisier’s sign (palpable gall bladder, painless and jaundice = pancreatic malignancy)
Hepatomegaly - mets
Lymphadenopathy
Ascites - mets
Treatment for pancreatic cancer
Most present with metastatic disease and are not suitable for radical surgery
Can do pancreatoduodenectomy - Whipples - if no mets
Chemotherapy delays progression
Palliation of jaundice and obstruction
Pain - opiates or radiotherapy
Prognosis for pancreatic cancer
Poor
5 year survival = 3%, 5-14% with whipples
What is acute pancreatitis?
Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion - initiated by acute injury
Causes of acute pancreatitis?
GET SMASHED
Gall Stones
Ethanol
Trauma
Steroids
Mumps and other viruses
Autoimmune - PAN = polyarteritis nodosa
Scorpion venom
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP and emboli
Drugs Azathioprine Sulfonamides Sulindac Tetracycline Valproic acid, Didanosine Methyldopa Estrogens Furosemide 6-Mercaptopurine Pentamidine Corticosteroids Octreotide
Symptoms of acute pancreatitis?
Gradual/sudden severe epigastric or central abdominal pain
Radiates to back
Relieved by sitting forward
Vomiting
Signs of acute pancreatitis
May be mild
Tachycardia, fever, hypotension
Jaundice
Shock, ileus (decreased bowel sounds)
Rigid abdomen + tenderness
Periumbilical bruising = Cullen’s sign
Flank bruising = Grey Turner’s sign
Blood tests in acute pancreatitis
Serum amylase - 3x upper limit of normal if measured within 24 hours of onset of pain - back to normal after 3-5 days
Urinary amylase - remains elevated for longer
Serum lipase - elevated and for longer
CRP - assessing severity and prognosis
Imaging in acute pancreatitis
Erect chest xray - exclude gastroduodenal perforation (raises serum amylase)
Abdominal ultrasound - gall stone cause of pancreatitis
CT to assess degree of pancreatic necrosis
MRCP - degree of damage and gall stone identification
ERCP - gall stone removal
Assessment of severity of pancreatitis
PANCREAS
- PaO2 less than 8
- Age older than 55
- Neutrophils > 15 x 109/l
- Calcium less than 2mmol/L
- Renal Function Urea > 16mmol/L
- Enzymes LDH > 600iu/L AST >200iu/L
- Albumin less than 32g/l
- Sugar (glucose) >10mmol/L
3 or more positive factors detected within 48hours of onset suggests severe pancreatitis
- Prompt transfer to ITU/HDU
Managment of acute pancreatitis
NBM - NG tube to decrease pancreatic stimulation
IV fluids
Analgesia - tramadol or morphine
May need debridement of necrotic tissue
Antibiotics
DVT prophylaxis
Early complications of acute pancreatitis
Shock or sepsis ARDS Renal failure Hypocalcaemia Hyperglycaemia
Late complications of acute pancreatitis
Necrosis
Pseudocyst
Abscesses
Bleeding - elastase eroding a major vessel
Thrombosis in SMA - causing bowel necrosis
Recurrent pancreatitis
Pathology of chronic pancreatitis
Trypsin activation
Increased pancreatic enzyme activity (trypsin) leads to precipitation of proteins within duct lumen - form plugs
Obstruction, hypertension and further damage
Presentation of chronic pancreatitis
Epigastric pain - through to back, relieved by leaning forward
Hot water bottles chronically on sore areas (epigastrium and back) cause erythema ab igne’s
Bloating Steatorrhoea Weight loss Diabetes Symptoms relapse and worsen
Causes of chronic pancreatitis
Alcohol - 70% Familial (rare) CF Haemochromatosis Pancreatic duct obstruction high PTH Congenital Autoimmune
Investigations in chronic pancreatitis
Amylase and lipase may be elevated
Raised glucose
Ultrasound
CT - shows pancreatic calcification and dilated pancreatic duct
MRCP - more subtle disease diagnosis
Endoscopic ultrasound - doubt about diagnosis
DDX of chronic pancreatitis
Similar presentation to pancreatic cancer
Management of pain in chronic pancreatitis
NSAIDs and opiates for short-term flare up
TCA, pregabalin for chronic pain
Coeliac axis block
Many patients become pain free after 6-10 years
Can do surgery in unretractable pain
Other management of chronic pancreatitis
Fat-soluble vitamins
Lipase
Low fat diet
No alcohol
Treat diabetes
Complications in chronic pancreatitis
Pseudocysts
Diabetes
Biliary obstruction - ascites, gastric varices
Pancreatic carcinoma
What is Trousseau sign of malignancy?
Thrombophelbitis migrans - particularly associated with pancreatic and lung cancer
