Pancreas Flashcards
Exocrine system of pancreas - which cells?
Acinar cells secrete pancreatic enzymes
Endocrine system - which cells?
Islets of Langerhans secrete hormones into the blood
Islets of Langerhans
> B cells (insulin)
Alpha cells (glucagon)
Delta cells (somatostatin)
F cells (secrete pancreatic polypeptides)
B cell secrete?
Insulin
70% of Islet cells
Alpha cells secrete?
Glucagon
20% of islet cells
Delta cells secrete?
Somatostatins
Inhibit release of GI hormones
5% of islet cells
F cells secrete?
Pancreatic Polypeptides
1% of islet cells
How are pancreatic fluid secretions regulated?
By vagus nerve and gastrin levels
Acinar cells secrete?
> Protease (trypsin and chymotrypsin)
Pancreatic lipase
Pancreatic amylase
Epithelial cells lining the ducts secrete?
> Bicarbonate
> Water
Pancreatitis
An acute inflammatory process in the pancreas - involves regional tissues and remote organs
Causes of pancreatitis?
I GET SMASHED
Idiopathic Gallstones*** Ethanol (alcohol)*** Trauma Steroids Mumps Autoimmune Scorpion sting Hypercalcaemia, hyperthyroidism, hyperlipidaemia ERCP Drugs (azathioprine)
Most common causes of pancreatitis?
Gallstones and ethanol
Pathophysiology
• bile reflux theory
> obstruction of CBD/PD
> Causes reflux of bile into pancreas
> Hyperstimulation of pancreatic acinar cells
> Damage to acinar cells will release activated trypsin —> necrosis, vascular damage, auto digestion of pancreatic tissue
4 main stages
- oedema and fluid shifts –>
- Autodigestion of blood vessels (retroperitoneal haemorrhage) –>
- Infarction due to blood supply (necrosis) –>
4 Infection (abscesses)
Presentation of pancreatitis
Clinical//
- acute onset epigastric pain radiating to the back
- double over
- nausea and vomiting
- jaundice (sometimes)
- identify the trigger - GET SMASHED
Examination//
> diffuse upper abdo tenderness > soft > normal bowel sounds > fullness in epigastrium? - pseudocyst > Can present like peritonitis with guarding and absent BS if severe
> Cullen’s sign (umbilicus)
Grey turner’s sign (flank)
Erythema ab igne
Investigations - pancreatitis
> IV access
Bloods - FBC, coat
U/E, LFT, Ca, glucose, CRP, lactate, amylase/lipase
> ABGs - hypoxia and ARDs > Plain imaging > USS > CT scan > ERCP
How elevated would amylase be in pancreatitis?
3 x ULN
ULN of amylase is 100.
What investigation should be used on ALL patients with suspected pancreatitis?
Ultrasound Scan
What is the CT scan used for?
As a follow up investigation
Looking for complications.
Prognostic scoring system for pancreatitis?
> Glasgow Criteria
Score higher than 3 is severe pancreatitis
pao2< 8kpa age >55 neutrophils (abc > 15) calcium < 2 renal function enzymes albumin sugar (glucose > 10mmol/L)
> Ranson’s criteria
– looks at markers on admission and 48 hours later
When should you re-score a patient (Glasgow criteria)?
24 hours later
Complications of pancreatitis?
Local//
- fluid collection
- pseudocysts
- abscess
- necrosis
- infection
- ascites
- pleural effusion
Systemic//
- pulmonary failure
- renal failure
- shcok
- sepsis
- metabolic acidosis
- hyperglycaemia
- hypocalcaemia
- MODS
Management
> Fluid resus, correct electrolytes, careful fluid balance, oxygen, sometimes abx, sometimes nutrition
> Lap chole if due to gallstones
Pseudocyst
> Complication of acute and chronic pancreatitis
Due ti pancreatic duct communication
Can cause biliary obstruction, gastric outlet obstruction
Pseuodcyst - presentation
Pain, nausea, vomiting, (jaundice) and weight loss
Pseudocysts - Treatment
nothin
endoscopic drainage
radiological drainage
surgical drainage
Abscesses
Drainage to control sepsis
CT/US sided retroperitoneal or transperitoneal drainage
Haemorrhage
Some pseudocysts can erode into nearby vessels
Pancreatic necrosis
- what investigation would you use?
CT for assessment sterile or infected? Fine needle aspiration for microbio Percutaneous drain Necrosectomy
Chronic pancreatitis
Progressive and irreversible damage
Loss of exocrine and endocrine function
Chronic pancreatitis - presentation
> Can present similarly to acute pancreatitis
Alcohol history, smokers, medications
> Masses, ascites, jaundice O/E
Chronic pancreatitis - imaging
CXR/AXR, USS, CT pancreas, MRI, ERCP
Chronic pancreatitis - causes
Main cause is alcohol
Idiopathic
Pancreatic duct obstruction (congenital or acquired)
Autoimmune
Tropical countries
Hereditary (CF, A1AT)
AXR and CT - calcifications and stones in pancreas
Management of chronic pancreatitis
CREON enzyme therapy
Surgical options
Complications//
Splenic vein thrombosis Pseudoaneurysm Splenic artery Pleural effusions Ascites Pancreatic cancer Pseudocysts Biliary obstruction Duodenal obstruction
Exocrine tumours
Adenocarcinoma (95% of pancreatic tumours)
Gastrinoma
Endocrine tumour
Produces gastrin
Increases stomach acid
Insulinoma
Endocrine tumour
Produces insulin
Encourages sugar uptake and storage
Hypoglycaemia
Glucagonoma
Produces glucagon
Increases serum blood sugars
Hyperglycaemia
Symptoms of pancreatic tumours
> Painless jaundice > Loosepale stools > Dark urine > Weight loss > Back pain
Risk factors
Smoking
Charred meat
Obesity
Type I and type II DM
Initial management - pancreatic tumours
inoperable cases//
> ERC or percutaneous drain and stent insertion
decompression of obstructed biliary ducts
operable cases//
> laparoscopy and staging
ercp
Treatment
TNM staging
Curative vs palliative
Surgery, chemo, radiotherapy
Surgical resection or palliative bypass
POOR PROGNOSIS
