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General Surgery > Pancreas > Flashcards

Pancreas Flashcards

1
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma of the head of the pancreas

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2
Q

how does pancreatic cancer tend to present?

A

Painless jaundice

Anorexia, weight loss

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3
Q

What is the investigation of choice if you suspect pancreatic cancer?

A

High resoluation CT

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4
Q

What is the treatment for pancreatic cancer?

A

whipple’s resection for resectable tumours in the head of the pancrea + adjuvent chemotherapy
ERCP and stenting tendsto be palliatiave

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5
Q

Whata re the side effects of a whipple’s procedure?

A

Dumping syndrome

Peptic ulcer disease

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6
Q

What is a whipple’s procedure?

A

Surgical removal of the head of the pancreas. due tot he shared blood supply this also means that the duodenum, proximal jejunum, gallbladder and sometimes part of the stomach also have to be removed. The common bile duct has to be attached to the liver to drain the bile and the stomach has to be aattached to the jejunum. The tail of the pancreas is also attached to the small bowel

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7
Q

What is the vascular supply to the pancreas?

A

Coeliac artery (superior pancreaticoduodenal artery)
SMA (Inferior pancreaticoduodenal artery)
Right gastric artery ( Celiac artery)

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8
Q

Why dot he duodenum and the pancreas both have to be removed in a whipples procedure?

A

the share the same blood supply (superior ad inferior pancreaticoduodenal arteries)

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9
Q

What are the complications of a whipple’s procedure

A
  1. Delayed gastric emptying
  2. Bile leak
  3. Pancreatic leak
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10
Q

How owuld you detect a pancreatic leak after a whipple’s procedure?

A

Amlyase in the abdominal drain

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11
Q

What would you know if you suspected a pancreatic leak following a whipple’s procedure?

A

CT scan

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12
Q

What gene predisposed people to pancreatic cancer?

A

BRCA2

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13
Q

What is the modified glasgow crteria for pancreatitis?

A

A score that predicts the severity of pancreatitis. If three or more of the feautures are detcted within 48 hours of onset then the patient should be transferred to HDU/ICU

  1. PaO2 less than 8
  2. Age over 55
  3. Neutrophilia (WCC over 15)
  4. Calcium less than 2
  5. Renal function (urea over 16)
  6. Enzymes (LDH over 600 or AST lover 200)
  7. Albumin less than 32
  8. Sugar more than 10
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14
Q

Is the level of amylase in acute pancreatitis related to disease severity?

A

No

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15
Q

What are the causes of acute pancreatitis?

A 
Gallstones
Ethanol 
Trauma
Steroids 
Mumps 
Autoimmune
Scorpian bites
Hypercalcaemia/hperlipidaemia/hypothermia
ERCP
Drugs eg mesalazine
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16
Q

What is the pathology in acute pancreatitis?

A

The pancreas starts to autodigest itself. This is caused by pancreaticoduodenal reflux, injury (due to recent surgery or a stone) This leads to inflammation and can lead to infarction and then necrosis. Once started acute pancreatitis can be very aggressive.

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17
Q

How does acute pancreatitis present?

A

Severe epigastric pain that radiates to the back. Vomiting.
Low grade fever.
may have grey turners (flank discolouration) or cullens signs (periumbilical discolouration)

18
Q

What investiagtions do you do if you suspect acute pancreatitis?

A 
Serum amylase - this is usally at least 5x normal in the acute phase but returns to normal within 2 - 3 days. (Urinary amylase is elevated for longer)
FBC (leucocytosis and anaemia)
Blood glucose (often raised)
ABG
Serum calcium
CT may help confirm diagnosis if it is unclear 
ECG
US to look for gallstones
19
Q

Wha three enzymes are raised in acute pancreatitis and what do they each do?

A

Trypsin - autodigestion of the pancreas
Lipase - fat necrosis of the pancreas
Amylase - helpful for diagnosis

20
Q

How do you manage acute pancreatitis?

A

Assess severity (glasgow criteria)
Analgesia
Fluids
Nil by mouth, NG aspiration (allows pancreas to rest) and may need TPN
Antibiotics in sever cases and if associated with gallstones
ERCP with sphincterectomy may be indicated in sever gallstone pancreatitis

21
Q

What are the main complications that occur as a result of acute pancreatitis?

A
  1. Pancreatic fluid collection
    - May resolve or develop into pseudocyts or abscesses
    - Not drained
  2. Pseudocysts
    - Typically occurs 4 or more weeks after attack
    - Mild persistent elevation of amylase
    - Investigated with CT, ERCP or MRI
    - May be observed for a period of time as 50% resolve
    - If treated then this is either cyctogastrostony or aspiration
  3. Pancreatic necrosis
    - May involve the pancreatic parenchyma ans surrounding fat
    - Managed conservatively
  4. Pancreatic abscess
    - Intra abdominal collection of pus
    - Drained
  5. Haemorrhage
22
Q

What pathologies (other than pancreatitis) cause a raised amylase?

A 
Renal failure
Salivary calculi and parotitis 
DKA
Alcohol intoxication
Morphine (causes sphincter of oddi spasm)
Perforated peptic ulcer
Acute cholecystitis
23
Q

What is the most common cause of chronic pancreatitis?

A

Alcohol

24
Q

What are the features of chronic pancreatitis?

A

This is an inflammatory condition which can ultimately affect both the endocrine and exocrine function of the pancreas.
Typical features are
- Pain 15 - 30 minutes after a meal
- Steatorrhoea (sigsn of pancreatic insufficiency develop between 5 - 25years after onset of pain)
- Diabetes mellitus (develops 20 years after symptoms begin)

25
Q

What investigations should you do if you suspect chronic pancreatitis?

A

Abdominal X Ray - may show calcification
CT - more sensitive for calcification (best diagnostic test)
- MRCP
- Endoscopic ultrasound

26
Q

What are the amylase levels like in chronic pancreatitis?

A

Often normal as there is not enough pancreatic tissue to cause a significant rise

27
Q

How do you manage chronic pancreatitis?

A
  • Analgesia
  • Remove causitive factors (eg alcohol)
  • Low fat diet and oral pancreatic supplements
  • Insulin when diabetes occurs
  • Surgery if attacks and paina re very frequent
28
Q

What are the benign tumours that can occur in the pancreas?

A
  1. Adenoma
  2. Cystadenoma
  3. Islet cell tumour
    - Zollinger ellison tumour
    - Insulinoma (beta cell tumour)
    - Glucagonoma (alpha cell tumour)
29
Q

What cells are in the pancreatic islets and what do they secrete?

A 
alpha cells (glucagon)
beta cells (insulin)
Delta cells (somatostatin)
30
Q

What is an insulinoma?

A

A tumour of pancreatic beta cells (90% are benign, 10% are malignant and 10% are associated with multiple tumour) They secrete insulin and two types of hypoglycaemic symptoms are produced:
1. CNS: Weakness, sweating, trempling, confusion and eventual coma
2. GI: Hunger, abdominal pain, diarrhea
Symptoms often appear when the patient is hungry and are releived by eating. They are worse in the early morning.
Excessive appetite and gross weight gain.
Whipple’s triad is
1. Attacks induced by starvation or exercise
2. Hypoglycaemia during attack
3. Symptoms relieved by sugar

31
Q

What investigations would you do if you suspected an insulinoma?

A
  1. Insulin leveks (high and with hypoglycaemia)
  2. C Peptide levels (rules out exogenous insulin)
  3. CT, MRI or endoscopic ultrasound to localise tumour
32
Q

What is the treatment of an insulinoma?

A

Surgical resection

33
Q

What is zollinger ellison syndrome?

A

Excessive levels of gastrin usually from a gastrin secreting tumour in the duodenum or pancreas. This then causes very high levels of stomach HCl
30% occur as pasrt of MEN 1

34
Q

What are the symptoms of zollinger ellison syndrome?

A

Muliple gastroduodenal ulcers
Oesophagitis
Diarrhea
Malabsoprtion

35
Q

what tests are done to diagnose zollinger ellison syndrome?

A

Fasting gastrin levels
Secretin stimulation test
Localisation of tumour

36
Q

How do you treat zollinger ellison syndrome?

A

Excision of the tumour

Control of high acid secretion with a high dose PPI.

37
Q

What is a glucoagnoma?

A

A rare tumour of the alpha cells of the pancreas that results in the overproduction of glucagon

38
Q

How does a glucoagnoma present?

A

Anemia
Diarrhea
Weight loss
Necrolytic migratory erythema (red blistering rash that spreads accross the skin especially the skin of the mouth, extermities, perineuma nd groin)

39
Q

How is a glucagonoma diagnosed?

A

High blood glucagon concentration

Tumour localisation

40
Q

How is a glucogonoma treated?

A

Octreotide (a somatostain analog)

Surgical resection

41
Q

Where does pancreatic cancer tend to spread to locally and how can this present?

A
  1. Common bile duct (obstructive jaundice)
  2. Duodenum (bleeding)
  3. Portal vein (portal vein thromobosis, portal hypertension and ascites)
  4. IVC (bilateral leg oedema)
42
Q

Where does pancreatic cancer tend to metastasise to?

A

Liver
Lungs
Transcoelemic with peritoneal seeding and ascites

General Surgery (10 decks)

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