Pancreas Flashcards
What is acute pancreatitis?
Inflammation of the pancreas leading to autodigestion
What are the causes of acute pancreatitis, and which are most common?
Idiopathic Gallstones (common) Ethanol (common) Trauma (common) Steroids Mumps Autoimmune (common) Scorpion bite Hyper-calcaemia/thyroidism/lipidaemia (common) ERCP Drugs (azathioprine, antibiotics, oestrogen)
What is mild, moderate and severe acute pancreatitis classed as?
Mild - absence of complications, uneventful recovery
Moderate - local complications, resolved in 48 hours
Severe - persistent organ dysfunction, complications like necrosis, abscess, pseudocysts etc
What is the pathogenesis of acute pancreatitis?
Premature activation of zymogen granules releases proteases that auto digest the pancreas
What are the 4 stages of acute pancreatitis?
- Oedema and fluid shifts leads to hypovolaemic shock, auto-digestion of fats and hypocalcaemia
- Autodigestion of blood vessels causes retroperitoneal haemorrhage
- Infarction due to compromised blood supply causes pancreatic necrosis
- Necrotic tissue becomes infected, causing abscess formation
What are some complications of acute pancreatitis?
Multiorgan dysfunction Hypovolaemic shock Necrosis Pseudocysts Abscess Paralytic ileus GI bleeding Pleural effusion Hypocalcaemia and hypo/hyperglycaemia
What signs are characteristic of acute pancreatitis?
Cullen’s sign - peri-umbilical area that looks purple and kinda like bruising
Grey Turner’s sign - same as above but on the flanks
What are the symptoms of acute pancreatitis?
Acute severe epigastric pain, may radiate to back
Pain alleviated in foetal position or when leaning forward
Pain may be associated with meals/excessive alcohol
Epigastric abdominal tenderness
Abdominal distension
Nausea and vomiting
Jaundice
Fever, tachycardia
Anorexia
What investigations are done for acute pancreatitis?
Amylase
Lipase
CRP
Imaging (erect CXR, abdo USS, CT)
What are amylase, lipase and CRP levels in acute pancreatitis?
Amylase - raised x3 initially but normalises after 3-4 hours
Lipase - elevated for longer than amylase
CRP raised
What does imaging show in acute pancreatitis?
CXR - air under diaphragm
Abdo USS - biliary causes, cysts, presence of free fluid
CT - detects pseudocysts
What scoring systems are used in acute pancreatitis?
Glasgow prognostic score
Ranson’s criteria
APACHE scoring system
What does the Glasgow prognostic score use?
PaO2 Age >55 Neutrophils Calcium Renal function (urea) Enzymes Albumin Sugar - glucose
What is the management for acute pancreatitis?
IV fluid resuscitation O2 therapy Pain relief Enteral nutrition Antibiotics If gallstones - ERCP/cholecystectomy Lifestyle - reduce alcohol Treat complications
What is chronic pancreatitis?
Chronic inflammation of the pancreas that is progressive and irreversible
What are the causes of chronic pancreatitis?
Mostly alcohol Idiopathic Pancreatic duct obstruction (stricture, tumour, stone, pseudocyst) Autoimmune Tropical countries Alpha1-antitrypsin Cystic fibrosis
What are the symptoms of chronic pancreatitis?
Epigastric pain radiating to the back Nausea and vomiting Jaundice Itching Ascites Masses History of alcohol, smoking Medications - antibiotics, steroids, ACEI
What are the investigations done for chronic pancreatitis?
LFTs CXR and AXR CT pancreas MRI USS to exclude other conditions
What is the management for chronic pancreatitis?
Manage acute phase
Lifestyle, pain management, screen for other diseases
Creon (replacement pancreatic enzymes if pancreatic insufficiency)
Surgery
What surgical procedures are done for chronic pancreatitis?
Pancreatico-jejunostomy or Frey’s procedure
What are pancreatic pseudocysts?
Collection of fluid that forms in the pancreas
Why are pancreatic pseudocysts called that, and not cysts?
The sac is not lined with epithelial cells so it cannot be called a cyst
What are the causes of pancreatic pseudocysts?
Trauma Idiopathic Pancreatico-duodenal communication following surgery Biliary obstruction Gastric outlet obstruction Complication of acute pancreatitis
What is the treatment for pancreatic pseudocysts?
Surgical drainage or resection
What is the most common type of pancreatic tumour?
Adenocarcinoma
Where do most pancreatic tumours form?
Exocrine compartment, in the head or the neck of the pancreas
What are the risk factors for pancreatic tumours?
Increasing age Male Smoking Alcohol Diabetes Chronic pancreatitis
What are the symptoms of pancreatic tumours?
Painless jaundice (main) Dark urine, pale stools Weight loss Back pain Fatigue, nausea, vomiting Malabsorption Courvoisier's sign (palpable, non-tender gallbladder + painless jaundice which indicates biliary obstruction)
What are the investigations for pancreatic tumours?
Blood tests USS Triple phase CT (gold standard) MRI MRCP
What is the management for pancreatic tumours?
Chemotherapy
Radiotherapy
Palliative surgery may be possible but resection can only be done in 20%
What are the surgical managements for pancreatic tumours?
If non-operable: ERCP and stent and decompression of the bile duct
If operable: Stent, laparoscopic staging, pancreatectomy, Whipple’s procedure, bypass
