Pancreas - Acute and Chronic pancreatitis, Cancer

Question 1

Acute pancreatitis
-pathophysiology
-most common causes

Answer 1

Inflammation of pancreas => extraductal release of pancreatic enzymes

Alcohol, gallstones (GET SMASHED)
Local
-protease enzymes damage soft tissue, vascular => retroperitoneal hemorrhage
-leads to pancreatic necrosis => fluid secretion (pseudocyst), infection risk

Systemic
-inflammatory cytokine release => systemic response
-can lead to CV shock, ARDS, DIC

Metabolic
-hyperglycemia
-lipase released => FA binds to Ca => hypocalcemia
-reduced ability to digest food => malabsorption

Question 2

Acute pancreatitis
-presentation

Answer 2

Abdo tender pain => back radiation
Sudden, severe in hours => persist for days
N+V
Jaundice
Grey Turner, Cullen

CV shock, resp distress, fever if progressed

Assess causes
-alcohol intake
-weight loss? => tumour
-steroids?
-recent trauma/surgery/ERCP
-mumps?

Question 3

Acute pancreatitis
-investigations

Answer 3

2 of the 3
-clinical - epigastric pain
-biochemical - amylase/lipase 3x upper limit of normal
-imaging

HCCT - to detect pancreatitis
Abdo US - look for stones

Assessing severity
-CRP = severity
-high glucose, WCC, urea (kidney dysfunction), AST, ALT (liver dysfunction), LDH
-low Ca, hypoxic O2

Assessing cause
-high bilirubin, US - GS
-isolated GGT - alcohol

Question 4

Acute pancreatitis
-management

Answer 4

ABCDE resus
-DO NOT KEEP NBM, encourage PO nutrition
-fluids, analgesia, antiemetics if needed
-enteral nutrition if severe

Pancreatic necrosis - drained if infected
Pseudocysts - drained if causing pressure symptoms, otherwise conservative
Ascites - multiple bore drains left in until no further fluid produced
Retroperitoneal hemorrhage - radiological embolisation
Removal of stones/obstructions - cholecystectomy/ERCP

Question 5

Chronic pancreatitis
-pathophysiology
-risk factors

Answer 5

Recurrent episodes of acute inflammation, oxidative stress => fibrosis, functional impairment

40-50, males
Alcohol, Smoking
Genetics
Obstructive - pancreatic duct obstruction (stones, tumours, stricture)

Question 6

Chronic pancreatitis
-presentation
-management

Answer 6

Pain worse 30min after meal
Steatorrhea - 5-25 years after pain onset
DM - 20 years after symptom onset

Abdo Xray/CT - pancreatic calcification
Fecal elastase - assess exocrine function

Pancreatic enzyme supplements
Analgesia
DM management
Alcohol, smoking cessation

Pseudocysts - drained if causing pressure symptoms
Removal of stones/obstructions - cholecystectomy/ERCP

Question 7

Pancreatic cancer
-2wk referral criteria

Answer 7

2wk suspected cancer pathway
-40+ AND jaundiced

2wk CT in 60+ AND weight loss AND
-back/abdo pain
-N/V/C/D
-new onset diabetes

Question 8

Pancreatic cancer
-types
-risk factors
-presentation
-investigations
-management

Answer 8

Majority exocrine - adenocarcinoma at head of pancreas
Can be endocrine

Age, smoking
DM, chronic pancreatitis
HNPCC (Lynch), MEN, BRCA2

Painless jaundice
Anorexia, weight loss
Epigastric/back pain
Lost exocrine function - steatorrhea
Lost endocrine function - DM
Migratory thrombophlebitis - increased clotting risk

ERCP FNA biopsy
PETCT for mets
CT - Double duct sign (dilation of CBD and pancreatic duct)

Surgery - pancreaticoduodenectomy if suitable
Adjuvant chemo
Palliative - ERCP with stenting

Question 9

Pancreatitis complications

Answer 9

Peripancreatic collections
-can resolve or develop into pseudocysts, abscess

Pseudocysts - CT, MRI, ECRP, endoscopic US
-cystogastrostomy or aspiration

Pancreatic necrosis

Pancreatic abscess

Hemorrhage