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GI > Pancreas Disease > Flashcards

Pancreas Disease Flashcards

1
Q

What causes pancreatitis

A 
Most common
Gall stone
Ethanol
Trauma - post ERCP / post op 
Drugs 
S - steroids / NSAID / sulphonamide 
M - malignancy 
A - Autoimmune / azathioprine 
S - Scorpion venom
H - hyperlipid / hypothermia / hyper Ca / hyper PTH
E - emboli / vascular
D - drugs
 V - virus (HIV)
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2
Q

What drugs can cause

A 
Steroid
NSAID 
Azathioprine
Suphonamide
Meleasasine - 5ASA
Diuretic
Sodium valproate
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3
Q

What does hyperlipiaemia cause

A

Pancreatitis most common
Gall stone
ISchaemic bowel

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4
Q

What is the issue with lipid

A

Rise in acute inflammation

Need to check 2+ weeks after

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5
Q

What are Ddx for high amylase

A 
Pseudocyst
Mesenteric infarct
Perforated viscous
Cholecystitis
Infection
DKA
Obstruction
Drugs
Renal failure
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6
Q

What is the pathophysiology of pancreatitis

A 
Injury
Enzyme release
Auto digestion = necrosis
Amylase + lipase released
Oedematous and haemorrhagic gland
Non bacterial inflammation
Cytokine release + SIRS
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7
Q

What is mild pancreatitis

A

No organ failure

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8
Q

What is severe

A

Organ failure >48 hours
Local complications
Glasgow score >3

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9
Q

What is DDX of pancreatitis

A 
Perforated ulcer
Acute cholecystitis 
Biliary colic 
High obstruction - vomit etc
MI
Ruptured AA
Mesenteric iscahemia
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10
Q

How do you Dx pancreatitis

A 
2+ of 
Abdo pain consistent with pancreatitis (acute severe epigastrium, radiates to back, better sitting forward, reaches max in a few hours) 
Serum lipase or amylase >3x
Vomiting (unlike perforation) 
Characteristic findings on CT
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11
Q

What are other symptoms of pancreatitis / consequences

A 
Low grade Fever
Tachycardia
Shock 
Diarrhoea
Constipation (ileus)
Dehydration
Tender and rigid abdomen - acute 
Can be haemodynamically unstable due to 3rd space loss 
Consequences
Jaundice due to CBD or oedema
Hypocalcaemia - fat binds to Ca 3-8 days after
Hyperglycaemia
ARDS 
Effusion due to high amylase
Cullens (umbilical) 
Grey turner (flank) due to retroperitoneal haemorrhage = severe
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12
Q

How do you Dx pancreatitis and why do you do certain

A 
Raised amylase x4
Raised lipase 
Increased CRP
FBC - leucocytosis
LFT (Cause) , U+E (AKI) , Ca, glucose, lipids, lactate
ABG if low sats
Imaging to look for complication not Dx
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13
Q

What imaging in pancreatitis

A

CT = DIAGNOSTIC - oedema/ indistinct margin
AXR - ileus / effusion / calcification / rule out perforation
Abdo USS for gall stone
EUS - stones
ERCP if LFT worsening

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14
Q

When do you do CT

A 
Severe
Uncertain after 24 hours
See complications 
Deterioration
48 hours after to look for complications
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15
Q

What does Glasgow score take into account

If >3 = HDU / ITU for organ support

A 
PANCREAS 
PaO2 <8
Age >55
Neutrophils / WBC >15
Calcium low <2 / CRP high 
Renal - urea >16
Enzymes - LDH and AST / LFT raised and lactate 
Albumin low <32
Sugar - glucose >10 (high) 
\+ Progressive hormone failure
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16
Q

What is important to remember

A

Amylase NOT prognostic

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17
Q

How do you treat pancreatitis

What enzyme should they get

A 
ABCDE
Analgesia
NBM 
NGT to decompress stomach 
Oxygen
Fluid resus
Catheter
Monitor HR, BP, UO
Daily FBC, U+E, Ca, glucose, amylase, ABG 
Encourage nutrition or NG tube 
Creon =. pancreatic enzyme supplement
TPN if ileus
Insulin? Calcium?
Treat underlying cause - early cholecystectomy / ERCP 
CT scan
Organ support - isotrope / ventilation / dialysis 
Alcohol cessation
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18
Q

What are non-local complications of pancreatitis

A 
Organ failure
Shock
ARDS
Pleural effusion 
Renal failure
DIC
Metabolic disturbance - hypocalcium, hyperglycaemia 
Paralytic Ileus
Encephalopathy
Sepsis
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19
Q

What are local complications usually 1-2 weeks after development

A 
Acute fluid collection - can lead to pseudocyst / abscess 
Pseudocyst 
Abscess
Stricture
Fistula
Peritonitis
Pancreatic necrosis
Haemorrhage
Thrombosis
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20
Q

What are the symptoms of a pseudocyst

A

Persistent increased amylase / abnormal LFT
Fever
Pain
Can rupture and fluid can tract

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21
Q

What are complications of pseudocyst

A

Infection
Rupture
Erosion into vessels = bleed

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22
Q

What causes pseudocyst

A

Pancreatic juice in fibrous capsule arise 4 weeks after

Can form not due to pancreatitis

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23
Q

What do you do for acute fluid collection

A

Avoid drain as risk of infection

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24
Q

What do you do for pseudocyst

A 
USS / CT / ERCP
Conservative as most will resolve
Wait 12 weeks
FNA if doesn't
Surgery and drain if ruptures / pressure on organs
25
Q

Why conservative

A

Risk of infection

26
Q

What causes abscess

A

Infected pseudocyst

27
Q

How do you treat

A

Ax and drain

28
Q

What do you do for pancreatic necrosis

A 
CT guided aspiration
If infected give Ax
Mostly conservative
Drainage / laparotomy
Nutrition is important
29
Q

What are complications of necrosis

A

Haemorrhage
Portal hypertension
Stricture

30
Q

What do you do for gallstone

A

ERCP

Lap chole

31
Q

When do you give Ax

A

Diagnosed infection of necrosis
Biliary obstruction
Cholangitis
Otherwise none as not an infection

32
Q

What is chronic pancreatitis

A

Irreversible grandular destruction

Affects endocrine and exocrine

33
Q

What causes chronic pancreatitis

A 
Alcohol = most common cause 
CF
Smoking
Haemochromatosis
Autoimmune
Hypercalcaemia
Hyperparathyroid
Obstruction - tumour / fibrosis
34
Q

What are the symptoms of chronic pancreatitis

A 
Abdominal pain - worse after food
Vomiting after food
Bloating
Weight loss due to malaborption
Steathorrhoea - post 20 year
DM - post 20
Protein malabsorption - B12 / weight loss
Jaundice
35
Q

How do you Dx chronic

A

Blood - raised amylase / decreased albumin / LFT / PT / glucose
Fetal elactase - assess exocrine

36
Q

What imaging is used in chronic

A

USS = 1st line
CT confirms with calcification
AXR - calcification
ERCP

37
Q

If chronic vomiting what do you do

A

Endoscopy
Coeliac
Blood test

38
Q

How do you manage chronic

A 
Avoid alcohol
Analgesia / coeliac plexus block
Creon + fat soluble vitamins
Insulin
Endoscopic Rx of duct
Surgery if malignancy
Low fat diet
39
Q

What are the complications of chronic

A 
Portal hypertension
Haemorrhage
Pseudocyst
DM
Cancer
Obstruction
Chronic pain 
Aneursm / thrombosis of splenic vein
40
Q

What is most common pancreatic cancer and where

A

Adenocarcinoma

Head of pancreas = 70%

41
Q

What mutation

A

KRAS

42
Q

What are the symptoms that make you suspect

A

Painless obstructive jaundice due to biliary tree being obstructed = most common
Pain in RUQ / back relieved sitting forward at L1-L2 suggest tail of pancreas
Weight loss
Anorexia
Often present late as asymptomatic until block biliary

43
Q

What are other symptoms

A 
Fatigue
Pale stool
Steathorrheoa due to malabsorption 
DM - loss of endocrine
Diarrhoea 
N+V
Dyspepsia
Bowel change
Portal hypertension
Palpable GB
HSM
Acute pancreatitis on top
44
Q

What are RF for pancreatic cancer

A 
Age
Chronic pancreatiti
Smoking
Obesity
Alcohol
HNPCC / MEN / BRCA
Stomach ulcer
H.pylori
45
Q

What does painless obstructive jaundice + palpable GB suggest

A

Malignancy until proven otherwise

Known as Courvosier law

46
Q

How do you Dx

Who gets urgent CT

A 
Blood test
CA19-19 marker
USS - dilatation
CT = Dx
EUS with biopsy

Urgent if >60, weight loss + diarrhoea / pain / constipation / DM

47
Q

What do you do if mass and jaundice

A

ERCP and stent

48
Q

What do you do if mass no jaundice

A

USS

Biopsy

49
Q

What do you do if cancerous

A

CT

Laparoscopy prior to Whipple to look for mets

50
Q

How do you treat

A

Treat and fix jaundice if can’t operate
Whipple if mass operable (remove head, GB, CBD, duodenum and pylorus) for tumour of head
Pancreatectomy for tumours of tail
Adjuvant chemo

51
Q

What signs suggest can’t operate

A 
DM
Ascites
Palpable GB 
HSM
Enlarged Ln
52
Q

What do you do for palliation if can’t operate

A 
Must relief jaundice 
ERCP +- stent
Palliative bypass
Duodenal stent if gastric obstruction 
Gastrostomy for feed
Chemo or RT
Creon
PPI
PAIN
53
Q

What are risks with pancreatic cancer

A 
Present late as vague
Obstruction - abnormal LFT
Increased calcium
Blood clot 
Splenic vein thrombosis
Thrombophlebitis migrans
Portal hypertension - ascites / HSM / GB
54
Q

Mnemonic for pancreatitis Glasgow score

A 
P - Pao2 <8
A - age >55
N - neutrophilic / WCC >15
C - calcium <2
R - renal urea >16
E - enzyme LDH / AST
A - albumin <32
S - sugar BG >10

Other
Lactate high
Progressive organ failure and high CRP

55
Q

What is pseudocyst

A

Fluid collection closed in fibrous capsule / granulation tissue unlike acute fluid collection

56
Q

When is it chronic

A

> 6 weeks

57
Q

What tests for causes of pancreatitis

A

EUS
ERCP - if LFT worsening as could be due to gall stone
USS
CT / MRI

58
Q

How do you monitor cases of severe pancreas

A 
Vital signs
Urine output
CVP
HR
Blood glucose
FBC, U+E, LFT, clotting, calcium, blood glucose, amylase

GI (29 decks)

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