Pancreas Disease Flashcards
What causes pancreatitis
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)
What drugs can cause
Steroid NSAID Azathioprine Suphonamide Meleasasine - 5ASA Diuretic Sodium valproate
What does hyperlipiaemia cause
Pancreatitis most common
Gall stone
ISchaemic bowel
What is the issue with lipid
Rise in acute inflammation
Need to check 2+ weeks after
What are Ddx for high amylase
Pseudocyst Mesenteric infarct Perforated viscous Cholecystitis Infection DKA Obstruction Drugs Renal failure
What is the pathophysiology of pancreatitis
Injury Enzyme release Auto digestion = necrosis Amylase + lipase released Oedematous and haemorrhagic gland Non bacterial inflammation Cytokine release + SIRS
What is mild pancreatitis
No organ failure
What is severe
Organ failure >48 hours
Local complications
Glasgow score >3
What is DDX of pancreatitis
Perforated ulcer Acute cholecystitis Biliary colic High obstruction - vomit etc MI Ruptured AA Mesenteric iscahemia
How do you Dx pancreatitis
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
What are other symptoms of pancreatitis / consequences
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
How do you Dx pancreatitis and why do you do certain
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
What imaging in pancreatitis
CT = DIAGNOSTIC - oedema/ indistinct margin
AXR - ileus / effusion / calcification / rule out perforation
Abdo USS for gall stone
EUS - stones
ERCP if LFT worsening
When do you do CT
Severe Uncertain after 24 hours See complications Deterioration 48 hours after to look for complications
What does Glasgow score take into account
If >3 = HDU / ITU for organ support
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
What is important to remember
Amylase NOT prognostic
How do you treat pancreatitis
What enzyme should they get
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
What are non-local complications of pancreatitis
Organ failure Shock ARDS Pleural effusion Renal failure DIC Metabolic disturbance - hypocalcium, hyperglycaemia Paralytic Ileus Encephalopathy Sepsis
What are local complications usually 1-2 weeks after development
Acute fluid collection - can lead to pseudocyst / abscess Pseudocyst Abscess Stricture Fistula Peritonitis Pancreatic necrosis Haemorrhage Thrombosis
What are the symptoms of a pseudocyst
Persistent increased amylase / abnormal LFT
Fever
Pain
Can rupture and fluid can tract
What are complications of pseudocyst
Infection
Rupture
Erosion into vessels = bleed
What causes pseudocyst
Pancreatic juice in fibrous capsule arise 4 weeks after
Can form not due to pancreatitis
What do you do for acute fluid collection
Avoid drain as risk of infection
What do you do for pseudocyst
USS / CT / ERCP Conservative as most will resolve Wait 12 weeks FNA if doesn't Surgery and drain if ruptures / pressure on organs
Why conservative
Risk of infection
What causes abscess
Infected pseudocyst
How do you treat
Ax and drain
What do you do for pancreatic necrosis
CT guided aspiration If infected give Ax Mostly conservative Drainage / laparotomy Nutrition is important
What are complications of necrosis
Haemorrhage
Portal hypertension
Stricture
What do you do for gallstone
ERCP
Lap chole
When do you give Ax
Diagnosed infection of necrosis
Biliary obstruction
Cholangitis
Otherwise none as not an infection
What is chronic pancreatitis
Irreversible grandular destruction
Affects endocrine and exocrine
What causes chronic pancreatitis
Alcohol = most common cause CF Smoking Haemochromatosis Autoimmune Hypercalcaemia Hyperparathyroid Obstruction - tumour / fibrosis
What are the symptoms of chronic pancreatitis
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
How do you Dx chronic
Blood - raised amylase / decreased albumin / LFT / PT / glucose
Fetal elactase - assess exocrine
What imaging is used in chronic
USS = 1st line
CT confirms with calcification
AXR - calcification
ERCP
If chronic vomiting what do you do
Endoscopy
Coeliac
Blood test
How do you manage chronic
Avoid alcohol Analgesia / coeliac plexus block Creon + fat soluble vitamins Insulin Endoscopic Rx of duct Surgery if malignancy Low fat diet
What are the complications of chronic
Portal hypertension Haemorrhage Pseudocyst DM Cancer Obstruction Chronic pain Aneursm / thrombosis of splenic vein
What is most common pancreatic cancer and where
Adenocarcinoma
Head of pancreas = 70%
What mutation
KRAS
What are the symptoms that make you suspect
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
What are other symptoms
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
What are RF for pancreatic cancer
Age Chronic pancreatiti Smoking Obesity Alcohol HNPCC / MEN / BRCA Stomach ulcer H.pylori
What does painless obstructive jaundice + palpable GB suggest
Malignancy until proven otherwise
Known as Courvosier law
How do you Dx
Who gets urgent CT
Blood test CA19-19 marker USS - dilatation CT = Dx EUS with biopsy
Urgent if >60, weight loss + diarrhoea / pain / constipation / DM
What do you do if mass and jaundice
ERCP and stent
What do you do if mass no jaundice
USS
Biopsy
What do you do if cancerous
CT
Laparoscopy prior to Whipple to look for mets
How do you treat
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
What signs suggest can’t operate
DM Ascites Palpable GB HSM Enlarged Ln
What do you do for palliation if can’t operate
Must relief jaundice ERCP +- stent Palliative bypass Duodenal stent if gastric obstruction Gastrostomy for feed Chemo or RT Creon PPI PAIN
What are risks with pancreatic cancer
Present late as vague Obstruction - abnormal LFT Increased calcium Blood clot Splenic vein thrombosis Thrombophlebitis migrans Portal hypertension - ascites / HSM / GB
Mnemonic for pancreatitis Glasgow score
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
What is pseudocyst
Fluid collection closed in fibrous capsule / granulation tissue unlike acute fluid collection
When is it chronic
> 6 weeks
What tests for causes of pancreatitis
EUS
ERCP - if LFT worsening as could be due to gall stone
USS
CT / MRI
How do you monitor cases of severe pancreas
Vital signs Urine output CVP HR Blood glucose FBC, U+E, LFT, clotting, calcium, blood glucose, amylase
