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Gastro > Pancreas Disease > Flashcards

Pancreas Disease Flashcards

1
Q

What causes pancreatitis

A

Gall stone
Ethanol
Trauma - post ERCP / post op

S - steroids
M - malignancy
A - Autoimmune
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 [5]

A 
Azathioprine
Suphonamide
Mesalazine - 5ASA
NSAID / steroid
Furosemide
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3
Q

What does hyperlipiaemia cause [3]

A

Pancreatitis most common
Gall stone
Ischaemic bowel

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4
Q

Causes of high amylase levels [8]

NB Amylase is non-specific and non prognostic

A 
Pseudocyst
Mesenteric infarct
Cholecystitis
Infection
DKA
Obstruction
Drugs
Renal failure
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5
Q

What is the pathophysiology of pancreatitis [6]

A
  1. Digestive enzymes activated & released
  2. Auto digestion = necrosis
  3. Non-bacterial inflammation
  4. Release of cytokines
  5. Edema and haemorrhage
  6. Cytokine release > SIRS
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6
Q

Mild pancreatitis - clinical definition?

Presentation [2]

A

No organ failure
Patient systemically well
Localised abdominal pain

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7
Q

What is severe pancreatitis? [3]

A

Organ failure >48 hours
Local complications
Glasgow score >3

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8
Q

What is DDX of pancreatitis [6]

A 
Perforated ulcer
Acute cholecystitis 
Biliary colic 
High obstruction - vomit etc
MI, Ruptured AA
Mesenteric iscahemia
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9
Q

Pancreatitis presentation:

What is needed for a diagnosis? [3]

A

2+ of:

  • Abdo pain consistent with pancreatitis
  • Serum lipase or amylase >3x
  • Characteristic findings on CT
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10
Q

Pancreatitis presentation:

  • Describe abdominal pain [5]
  • General signs [4]
  • Abdominal signs [4]
A

Characteristics of abdominal pain in pancreatitis:

  • Severe epigastric pain
  • Radiating to back
  • Vomiting, retching
  • Relieved by tripod position
  • Diarrhea, constipation (ileus)

General signs:

  • Low grade fever
  • Tachycardia, Shock
  • Hypoxic (ARDS)
  • Jaundice
  • Abdomen tender, rigid, no BS
  • Cullens sign (bluish discoloration, periumbilical)
  • Grey-Turners sign (flank bruising)
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11
Q

Investigations: pancreatitis
Bloods [5]
Describe LFT results you would see [3]

A 
FBC - leukocytosis
Ca low, Glc low, lactate up
ABG - risk of acute respiratory failure, metabolic upset due to ischemic bowel
Elevated serum amylase 
U&E (AKI)

LFTs

  • Mainly direct bilirubin increased
  • ALT & AST: Mild increase
  • VERY Elevated ALP
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12
Q

Describe the course that serum amylase follows in pancreatitis [4]

Diagnostic imaging: pancreatitis [3]

A

400U suggestive of pancreatitis
>1000U diagnostic
Rises within 6h
Returns to normal 3-5d after

Diagnostic imaging: pancreatitis
Abdo USS: gallstones
AXR: colon cut off sign, sentinel loop, ileus
IV contrast enhanced CT

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13
Q

When do you do CT [3]

A

Uncertain after 24 hours
Clinical deterioration
Organ failure, sepsis (necrosis) after 3-10d of admission

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14
Q

Severity stratification tool for pancreatitis [8]

A

Assesses severity of pancreatitis:

GLASGOW 3 (mnemonic)
Glucose
LDH
Age
Serum calcium, albumin and urea
Gasping for O2 (PaO2)
WBC 3
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15
Q

What is important to remember

A

Amylase NOT prognostic

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16
Q

Describe immediate management of pancreatitis [7]

A 
ABCDE
Admit to HDU/ITU
Analgesia, Oxygen, Fluid resus, Catheter
NG tube and NBM
Creon = pancreatic enzyme supplement
Organ support - isotrope / ventilation / dialysis 
Alcohol cessation
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17
Q

What are non-local complications of pancreatitis [7]

A 
Organ failure eg renal
Shock
ARDS
DIC, Sepsis
Metabolic disturbance - hypocalium, hyperglycaemia 
Paralytic Ileus
Encephalopathy
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18
Q

What are local complications [9]

A 
Acute fluid collection - can lead to pseudocyst / abscess 
Pseudocyst 
Abscess
Stricture
Fistula, Peritonitis
Pleural effusion
Pancreatic necrosis
Pseudoaneurysm
Portal/splenic vein thrombosis
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19
Q

What are the symptoms of a pseudocyst [4]

A

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

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20
Q

What are complications of pseudocyst [3]

A

Infection
Rupture
Erosion into vessels = bleed

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21
Q

What causes pseudocyst

A

Pancreatic juice in fibrous capsule arise 4 weeks after

Can form not due to pancreatitis

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22
Q

What do you do for acute fluid collection [3]

A

50% resolve spontaneously; only percutaneously aspirate if suspect infection or symptomatic
Avoid drain as risk of infection

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23
Q

Investigations for pseudocysts [3]
When should you do diagnostic imaging? [1]
Procedure to remove? [3]

A

EUS, CT, ERCP

Do these tests after 4 weeks as only then it is visible

Procedure: endoscopic/laparoscopic/open cystogastrostomy

24
Q

When do you choose intervention over conservative management? [2]

A

If >6cm and >12w then unlikely to resolve. Conservative as most will resolve unless symptomatic/complicated

25
Q

What causes abscess

A

infected pseudocyst

26
Q

How do you treat abscess [2]

A

Abx and drain

27
Q

What do you do for pancreatic necrosis [4]

A

Mostly conservative unless infected otherwise:

  • CT guided aspiration
  • Give antibiotics
  • Necrosectomy
28
Q

What are complications of necrosis [3]

A

Haemorrhage
Portal hypertension
Stricture

29
Q

What do you do for gallstone [2]

A

ERCP (Endoscopic retrograde cholangiopancreatography)

Laparoscopic cholecystectomy

30
Q

When do you give Abx [4]

A

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

31
Q

What is chronic pancreatitis [2]

A

Irreversible grandular destruction

Affects endocrine and exocrine

32
Q

What causes chronic pancreatitis [5]

A 
Alcohol, Smoking
Congenital abnormalities of pancreas, CF
Haemochromatosis, Autoimmune
Hypercalcaemia, Hyperparathyroid
Obstruction - tumour / fibrosis
33
Q

Presentation: chronic pancreatitis
Describe the pain felt in pancreatitis [4]
Associated symptoms [4]

Symptoms that present 20y after onset of pain [3]

A

Epigastric pain

  • bores through to back
  • worse 15-30 mins after meal
  • may be relieved by sitting forward, hot water bottle (erythema ab igne)
  • Bloating
  • Steatorrhea
  • Jaundice
  • Vomiting after food

Symptoms that present 20y after onset of pain [3]
Weight loss & malabsorption, DM

34
Q

Lab investigations in chronic pancreatitis [7]

A
  • Amylase (up)
  • Albumin (low)
  • LFT
  • PT
  • Glucose (hyperglyc)
  • Fecal elactase - assess exocrine
  • Breath tests eg C-hiolen
35
Q

What imaging is used in chronic [4]

A

Abdo USS
CT abdo with IV contrast or AXR (calcification confirms dx)
ERCP

36
Q

If chronic vomiting what do you do [3]

A

Gastroscopy
Coeliac
Blood test

37
Q

Describe immediate management of chronic pancreatitis [3]

Describe surgical procedures [2]

A
  1. Analgesia / coeliac plexus block
  2. Creon + fat soluble vitamins
  3. Nutrition: low fat, no alcohol
    Insulin

Pancreatectomy or pancreatojejunostomy (duct drainage procedure)

38
Q

What are the complications of chronic [8]

A 
Portal hypertension
Haemorrhage
Pseudocyst
DM
Pancreatic cancer
Biliary Obstruction
Chronic pain 
Local arterial aneurysm / thrombosis of splenic vein
39
Q

What is most common pancreatic cancer [2]

A

Adenocarcinoma

Head

40
Q

What mutation

A

KRAS

41
Q

Presentation of pancreatic cancer [4]

A
  1. Painless obstructive jaundice (head)
  2. Epigastric pain radiating to back and relieved by sitting forward (body or tail)
    - Vague abdominal pain means late presentation
  3. Anorexia, weight loss, DM (loss of endocrine function)
  4. Acute pancreatitis
42
Q

What are other clinical features [9]

A 
N+V, diarrhea
Steatorrhea, DM - loss of exocrine
Dyspepsia
Bowel change
Portal hypertension
HSM
Hypercalcemia
Marantic endocarditis
Nephrosis if renal vein mets
43
Q

What are RF for pancreatic cancer [6]

A 
Age
Pancreatitis
Smoking, Alcohol
Obesity
HNPCC / MEN / BRCA
Stomach ulcer, H.pylori
44
Q

What does painless obstructive jaundice + palpable GB suggest?
What is this clinical sign?

A

Malignancy

Courvoisier’s sign

45
Q

How do you diagnose? [4]

A

Blood test

  • CA19-19 marker (prognostic)
  • LFT (obstructive jaundice picture)

USS - dilatation
CT = Dx

46
Q

What do you do if mass and jaundice [2]

A

ERCP and stent

47
Q

What do you do if mass but no jaundice [2]

A

USS

Biopsy

48
Q

What do you do if cancerous [2]

A

CT

Laparoscopy prior to Whipple to look for mets

49
Q

How do you treat [3]

A

Medical mx of jaundice
Whipple’s resection if mass is operable
Adjuvant chemo

50
Q

What signs suggest can’t operate [5]

A 
DM
Ascites
Palpable GB 
HSM
Enlarged LN
51
Q

What do you do for palliation [7]

A 
ERCP +- stent - jaundice
Palliative bypass
Gastrostomy for feed
Chemo or RT
Creon
PPI
High dose opiates, coeliac plexus block
52
Q

What are the sequelae of pancreatic cancer [5]

A 
Obstruction - abnormal LFT
Increased calcium
Blood clot, Splenic vein thrombosis
Thrombophlebitis migrans
Portal hypertension - ascites / HSM / GB
53
Q

How do you monitor cases of severe pancreas [5]

A 
Vital signs
Urine output
CVP
Blood glucose
FBC, U+E, LFT, clotting, calcium, blood glucose
54
Q

What is Whipple’s resection? [3]

Indication?

A

Pancreaticoduodenectomy

  • Removal of pancreas head, portion of bile duct, gallbladder, duodenum and part of stomach
  • Stomach is re-joined with intestine

Ind: Resectable lesions at pancreatic head

55
Q

What surgery would you do for tail lesions?

A

Laparoscopic resection

56
Q

Timing of cholecystectomy [3]
Mild acute pancreatitis
Severe acute pancreatitis
Complicated acute pancreatitis

A

Mild Acute Pancreatitis - during the Same admission
Severe Acute Pancreatitis- should be delayed until inflammatory process settled
Complicated Acute Pancreatitis- cholecystectomy should be done when these are resolved or dealt with surgically

Gastro (17 decks)

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