Pancreas- Inflammation and tumours Flashcards
where is the uncinate process
beneath the head of the pancreas
what is the venous drainage of the pancreas
pancreatic duodenal into SMV
inf. pancreatic vein into splenic
what is the exocrine function of the pancreas
acinar cells secrete pancreatic enzymes
what is the endocrine function of the pancreas
iselts of langerhans secrete hormones into the blood
what do the different cells of the iselts of langerhans secrete
beta- insulin
alpha- glucagon
delta- somatostatin
F cells- pancreatic polypeptide
what are secretions of pancreatic fluid regulated by
vagus nerve and gastrin levels
what are the secretions from acinar cells and there role
protease- polypeptides to peptides
pancreatic lipase- triglycerides into fatty acids and monoglycerides
pancreatic amylase- carbohydrates into dissaccharides/ momsaccharides
+other enzymes
what do the epithelial cells lining the duct secrete
bicarbonate, water
how much pancreatic fluid do you secrete a day
one litre
what tissues does pancreatitis involve
regional tissues and distal organs
how are the majority of pancreatitis’ managed
analgesia and IV fluids
what are the causes of acute pancreatitis
Idiopathic
Gall stones
Ethanol
Trauma
Steroids Mumps + other infections + malignancy Autoimmune Scorpion bites Hyper: calcaemia, parathyroidism, lipidaemia ERCP Drugs (azathoprin)
what are the theories behind the pathophysiology of acute pancreatitis
bile reflux- obstruction of CBD/PD
hyperstimulation of pancreatic ancinar cells with cholecystokinin
enzymes released and activated, then autodigest the pancreas
what do the activates enzymes do outwith the pancreas
interstitial inflammation and oedema (hypovolaemic shock)
fat necrosis by lipase and phospholipase (hypocalcaemia)
proteolysis by proteases
haemorrhage (elastase)
what leads to the formation of a psuedocyst
trigger- parenchymal inflammation- peripancreatic exudation or PD leakage
what does hypoperfusion in pancreatitis lead to
necrosis: release of toxic metabolites into blood and peritoneal cavity
(if bacteria infected necrosis or abscess)
how does an acute pancreatitis present
acute onset epigastric pain- radiating through to the back- very severe
nausea and vomiting
jaundice
trigger identified
what is found on exam in acute pancreatitis
diffuse upper abdominal tenderness, soft, normal bowel sounds, fullness in epigastrium
if severe can present like peritonitis with widespread guarding and absent bowel sounds
what are the signs of pancreatitis
cullens (staining around umbilicus) and grey turners (staining around the flanks)
what initial investigations should be done
IV access, bloods (FBC and coagulation, U&Es, LFTs, calcium, glucose, amylase/lipase, CRP and lactate)
arterial blood gas
ultrasound FOR ALL PATIENTS WITH PANCREATITIS
CT to assess severity (follow up, for potential intervention, look for complications)
what should ERCP be used for in pancreatitis
not as a diagnostic tool, but for treatment for CBD stones with obstruction
what does the glasgow criteria assess
prognostic
what does the ransons criteria assess
severity of pancreatitis- a score or 3 or more indicates severe pancreatitis
what are the local complications of pancreatitis
fluid collection, pseudocysts, abscess, necrosis +/- infection, asites, pleural effusion
what are the systemic complications of pancreatitis
pulmonary failure, renal failure, shock, sepsis, metabolic acidosis, hyperglycaemia, hypocalcaemia, MODS (multiple organ dysfunction syndrome)
what is the prognosis of pancreatitis
mild (85% of cases) is self limiting- 1%
severe: sterile necrosis (60%) - 10%
infected necrosis- 20%
what is the management for pancreatitis
firstly conservative
- fluid resus
- correct electrolytes
- fluid balance
- oxygen
- antibiotics
- nutrition
what can pancreatic pseudocysts cause
biliary obstruction, gastric outlet obstruction
how are pancreatic psuedocysts diagnosed
pain, nausea, vomiting, jaundice, weight loss
how are pseudocysts treatmd
endoscopic drainage
how are pancreatic abscesses treated
drained to control sepsis
how is pancreatic necrosis treated
CT for assessment sterile or infected? fine needle aspiration for micro percutaneous drainage necrosectomy and lavage
what is chronic pancreatitis
progressive and irreversible damage, loss of exocrine +/- endocrine function
how does chronic pancreatitis present
v similar to acute
alcohol, smoker, medication
masses/ ascites/ jaundice on examination
what causes chronic pancreatitis
alcohol, idiopathic, pancreatic duct obstruction (stone, stricture, tumour, pseudocysts, pancreas divisum)
autoimmune
tropical countries
hereditary (cystic fibrosis and alpha-1-antitrypsin
calcifications and stones can be found in chronic pancreatitis
yes
what can be seen on a CT of chronic pancreatitis
calcifications and stones
how is chronic pancreatitis managed
manage acute episodes
creon as enzyme replacement therapy in pancreatic insufficiency
- bloating
- pain
- loose, fatty, pale stools
- weight loss
- increase in stool frequency
surgical options
what is the pustow procedure
opening the pancreatic duct and fusing it to the jejunum
what are the complications of pancreatic surgery
splenic vein thrombosis
pseudoaneurysm of the splenic artery
what are the complications of chronic pancreatitis
splenic vein thrombosis
pseudoaneurysm- splenic atery
pleural effusions
ascites
pancreatic cancer
pseudocyts
biliary obstruction
duodenal obstruction
what can pseudocysts obstruct
biliary obstruction
gastric outflow obstruction
what can cause a duodenal obstruction
odema due to acute flare up
fibrosis and pancreatic head tumour
pseudocysts
how is a duodenal obstruction managed
stent, bypass, resection
what are the exocrine pancreatic tumours
adenocarcinoma (95%)
what are the endocrine pancreatic tumours
gastrinoma (increases gastrin, stomach acid)
insulinoma (produces insulin, hypoglycaemia)
glucagonoma (produces glucagon, hyperglycaemia)
somatostatinoma (diabetes, steatorrhoea)
what are the general symptoms of pancreatic cancer
jaundice (painless):
- loose stools
- steatorrhoea
weight loss
back pain
what are the risk factors for pancreatic cancer
smoking, charred meat, obesity, diabetes
what investigations can be done into pancreatic cancers
ultrasound, triple phase CT, MRI and MRCP
how are inoperable pancreatic cancers (70-80%) treated
ERCP or PTC and stent insertion
decompression of obstructed biliary ducts
chemotherapy, radiotherapy
how are operable pancreatic cancers managed
laparoscopy and staging
ERCP stent
resection or palliative bypass
surgery, chemotherapy, radiotherapy
what is a biliary bypass
formation of a hepaticojejunostomy- palliative
