Pancreatic conditions Flashcards
Risk factors associated with pancreatic cancer
- increasing age
- smoking
- diabetes
- chronic pancreatitis (alcohol does not appear an independent risk factor though)
- hereditary non-polyposis colorectal carcinoma
- multiple endocrine neoplasia
- BRCA2 gene
*
Features/presentation of pancreatic cancer
Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way
- classically painless jaundice
- Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
- loss of exocrine function (e.g. steatorrhoea)
- loss of endocrine function (e.g. diabetes mellitus)
- atypical back pain is often seen
- migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
The most common type and location of pancreatic cancer
- 80% of pancreatic tumours are adenocarcinomas
- typically occur at the head of the pancreas
What’s Courvoisier’s law?
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones → possible head of the pancreas cancer
Possible signs of pancreatic cancer
- Palpable gallbladder
- Jaundice
- Epigastric mass
- Thrombophlebitis migrans (Trousseau sign)
- Splenomegaly: PV thrombosis → portal HTN
- Ascites
What do the bloods may show in pancreatic cancer? (3)
Bloods:
- cholestatic LFTs
- ↑Ca19-9
- ↑Ca
Imaging Ix in pancreatic cancer
Imaging
- high-resolution CT scanning → Ix of choice when pancreatic ca is suspected
- US: pancreatic mass, dilated ducts, hepatic mets, guide biopsy
- EUS: better than CT/MRI for staging
- CXR: mets
- Laparoscopy: mets, staging
- ERCP
- Shows anatomy
- Allows stenting
- Biopsy of peri-ampullary lesions
Management of Pancreatic cancer
- less than 20% are suitable for surgery at diagnosis
- a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas
- adjuvant chemotherapy is usually given following surgery
- ERCP with stenting is often used for palliation
Side effects of Whipple’s procedure
dumping syndrome and peptic ulcer disease
Prognosis for pancreatic ca
- Mean survival <6mo
- 5ys = <2%
Spread of metastasis in pancreatic ca
Present late, metastasise early
- Direct extension to local structures
- Lymphatics
- Blood → liver and lungs
What’s acute pancreatitis?
Autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis
Symptoms of acute pancreatitis
- Severe epigastric pain → back
- May be relieved by sitting forward
• Vomiting
Signs of acute pancreatitis
↑HR, ↑RR
- Fever
- Hypovolaemia → shock
- Epigastric tenderness
- Jaundice
- Ileus → absent bowel sounds
- Ecchymoses
- Grey Turners: flank
- Cullens: periumbilical
Causes of pancreatitis
I GET SMASHED
- Gallstones (45%)
- Ethanol (25%)
- Idiopathic (20%): ?microstones
- Trauma
- Steroids
- Mumps + other infections: Coxsackie B
- Autoimmune: e.g. PAN
- Scorpion (Trinidadian)
- Hyperlipidaemia (I and V), ↑Ca, Hypothermia
- ERCP: 5% risk
- Drugs: e.g. thiazides, azathioprine
Factors indicating severe pancreatitis
- age > 55 years
- hypocalcaemia
- hyperglycaemia
- hypoxia
- neutrophilia
- elevated LDH and AST
* the actual amylase level is not of prognostic value.
(3) scoring systems identifying cases of severe pancreatitis
cases of severe pancreatitis → may require intensive care management
These include:
- Ranson score
- Glasgow score
- APACHE II
Components of Glasgow Criteria
Glasgow criteria → to estimate severity of pancreatitis
Bloods and urinalysis in acute pancreatitis
Bloods
- FBC: ↑WCC
- ↑amylase (>1000 / 3x ULN) and ↑lipase (↑ in 80%); returns to normal by 5-7d
- U+E: dehydration and renal failure
- LFTs: cholestatic picture, ↑AST, ↑LDH
- Ca2+: ↓
- Glucose: ↑
- CRP: monitor progress, >150 after 48hrs = sev
- ABG: ↓O2 suggests ARDS
• Urine: glucose, ↑cBR, ↓urobilinogen
Imaging in acute pancreatitis
Imaging
- CXR: ARDS, exclude perforated duodenal ulcer
- AXR: sentinel loop, pancreatic calcification
- US: Gallstones and dilated ducts, inflammation
- Contrast CT: Balthazar Severity Score
Conservative management of acute pancreatitis
- Manage at appropriate level: e.g. ITU if severe
- constant reassessment is key
- Fluid Resuscitation
- Aggressive fluid resus: keep urine output >30ml/h
- Catheter ± CVP
- Pancreatic Rest
- NBM
- NGT if vomiting
- TPN may be required if severe to prevent catabolism
- Analgesia
- Pethidine via PCA
- Or morphine
- Antibiotics
- Not routinely given if mild
- Used if suspicion of infection or before ERCP
- Penems often used: e.g. meropenem, imipenem
Management of complication of acute pancreatitis
Mx Complications
- ARDS: O2 therapy or ventilation
- ↑ glucose: insulin sliding scale
- ↑/↓Ca
- EtOH withdrawal: chlordiazepoxide
Interventional management in acute pancreatitis
- what and when
Interventional Mx: ERCP
- If pancreatitis with dilated ducts secondary to gallstones
- ERCP + sphincterotomy → ↓ complications
Surgical management of acute pancreatitis
- indications
- procedures
Surgical Mx
Indications:
- Infected pancreatic necrosis
- Pseudocyst or abscess
- Unsure Dx
Operations:
- Laparotomy + necrosectomy (pancreatic debridement)
- Laparotomy + peritoneal lavage
- Laparostomy: abdomen left open with sterile packs in ITU
Early complications of acute pancreatitis
- systemic
- metabolic
Early:
A. Systemic
- Respiratory: ARDS, pleural effusion
- Shock: hypovolaemic or septic
- Renal failure
- DIC
B.Metabolic
- ↓ Ca2+
- ↑ glucose
- Metabolic acidosis
Late complications of acute pancreatitis (4)
Late (>1wk):
A. Local
- Pancreatic necrosis
- Pancreatic infection
- Pancreatic abscess
- May form in pseudocyst or in pancreas
- Open or percutaneous drainage
B. Bleeding: e.g. from splenic artery
- May require embolisation
C.Thrombosis
- Splenic A., GDA or colic branches of SMA
- May → bowel necrosis
- Portal vein → portal HTN
D. Fistula formation
- Pancreato-cutaneous → skin breakdown
What’s pancreatic pseudocyst?
- Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue
• Occur in 20% (esp. in EtOH pancreatitis)
Symptoms of pancreatic pseudocyst
- 4-6wks after acute attack
- Persisting abdominal pain
- Epigastric mass → early satiety
Complications of pancreatic pseudocyst
- Infection → abscess
- Obstruction of duodenum or CBD
Ix in pancreatic pseudocyst
- Persistently ↑ amylase ± LFTs
- US / CT
Management of pancreatic pseudocyst
- <6cm: spontaneous resolution
- >6cm
- Endoscopic cyst-gastrostomy
- Percutaneous drainage under US/CT
Causes of Chronic Pancreatitis
Causes: AGITS
- Alcohol (70%)
- Genetic
- CF
- haemochromatosis
• Immune
- Lymphoplasmacytic sclerosing pancreatitis
- Triglycerides ↑
- Structural
- Obstruction by tumour
- Pancreas divisum
Presentation of chronic pancreatitis
- Epigastric pain
- Bores through to back
- Relieved by sitting back or hot water bottle → erythema ab igne
- Exacerbated by fatty food or EtOH
- Steatorrhoea and wt. loss
- DM: polyuria, polydipsia
- Epigastric mass: pseudocyst
Investigations in chronic pancreatitis
- ↑ glucose
- ↓ faecal elastase: ↓ exocrine function
- US: pseudocyst
- AXR: speckled pancreatic calcifications
- CT: pancreatic calcifications
Management of chronic pancreatitis
Diet
- No alcohol
- ↓ fat, ↑ carb
Drugs
- Analgesia: may need coeliac plexus block
- Enzyme supplements: pancreatin (Creon)
- ADEK vitamins
- DM Rx
Surgery
- Indications
- Unremitting pain
- Wt. loss
- Duct blockage
- Procedures
- Distal pancreatectomy, Whipple’s
- Pancreaticojejunostomy: drainage
- Endoscopic stenting
Complications of chronic pancreatitis
Complications
- Pseudocyst
- DM
- Pancreatic Ca
- Pancreatic swelling → biliary obstruction
- Splenic vein thrombosis → splenomegaly
What’s that?
Multiple small calcific foci projected in the pancreas consistent with chronic pancreatitis
What’s that?
CT showing an irregular shaped pancreas with the typical calcification of chronic pancreatitis
