Pancreatic conditions Flashcards

1
Q

Risk factors associated with pancreatic cancer

A
  • 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
    *
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2
Q

Features/presentation of pancreatic cancer

A

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
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3
Q

The most common type and location of pancreatic cancer

A
  • 80% of pancreatic tumours are adenocarcinomas
  • typically occur at the head of the pancreas
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4
Q

What’s Courvoisier’s law?

A

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

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5
Q

Possible signs of pancreatic cancer

A
  • Palpable gallbladder
  • Jaundice
  • Epigastric mass
  • Thrombophlebitis migrans (Trousseau sign)
  • Splenomegaly: PV thrombosis → portal HTN
  • Ascites
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6
Q

What do the bloods may show in pancreatic cancer? (3)

A

Bloods:

  • cholestatic LFTs
  • ↑Ca19-9
  • ↑Ca
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7
Q

Imaging Ix in pancreatic cancer

A

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
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8
Q

Management of Pancreatic cancer

A
  • 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
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9
Q

Side effects of Whipple’s procedure

A

dumping syndrome and peptic ulcer disease

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10
Q

Prognosis for pancreatic ca

A
  • Mean survival <6mo
  • 5ys = <2%
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11
Q

Spread of metastasis in pancreatic ca

A

Present late, metastasise early

  • Direct extension to local structures
  • Lymphatics
  • Blood → liver and lungs
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12
Q

What’s acute pancreatitis?

A

Autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

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13
Q

Symptoms of acute pancreatitis

A
  • Severe epigastric pain → back
  • May be relieved by sitting forward

• Vomiting

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14
Q

Signs of acute pancreatitis

A

↑HR, ↑RR

  • Fever
  • Hypovolaemia → shock
  • Epigastric tenderness
  • Jaundice
  • Ileus → absent bowel sounds
  • Ecchymoses
  • Grey Turners: flank
  • Cullens: periumbilical
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15
Q

Causes of pancreatitis

A

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
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16
Q

Factors indicating severe pancreatitis

A
  • age > 55 years
  • hypocalcaemia
  • hyperglycaemia
  • hypoxia
  • neutrophilia
  • elevated LDH and AST

* the actual amylase level is not of prognostic value.

17
Q

(3) scoring systems identifying cases of severe pancreatitis

A

cases of severe pancreatitis → may require intensive care management

These include:

  • Ranson score
  • Glasgow score
  • APACHE II
18
Q

Components of Glasgow Criteria

A

Glasgow criteria → to estimate severity of pancreatitis

19
Q

Bloods and urinalysis in acute pancreatitis

A

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

20
Q

Imaging in acute pancreatitis

A

Imaging

  • CXR: ARDS, exclude perforated duodenal ulcer
  • AXR: sentinel loop, pancreatic calcification
  • US: Gallstones and dilated ducts, inflammation
  • Contrast CT: Balthazar Severity Score
21
Q

Conservative management of acute pancreatitis

A
  • 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
22
Q

Management of complication of acute pancreatitis

A

Mx Complications

  • ARDS: O2 therapy or ventilation
  • ↑ glucose: insulin sliding scale
  • ↑/↓Ca
  • EtOH withdrawal: chlordiazepoxide
23
Q

Interventional management in acute pancreatitis

  • what and when
A

Interventional Mx: ERCP

  • If pancreatitis with dilated ducts secondary to gallstones
  • ERCP + sphincterotomy → ↓ complications
24
Q

Surgical management of acute pancreatitis

  • indications
  • procedures
A

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
25
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
26
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
27
What's **pancreatic pseudocyst**?
* Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue • Occur in 20% (esp. in EtOH pancreatitis)
28
Symptoms of **pancreatic pseudocyst**
* 4-6wks after acute attack * Persisting abdominal pain * Epigastric mass → early satiety
29
Complications of pancreatic pseudocyst
- Infection → abscess - Obstruction of duodenum or CBD
30
Ix in **pancreatic pseudocyst**
* Persistently ↑ amylase ± LFTs * US / CT
31
Management of pancreatic pseudocyst
* \<6cm: spontaneous resolution * \>6cm - Endoscopic cyst-gastrostomy - Percutaneous drainage under US/CT
32
Causes of **Chronic Pancreatitis**
Causes: **AGITS** * **A**lcohol (70%) * **G**enetic - CF - haemochromatosis • **I**mmune - Lymphoplasmacytic sclerosing pancreatitis * **T**riglycerides ↑ * **S**tructural - Obstruction by tumour - Pancreas divisum
33
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
34
Investigations in **chronic pancreatitis**
* ↑ glucose * ↓ faecal elastase: ↓ exocrine function * US: pseudocyst * AXR: speckled pancreatic calcifications * CT: pancreatic calcifications
35
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
36
Complications of **chronic pancreatitis**
**Complications** * Pseudocyst * DM * Pancreatic Ca * Pancreatic swelling → biliary obstruction * Splenic vein thrombosis → splenomegaly
37
What's that?
Multiple small calcific foci projected in the pancreas consistent with chronic pancreatitis
38
What's that?
CT showing an irregular shaped pancreas with the typical calcification of chronic pancreatitis