Pancreatic conditions Flashcards
Explain the anastamoses of pancreas with the GI tract
Pancreatic duct joins the common bile duct at the Ampulla of Vater.
At the duodenal papilla the Ampulla of Vater joins the duodenum, with bile/pancreatic juice flow controlled by the sphincter of Oddi
State the exocrine and endocrine functions of the pancreas
Exocrine:
- secretes lipase, amylase and proteases
- Secretion is influenced by gut hormones
Endocrine:
- secretes insulin, glucagon and somatostatin
- hormones involves in regulation of glucose storage and use
Define pancreatic cancer
Primary pancreatic ductal adenocarcinoma
>85% of all pancreatic neoplasms
Explain pathogenesis of pancreatic cancer
Follow a linear progression model from:
pre-invasive pancreatic intraepithelial neoplastic lesions
→ invasive ductal adenocarcinoma
What are the risk factors for pancreatic cancer
- Age
- Smoking
- Alcohol
- Diabetes mellitus
- Chronic pancreatitis
- Dietary (low intake of fresh fruit and vegetables, high fat and red/processed meat)
- Family history of pancreatic cancer
Summarise the epidemiology of pancreatic cancer
- Median age = 70
- 2 x more common in MALES
What is the prognosis of pancreatic cancer?
5-year survival rate is 8.5%
Overall median survival from diagnosis was 4.6 months
What are the presenting symptoms of pancreatic cancer?
Key signs:
- COURVOISIER’S sign- palpable gallbladder and painless jaundice
- Epigastric pain – radiates to back and relieved by sitting forward (75% of tumours in body and tail present with this)
- non-specific: weight loss/anorexia/nausea/weight loss
Signs of endocrine dysfunction
- thirst, polyuria, nocturia
- new diabetes mellitus
- steatorrhoea
Signs of thromboembolic disease
- TROUSSEAU’S SIGN - migratory thrombophlebitis
- petchiae, purpura, bruising
- venous thrombosis/thromboembolism
What investigations would you do for pancreatic cancer?
First line if suspected: LFTs and abdo USS
- pancreatic mass, dilated bile ducts, hepatic mets
- obstructive jaundice causing: raised ALP, gamma-GT and bilirubin
Bloods
- clotting screen- raised PTT (derangement of vitK clotting factors)
- FBC- anaemia in GI bleeding, thrombocytopaenia
- Tumour markers- (CA)19-9
Imaging- check for spread + mass
- Pancreatic protocol CT- DIAGNOSTIC
- PET scan
- ERCP - may allow biopsy, bile cytology and stenting
Define acute pancreatitis
Acute systemic and local inflammatory response of the exocrine pancreas associated with acinar cell injury
How is the severity of pancreatitis classified?
Mild:
- No organ failure or local/systemic complications
- resolves within a week
- commonest form
Moderate = 1 of :
- +/- transient organ failure lasting <48 hours
- +/- local complications/ exacerbations of comorbidities
Severe:
- Persistant organ failure >48 hours
- local complications:
- abscess
- necrosis
- pseudocyst
- local complications:
Briefly explain the pathophysiology behind acute pancreatitis
self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion
An insult results in activation of pancreatic proenzymes within the pancreatic duct/acini
Leads to tissue damage and inflammation
State the common causes of pancreatitis
I GET SMASHED (first 4 = most common)
- Idiopathic
- Gallstones
- Ethanol- has to be frequent binge/6 units daily for 5 years
- Trauma- recent abdo or invasive procudures (ERCP)
- Steroids
- Mumps + Malignancy + mycoplasm
- Autoimmune
- Scorpion venom
- Hypercalcaemia/Hyperthyroidism/hypothermia
- ERCP/emboli
- Drugs: sodium valproate, azathioprine, thiazides, mercaptopurine
Summarise the epidemiology of pancreatitis
Common, increasing in incidence
- 50% gallstones (older, in women)
- 25% alcohol (younger, in men)
peak age = 60
What are the presenting symptoms of acute pancreatitis?
Severe constant epigastric pain radiating to the back
- relieved by sitting forward
- sudden onset (like being stabbed)
- worsens with movement
Associated with nausea + vomiting + anorexia
May present with dysponea due to pleural effusion
What are the common signs O/E of acute pancreatitis?
Common
- Tender, distended abdomen
- Voluntary guarding on palpation of the upper quadrants
- Diminished bowel sounds if ileus has developed
What are the common signs O/E of acute pancreatitis?
Blood vessel autodigestion
→ retroperitoneal haemorrhage + necrotic exudates
→ ecchymotic bruising:
- Periumbilical region: Cullen’s sign
- Flanks: Gey-Turner’s sign
- Inguinal ligament: Fox’s sign
Hypocalcaemia:
- Facial nerve entrappement + spasm: Chvosek’s sign
- Carpopedal spasm on inflation of BP cuff: Trousseau’s sign
What key blood test would you do for acute pancreatitis? What are the lmiitations of this test?
Serum lipase/amylase >3X upper limit of normal
- CONFIRMS DIAGNOSIS with associated acute UQ pain
- fall within 3-5 days so may be normal
30% of patients presenting with acute pancreatitis will have a normal amylase level – either because of:
- a late presentation
- very severe pancreatitis
- acute-on-chronic pancreatitis
What blood investigations would you do for acute pancreatitis?
FBC-
- Leukocytosis + left cell shift (increase in proportion of immature WBCs). Seen in SIRS
-
Elevated haematocrit >44% (due to dehydration through third-space fluid loss)
- predicts severity, prognosis + likelihood of progression to necrotising pancreatitis
LFTs-
- Pancreatic amylase/lipase >3x UL normal = diagnostic
- ALT >3x = GALLSTONE aetiology
- ALP + GGT may be slightly raised
U+Es-
- elevated urea + creatine in severe disease
- dehydration/hypovolaemia (shock, vomiting, 3rd spacing)
- elevated calcium if hypercalcaemia is the cause
Inflammatory markers-
-
CRP- indicates severity.
- cereal readings allow monitoring of progression
- high readings associated w/necrosis
Blood glucose (BM)-
- hyperglycaemia marks severity
What imaging would you do for acute pancreatitis?
-
Abdominal USS
- not diagnostic- only need clinical signs + amylase
- for all patients, to look for biliary aetiology
-
Abdominal Xray
- exclude other causes of acute abdomen
-
Erect CXR
- check for pleural effusion, atelectasis
-
Contrast Enhanced CT (CECT) abdomen
- May see necrosis, pseudocysts, enlarged pancreas
- ie determines disease severity if PT not improving
Describe the UK scoring scale for acute pancreatitis
Glasgow scale
PANCREAS (severity based on results within 48h of admission)
Each score is 1, >3 = severe pancreatitis
How is pancreatitis managed medically?
-
A-E approach
- can develop ARDS, hypotension (3rd spacing)
- large bore IV access + catheter to monitor
- Once stable:
- IV fluids
- Oxygen
- Stop oral feeding- avoid stimulating pancreas with food
- Analgesia
- Anti-emetics
- DVT prophylaxis
- Prophylactic Abx in severe disease
Most patients recover in a week.
ERCP + spincterectomy if gallstones are the cause. Necresectomy if pancreas is necrotised.
What are the common complications of pancreatitis?
Local:
- Pancreatic necrosis
- Pseudocyst (peripancreatic fluid collection lasting > 4 weeks)
- Abscess
- Bleeding
- Ascites
- Pseudoaneurysm
- Venous thrombosis
Systemic:
- Multiorgan dysfunction
- Sepsis
- Renal failure
- ARDS
- DIC
- Hypocalcaemia
- Diabetes
Long-Term: could result in chronic pancreatitis with diabetes and malabsorption
What is the prognosis for patients with acute pancreatitis?
- 20% follow severe fulminating course with high mortality
- Infected pancreatic necrosis has a 70% mortality
- 80% follow a milder course (but this still has 5% mortality)
