Pancreatic Disease Flashcards
The endocrine portion of the pancreas is contained where?
Pancreatic islets
What is produced by the pancreatic islets?
Insulin by beta cells
Glucagon by alpha cells
Somatostatin
The exocrine function of the pancreas is carried out by which cells?
Acinar cells forming lobules
Describe connection of acinar lobules to the duodenum
Connected individually by ducts, intralobular ducts drain to main pancreatic duct to common bile duct to Sphincter of Oddi, to the duodenum
What is the function of the accessory pancreatic duct?
Connected to duodenum, utilised only if other ducts become blocked
What is the function of the exocrine pancreas?
Digestion
Secrete bicarbonate and digestive enzymes to pancreatic duct
What are pancreatic zymogens>
Inactive form of enzymes, produced in bicarbonate rich medium to prevent autodigestion
What is converted by enterokinase and where>
Trypsinogen to trypsin at brush border of duodenal enterocytes
What converts zymogens to active form>
Trypsin
Which enzymes are secreted by the pancreas?
Proteases Nucleases Elastases Phospholipases Lipases Alpha amylase
What stimulates bicarbonate secretion?
Secretin - activated by acid
Zymogen secretion is stimulated by?
CCK - released due to fat or amino acid in duodenum
Features of Acute pancreatitis
Acute inflammation causing upper abdominal pain
Elevation of serum amylase
Multi-organ failure in severe cases
Aetiology of acute pancreatitis
G- Gallstones E- Alcohol T- Trauma S- steroids M- Mumps A- Autoimmune S- Scorpion H- Hypercalcaemia, hypertriglyceridemia, Hypothermia E- ERCP D- Drugs; azathioprine, sodium valproate, diuretics
Pathogenesis of acute pancreatitis
Primary insult causes release of activated pancreatic enzymes leading to autodigestion
Release of proinflammatory cytokines and ROS
Oedema
Fat necrosis
Haemorrhage
Investigations for acute pancreatitis
Blood tests - amylase, lipase, FBC, U&Es, CRP, ABG, lipids, Calcium, LFTs
Abdominal X-ray and Chest X ray
Abdominal US
CT contrast enhanced
Management of acute pancreatitis
Analgesia IV Fluids Blood transfusion if required Monitor urine output Naso-gastric tube Oxygen Insulin Calcium Nutrition
Which scoring system is used for severity in acute pancreatitis?
Glasgow Criteria
If greater than 3 severe
Treatment for pancreatic necrosis
CT guided aspiration - antibiotics and surgery
Treatment for gallstones
EUS/MRCP/ERCP
Cholecystectomy
Complications of treatment in acute pancreatitis
Abscess
Pseudocysts
Management of abscess and pseudocysts
Antibiotics and drainage of abscess
Endoscopic drainage or surgery
Indications for US or CT in complications of acute pancreatitis
Jaundice
Haemorrhage
Infection
Rupture
Which patient group is chronic pancreatitis most common in?
Males
Age 35-50
Causes of chronic pancreatitis
Alcohol Cystic fibrosis Congenital abnormalities - annular pancreas, pancreas, divisium Hereditary pancreatitis Hypercalcaemia Diet
Which genetic associations are there to chronic pancreatitis?
PRSS1 - trypsinogen mutation
SPINK 1- pancreatic secretory trypsin inhibitor
CFTR
Pathogenesis of chronic pancreatitis
Duct obstruction - calculi, inflammation, protein plugs
Abnormal sphincter of Oddi - Spasm - intrapancreatic pressure increase, or relaxation - reflux of duodenal contents
Genetic polymorphisms - abnormal trypsin activation
Consequence of fibrotic changes in the pancreas in chronic pancreatitis
Spleni , Superior mesenteric and portal veins can fibrose leading to portal hypertension
Clinical features of chronic pancreatitis
Abdominal pain Weight loss Steatorrhoea Decreased Ca/Mg Decreased Vitamin B12 Diabetes
Jaundice Portal HT GI haemorrhage Pseudocysts Pancreatic carcinoma
Investigations of chronic pancreatitis
Abdominal X ray CT US EUS Bloods - amylase, albumin, LFTs, PT
Management of chronic pancreatitis
Avoid alcohol Pancreatic enzyme supplements Opiate analgesia Celiac plexus block Pain clinic Endoscopic treatment of strictures and stones Surgery Low fat diet Vitamin supplements Diabetic management
Complications of chronic pancreatitis
Acute on chronic attacks Cardiac complications of diabetes Associated cirrhosis Drug dependance Suicide
Most common tumour of the pancreas
Duct cell mucinous adenocarcinoma
Carcinosarcoma
Cystoadenocarcinoma
Acinar cell
Clinical features of pancreatic cancer
Painless obstructive jaundice Upper abdominal pain Weight loss Anorexia, fatigue, diarrhoea, steatorrhoea, nausea, vomiting Tender subcutaneous fat nodules - metastatic fat necrosis Thrombophlebitis migrans Asvites Portal hypertension
Signs on examination for pancreatic cancer
Hepatomegaly Jaundice Abdominal mass, tenderness Ascites Palpable gallbladder - ampullary carcinoma Splenomegaly Supracvlavicular lymphadenotpahty
Investigations for pancreatic cancer
Abdominal US CT EUS Jaundice and mass - ERCP and stent Mass no jaundice - EUS percutaneous needle biopsy - Laparoscopy/Laparotomy
Management of pancreatic cancer
Radical surgery - pancreatoduodenectomy - Whipple’s
Palliation of jaundice - stent, cholechoduodenostomy
Pain control - opiates, coeliac plexus block, radiotherapy
Chemotherapy
Prognosis for inoperable pancreatic cancer
Less than 6 months
Prognosis for operable pancreatic cancer
15% 5 year survival
Ampullary 30-50% 5 year survival
Differentials for acute pancreatitis - pain radiating to the back
AAA Renal calculi Chronic pancreatitis Aortic dissection Peptic ulcer disease
When is serum amylase diagnostic of acute pancreatitis?
When 3x normal upper limit
Other causes of raised serum amylase
Bowel perforation
Ectopic pregnancy
Diabetic ketoacidosis
What is included within the Glasgow score?
PANCREAS PO2 Age over 55 Neutrophils over 15 Calcium less than 2 Renal function - Urea greater than 16 Enzymes - LDH Ablumin /AST Sugar - Blood glucose greater than 10
Systemic complications of acute pancreatitis
Acute Respiratory Distress Syndrome
Disseminated Intravascular Coagulation
Hypocalcaemia
Hyperglycaemia
Local complications of acute pancreatitis
Pancreatic necrosis
Pseudocysts
Management of pseudocysts
Surgical debridement
Endoscopic drainage
