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Year 2- Alimentary > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

Define Acute Pancreatitis

A

Sudden onset inflammation of the pancreas

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2
Q

How does acute pancreatitis present?

A
  • Severe Epigastric pain (may radiate to the back)
  • Vomiting/Nausea
  • Pyrexia

Can also cause a number of less common symptoms:
- Jaundice
- Acute Renal Failure
- Tachycardia (hypovolaemic shock)
- Retroperitoneal haemorrhage
- Effusions (Ascites/pleural)
- Paralytic Ileus

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3
Q

What do we call the visible signs of retroperitoneal haemorrhage in acute pancreatitis?

A

Grey Turner’s (on the flanks) & Cullen’s (Around the umbilicus) Signs

Both are severe bruising in the subcutaneous fat

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4
Q

How do we differentiate mild and severe acute pancreatitis?

A

Severe comes with organ failure or local complications.
Its determined by the modified glasgow criteria, if 3 or more of the criteria are +ve its severe.

A raised CRP also indicates its severe

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5
Q

What are the glasgow criteria for acute pancreatitis?

A

PANCREAS

PaO2 (<8)
Age >55yrs
Neutrophilia (Raised WCC)
Calcium (Low)
Renal Function (High Urea)
Enzymes (Raised LDH and AST/ALT Ratio)
Albumin (Low)
Sugar (Blood Glucose raised)

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6
Q

What are the local complications of acute pancreatitis?

A
  • Fluid Collection
  • Pseudocysts
  • Pancreatic Abscesses or necrosis
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7
Q

What are the common causes of acute pancreatitis?

A
  • Alcohol abuse is the biggest
  • Gallstones
  • Idiopathic

Can also be blunt trauma or post-op.

Rarely drugs/viruses/pancreatic carcinoma/metabolic/auto-immune

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8
Q

How do gallstones cause acute pancreatitis?

A

They raise intra-ductal pressure preventing flow of digestive enzymes out

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9
Q

What blood tests do we do for pancreatic disease?

A
  • Serum amylase/lipase (raised)
  • Glucose/U&E (Raised)
  • LFT (Raised AST/ALT)
  • FBC (Raised WCC)
  • Albumin (low)
  • Ca2+ (low)
  • ABG (can be low)
  • Coagulation Screen
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10
Q

What imaging can be done for acute pancreatitis?

A

AXR -
CXR - Pleural Effusion
Abdominal US - Gall stones, Pseudocyst, pancreatic oedema
CT

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11
Q

What emergency care do we give for an acute pancreatitis case?

A

HDU/ITU:
- Analgesia
- IV fluids
- Transfusion (If necessary)
- Catheterise
- NG tube to maintain nutrition
- O2 (can go into resp. failure)
- Insulin
- Ca supplement

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12
Q

Why do we catheterize an acute pancreatitis patient?

A

We want to monitor urine output in order to monitor Kidney function.
acute pancreatitis can cause kidney failure which show up as small urine volume (Oliguria)

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13
Q

How would we treat pancreatic abscess/necrosis as a complication of acute pancreatitis?

A

CT guided fine needle aspiration
Then antibiotics and/or surgery as necessary

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14
Q

What is a pseudocyst?

A

A fluid collection without an epithelial lining

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15
Q

What would indicate presence of a pseudocyst in acute pancreatitis?

A

Persistantly high serum amylase and/or pain.
Diagnose with US or CT

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16
Q

What further problems can a pseudocyst cause?

A

Jaundice
Infection
Haemorrhage
Rupture

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17
Q

How do we treat a pseudocyst?

A

Endoscopic drainage or surgery if it doesnt dissapear alone

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18
Q

How do we treat acute pancreatitis?

A
  • Emergency supportive care
  • Treat the complications
  • Treat the underlying causes (e.g. alcohol, abstinence, surgery etc)
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19
Q

Define Chronic Pancreatitis?

A

Continuing inflammatory disease of the pancreas characterized by irreversible glandular destruction and typically causing pain and/or impairment of function

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20
Q

What causes Chronic Pancreatitis?

A

O-A-TIGER
Obstruction - Main Pancreatic duct e.g. Cystic Fibrosis
Autoimmune
Toxin - Alcohol is the biggest cause of CP
Idiopathic
Genetic
Environmental
Recurrent injury

Also can be a congenital anatomical abnormality such as annular pancreas divisum where the ventral/dorsal pancreatic buds fail to fuse

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21
Q

Name a genetic cause for Chronic Pancreatitis?

A

Hereditary CP
Its a rare autosomal dominant disorder

22
Q

Name an environmental cause of Chronic Pancreatitis?

A

Tropical Chronic Pancreatitis

23
Q

What can cause recurrent pancreatic injury?

A

Hyperlipidaemia or hypercalcaemia

24
Q

What happens to the pancreas in Chronic Pancreatitis?

A
  • Glandular atrophy & fibrous replacement.
  • Ducts become dilated/tortuous/strictured
  • Inspissated secretions can calcify
  • Nerves can become exposed
  • Splenic/Sup Mesenteric/Portal veins can thrombose
25
Q

What does inspissated mean?

A

Thickened in consistency

26
Q

How do nerves become exposed in Chronic Pancreatitis?

A

Perineural cells are lost

27
Q

What is consequence of thrombosis of the portal vein, splenic vein or superior mesenteric vein?

A

Portal hypertension

28
Q

How does Chronic Pancreatitis present?

A

Early CP is often asymptomatic

  • Abdominal pain exacerbated by food or booze
  • Weight loss due to pain/anorexia/malabsorption
  • Exocrine insufficiency
  • Endocrine insuffciency

Also less commonly:
Jaundice/Portal hypertension/GI hemorrhage/Pseudocysts

29
Q

What are the consequences of hormonal insufficiency in Chronic Pancreatitis?

A

Exocrine:
- Fat Malabsorption -> Steatorrhea
- Protein Malabsorption -> Weight loss

Endocrine:
- Diabetes

30
Q

How would we investigate suspected Chronic Pancreatitis?

A

AXR - May see pancreatic calfication
US - Large pancreas, cysts, duct diameter, tumours
Endoscopic US
CT
Bloods
Pancreatic Function Tests

31
Q

What would we see on Chronic Pancreatitis bloods?

A

Low:
Albumin, Ca, Mg, B12
Raised LFTs, prothrombin time, glucose

Raised serum amylase in an acute exacerbation

32
Q

What kind of pancreatic function test are there?

A
  • Faecal/Serum enzymes
  • Diagnostic Enzyme replacement
  • Pancrealauryl test, response of enzymes to stimulus
33
Q

How do we manage Chronic Pancreatitis?

A
  • Pain control
  • Hormonal management
  • Surgery if indicated
34
Q

What kind of pain control is there for Chronic Pancreatitis?

A
  • Avoid alcohol
  • Opiate analgesia
  • Pain clinic referal
  • Endoscopically treat pancreatic duct stones/strictures
  • Some surgeries
  • Coeliac plexus block
35
Q

Explain a coeliac plexus block?

A

Done by injection
Suppresses of destroys coeliac plexus
This prevents pain long term.

36
Q

How do we manage the exocrine/endocrine sides of Chronic Pancreatitis?

A
  • Low Fat Diet
  • Pancreatic Enzyme supplements (they may require acid suppression therapies to survive the stomach)
37
Q

What would indicate surgery in Chronic Pancreatitis?

A

Malignancy
Intractable pain
Complications:
- Duct/duodenal Stenosis
- Biliary Obstruction or colonic stricture
- Cyst/pseudocyst
- Thrombosis or gastric varices
- Compression of portal vein

38
Q

What surgical options are there for Chronic Pancreatitis?

A

Depends on the cause and complications.

  • CBD Stent or bypass
  • Endoscopic PD sphincterectomy/dilatation/lithotripsy
  • Cyst drainage
  • Resection
  • Thorascopic Splanchectomy
39
Q

Who is most at risk of pancreatic carcinoma?

A

Westerners in their 60s-80s

40
Q

What are the risk factors for a pancreatic carcinoma?

A

Smoking
Chronic Pancreatitis
FAP (Familial Adenomatous Polyposis)
Hereditary Pancreatitis
Adult onset diabetes of less than 2 yrs

41
Q

What types of pancreatic carcinoma are there?

A
  • Duct Cell Mucinous Adenocarcinoma - 75% of total (msot are in the head)
  • Carcinosarcoma
  • Cystadenocarcinoma
  • Acinar Cell
42
Q

Whats a cystadenocarcinoma?

A

Basically the malignancy forms a cyst containing retained secretions

43
Q

What are the common clinical features of pancreatic carcinoma?

A
  • Upper Abdominal pain
  • Painless, slow, obstuctive jaundice
  • Weight loss

Also loads of less common stuff like
Anorexia - Fatigue - Steatorrhea - vomiting/nausea - ascites - portal hypertension etc

44
Q

What signs would indicate an unresectable pancreatic carcinoma?

A

Hepatomegaly
Jaundice
Abdominal mass/tenderness
Ascites
Splenomegaly
Supraclavicular lymphadenopathy

45
Q

In what form of pancreatic carcinoma would you feel a palpable gall bladder?

A

An ampullary carcinoma (not technically of the pancreas but related)

46
Q

What investigations could we do for suspected pancreatic carcinoma?

A

(Assuming each test comes up +ve for mass/carcinoma etc this is the suggested progression)

1) Abdominal US +/- CT/EUS

If they’re jaundiced do an ERCP with stent.

2) Then Percutaneous needle biopsy

3) CT/EUS/Laparoscopy/Laparotomy to stage

Bloods, CXR and tumour marker tests are also possible

47
Q

How do we determine if someone is fit for surgery?

A
  • Recieve fully informed consent
  • CXR/ECG/Resp function tests
  • Performance status
48
Q

What surgeries are available for pancreatic carcinoma?

A
  • Pancreatoduodenectomy (whipples procedure)
  • Pylorus Preserving Pancreatic Duodenectomy (PPPD)
  • Stent or cholechoduodenostomy for jaundice
49
Q

How does the whipples procedure work?

A

You remove the duodenum and pylorus.
Then anastomose the stomach, bile duct and pancreas directly to the small intestine

50
Q

How does PPPD work?

A

Remove duodenum and diseased part of pancreas.
Then anastomose the pylorus, bile duct and pancreas directly to the small intestine

51
Q

What is a cholechoduodenostomy?

A

Surgical anastomoses of the bile duct straight to the duodenum

52
Q

What is the prognosis for Pancreatic Cancer??

A

Inoperable - <6months
Operable - 15% survive to 5 yrs

Only 10% are operable by presentation anyway

I.e. no fuckin sunshine an rainbows over here

Year 2- Alimentary (37 decks)

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