Pancreatic disease Flashcards
Causes of pancreatitis
I idiopathic
G gallstones
E ethanol
T trauma
S steroid
M mumps
A autoimmune eg SLE
S scorpion sting
H hypercalcaemia, hypertriglyceridemia, hypothermia, hyperparathyroidism
E RCP
D drugs (azathioprine, mesalazine, didanosine, pentamidine, steroids, sodium valproate, NSAIDs, or Diuretics)
Clinical presentation of pancreatitis
Pain - Sudden onset, Mid-epigastric or LUQ, radiates to the back,worsens with movement, worsens on lying down, some patients find it is eased by taking the fetal position
N&V
Anorexia
Jaundice if gallstone aetiology
Pancreatitis signs
tender and distended abdomen with voluntary guarding
haemorraghic pancreatitis can result In bluish discolouration around the umbilicus (Cullen’s sign)
or the flank (Grey-Turner’s sign)
Diminished bowel sounds if an ileus has developed
Signs of Hypovolaemia
Signs of pleural effusion
Glasgow scale of Pancreatitis Severity (PANCREAS)
PaO2< 7.9kPa Age > 55 years Neutrophils (WBC > 15) Calcium < 2 mmol/L Renal function: Urea > 16 mmol/L Enzymes LDH > 600IU/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
To diagnose pancreatitis
characteristic pain and amylase/ lipase >3 times normal level
Pancreatitis Ix
Pulse oximetry
FBC- leukocytosis can indicate the presence of necrotising pancreatitis
Serum lipase or amylase
LFTS- Elevated ALT levels strongly suggest gallstones as the cause
Pancreatitis imaging Ix
US - gallstones
AXR -‘sentinal loop sign’ a dilated proximal bowel loop adjacent to the pancreas,calcifications
CXR- pleural effusion/ ARDS/lung ca
CT- diagnostic doubt or failure to improve, can show pancreatic oedema,pseudocysts,necrotizing pancreatitis
Pancreatitis Mx
Resuscitation with intravenous fluids
Supplemental oxygen
Pain relief
Abx if infection
Catheterisation to accurately monitor urine output and start a fluid balance chart
Early nutritional support & Nasogastric tube if patient is vomiting profusely
Antiemetic
Pancreatic infected necrosis Mx
radiological drainage or surgical necrosectomy
Pancreatitis differentials
Perforated peptic ulcer, bowel obstruction, or ischaemic bowel
Ruptured abdominal aortic aneurysm
Myocardial infarction
Biliary colic, acute cholecystitis, or cholangitis
Viral hepatitis
Gastroenteritis
Symptoms of exocrine insufficiency in chronic pancreatitis
Weight loss
diarrhoea
Malnutrition/malabsorption
Steatorrhoea
Type 3c (pancreatogenic) diabetes
due to endocrine insufficiency secondary to damage to the endocrine tissue the islet of langerhans resulting in failure to produce insulin
needs to be monitored long-term using annual HbA1c measurements
Chronic pancreatitis Ix
FBC,LFT,
Amylase may not rise bc pancreas has lost its ability to produce the enzyme
Blood glucose
Faecal elastase level- low in most cases of chronic pancreatitis with exocrine insufficiency
Chronic pancreatitis Imaging Ix
US
CT- more sensitive at detecting pancreatic calcification, detects pseudocysts
Chronic pancreatitis Mx
can only be managed definitively by treating any reversible underlying cause. This can include alcohol cessation or statin therapy for hyperlipidaemia
Chronic pancreatitis pain relief
- prescribe paracetamol or a nonsteroidal anti-inflammatory drug (NSAID), for example ibuprofen, first-line.
- weak opiod like codeine phosphate
Chronic pancreatitis screening
Diabetes mellitus- Check serum HbA1c levels every 6 months
Osteoporosis- Offer a dual-energy X-ray absorptiometry (DXA) scan to assess bone density every 2 years
Cx chronic pancreatitis
Carcinoma occurs in 2-3%
pain
Pseudocyst
Pancreatic cancer histology
90% are adenocarcinomas of the head of the pancreas
The World Health Organisation Performance Status classification
0 : able to carry out all normal activity
1: restricted in strenuous activity
2: up and about more than 50% of waking hours
3 : symptomatic and in a chair/bed for greater than 50% of the day but not bedridden
4 : completely disabled
pancreatic cancer risk factors
Smoking
chronic pancreatitis
hereditary element
Late onset diabetes mellitus
age
Alcohol
Courvoisier’s law
Painless jaundice plus a non-tender palpable gallbladder is pancreatic cancer until proven otherwise
Pancreatic cancer clinical presentation
Painless obstructive jaundice
Unintentional weight loss
Pale stools
Steatorrhoea
Dark urine
Palpable mass in epigastric region
Upper Abdominal/back pain
Pancreatic cancer clinical presentation
Painless obstructive jaundice
Unintentional weight loss
Pale stools
Steatorrhoea
Dark urine
Palpable mass in epigastric region
Upper Abdominal/back pain
