Pancreatic Disease Flashcards
What is Acute Pancreatitis?
- Acute inflammation of the pancreas
- Upper abdominal pain
- Elevation of serum amylase (>4 times the upper limit of normal)
- May be associated with multi-organ failure in severe cases
What is the aetiology of acute pancreatitis?
Alcohol abuse (60-75%) Gallstones (25-40%)
Trauma: blunt, post op, post-ERCP
Misc:
- Drugs (steroids, azathioprine, diuretics)
- Virus’ (mumps, coxsackie B4, HIV, CMV)
- Pancreatic Carcinoma
- Metabolic (Increased calcium and triglycerides. Decreased temperature)
- Auto-immune
Ideopathic
What is the pathogenesis of Acute pancreatitis?
Primary insult causes activated pancreatic enzymes to be released.
Autodigestion causes:
- oedema, fat necrosis and haemorrhage
- Reactive oxygen species, pro-inflammatory cytokines
What are Ecchymoses?
Subcutaneous spot of bleeding with diameter over 1cm.
Around the umbilicus and the flanks are what to keep an eye out for in acute pancreatitis.
Indicate severe nectrotising pancreatitis
What blood tests would you carry out as part of the investigations for acute pancreatitis?
Amylase/Lipase FBC, U+Es LFT, Ca Glucose, Lipids ABGs Coagulation screen
What imaging techniques would you use in investigation into acute pancreatitis?
AXR (ilius), CXR (pleural effusion) Abdominal USS (Pancreatic oedema, gallstones, pseudocyst) CT scan (contrast enhanced)
How do you assess severity in acute pancreatitis?
White cell count >15x10^9/l Blood Glucose >10 mol/l Blood urea >16mmol/l AST >200iu/l LDH >600iu/l Serum albumin 3 = SEVERE (within 48hrs of admission)
CRP >150mg/l also indicates severe pancreatitis
What is the general management of acute pancreatitis?
Analgesia (pethidine, indomethacin) IV Fluids Blood transfusion (Hb
What is the specific management of Acute pancreatitis?
Pancreatic Necrosis:
- CT guided aspiration
- Antibiotics +/- surgery
Gallstones
- EUS/MRCP/ERCP
- Cholecystectomy
What are the management of complications in acute pancreatitis?
Abscess = antibiotics and drainage
Pseudocyst =
-Fluid collection without an epithelial lining
-Persistent hyperamylasaemia and/or pain
-Dx by ultrasound or CT scan
-Complications: jaundice, infection, haemorrhage, rupture
-
What is a pseudocyst?
Fluid collection without an epithelial lining
Persistant hyperamylasaemia and/or pain
Dx by ultrasound or CT scan
Complications = jaundice, infection, haemorrhage, rupture
Define chronic pancreatitis
Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and or permanent loss of function
What is the epidemiology of chronic pancreatitis?
Prevalence = 0.01% in Japan -> 5.4% in S. India
Incidence = 3.5/100,000 pop per year
Males > females
Age 35-50 years
What is the aetiology of chronic pancreatitis?
Alcohol (80%) Cystic Fibrosis (CP in 2%) -High Frequency of CFTR mutations in CP Congenital anatomical abnormalities -Annular Pancreas -Pancreas Divisum (failed fusion of dorsal and ventral buds) Hereditary Pancreatitis: rare, auto. dom. Hypercalcaemia
What genes are associated with Pancreatitis?
PRSS1 - Cationic trypsinogen
SPINK 1 - Pancreatic secretory trypsin inhibitor
CFTR
What is the pathogenesis of chronic pancreatitis?
Duct obstruction:
- Calculi
- Inflammation
- Protein plugs
?Abnormal sphincter of Oddi function
- spasm increases intrapancreatic pressure
- Relaxation: reflux of duodenal contents
?Genetic polymorphisms
-Abnormal trypsin activation
What is the pathology of chronic pancreatitis?
Glandular atrophy and replacement by fibrous tissue
Ducts become dilated, tortuous and structured
Inspissated secretions may calcify
Exposed nerves due to loss of perineurall cells
Splenic, superior mesenteric and portal veins may thrombose -> portal hypertension
What are the clinical features of chronic pancreatitis?
Early disease is asymptomatic
ABDOMINAL PAIN (85-95%) -Exacerbated by food and alcohol; severity decreases with time
WEIGHTLOSS (pain, anorexia, malabsorption)
Exocrine insufficiency
- Fat malabsorption -> steatorrhoea
- —decrease in fat soluble vitamins, Ca and Mg
- Protein malabsorption
- —WEIGHTLOSS and decreased it B12
Endocrine insufficiency -> DIABETES in 30%
Misc: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma
What are the investigations for chronic pancreatitis?
Plain AXR (30% have calcification of pancreas)
USS = Pancreatic size, cysts, duct diameter, tumours
EUS
CT scan
Blood tests =
- Serum amylase (raised in acute exacerbations)
- Decreased albumin, Ca, Mg, Vit B12
- Increased LFTs, Prothrombin time (Vit K), glucose
Pancreatic function tests (Lundh, pancreolauryl)
What is the management of chronic pancreatitis?
PAIN CONTROL
Avoid alcohol
Pancreatic enzyme supplements
Opiate analgesia (dihydrocodeine, pethidine)
Coeliac plexus block
Referral to pain clinic/ psychologist
Endoscopic treatment of pancreatic duct stones and strictures
Surgery in selected cases
how do you manage exocrine and endocrine problems in chronic pancreatitis?
Low fat diet
Pancreatic enzyme supplements (e.g. Creon, Pancrex)
-May need acid suppression to prevent hydrolysis in stomach
Vitamin supplements usually not required
Insulin for diabetes mellitus
What is the prognosis in chronic pancreatitis?
Death from complications of acute on chronic attacks Cardiovascular complications of diabetes Associated cirrhosis Drug dependence Suicide
Continued alcohol intake -> 50% 10 year survival
Abstinence -> 80% 10 year survival
What is the epidemiology for carcinoma of the pancreas?
Incidence: 11/100,000 pop/year (increasing) Males>Females 80% in 60-80 year age group More common in western countries - Highest rates in Maoris and Hawaiians
What is the pathology for carcinoma of the pancreas?
75% are duct cell mucinous adenocarcinoma
(Head 60%, body 13%, tail 5%, multiple sites 22%)
Other pathological types
- carcinosarcoma
- cystadenocarcinoma (better prognosis)
- Acinar cell
What are the clinical features of pancreatic cancer?
Upper ABDOMINAL PAIN (75%)- Ca body and tail
Painless obstructive JAUNDICE (25%)- Ca head
WEIGHTLOSS (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans
Ascites, portal hypertension
What are the physical signs of carcinoma of the pancreas?
Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites, splenomegaly
Supraclavicular lymphadenopathy (shows an unresectable tumour)
Palpable gallbladder (with ampullary carcinoma)
What imaging do you use in pancreatic carcinoma?
USS
CT
MRI
EUS
What is the management of pancreatic carcinoma?
Majority of patients have advanced disease at presentation and
What is the prognosis of pancreatic cancer?
Inoperable cases:
-Mean survival
