Pancreatic Disease Flashcards
Acute Pancreatitis
-Acute inflammation of the pancreas resulting in upper abdominal pain and elevation of serum amylase (>4x upper limit of normal) and can be associated with multi-organ failure in severe cases
What is the epidemiology of acute pancreatitis?
- Incidence 20-300 cases/million
- Mortality 6-12/million
What is the aetiology of acute pancreatitis?
- Alcohol abuse
- Gallstones
- Trauma
- Miscellaneous
- Idiopathic
What falls into the miscellaneaos category of acute pancreatitis aetiology?
- Drugs (steroids, azathioprine, diuretics)
- Viruses (mumps, coxsackie B4, HIV, CMV)
- Pancreatic carcinoma
- Metabolic (increased CA, increased triglycerides, decreased temp)
- Auto-immune
What is the pathogenesis of acute pancreatitis?
- Primary insult
- Release of activated pancreatic enzymes
- Autodigestion
What are the 2 pathways that can occur as a result of autodigestion?
- Pro-inflammatory cytokines and reactive oxygen species
- Oedema, fat necrosis and haemorrhage
What are the clinical features of acute pancreatitis?
- Abdominal pain
- Vomiting
- Pyrexia
- Tachycardia, hypovolemic shock
- Oliguria, acute renal failure
- Jaundice
- Paralytic ileus
- Retroperitoneal haemorrhage
- Hypoxia
- Hypocalcaemia
- Hyperglycaemia
- Effusions
ERCP
Endoscopic retrograde cholangio-pancreatography
What blood tests should be carried out in acute pancreatitis?
- Amylase, lipase
- FBC
- U+Es
- LFTs
- Ca
- Glucose
- ABG
- Lipids
- Coagulation screen
What X-rays should be carried out in acute pancreatitis?
- Abdominal X-ray for ileus
- Chest X-ray for effusion
What are you looking for on an abdominal ultrasound in acute pancreatitis?
- Pancreatic oedema
- Gallstones
- Pseudocysts
What type of CT should be carried out in acute pancreatitis?
Contrast enhanced
What criteria is used to assess the severity of acute pancreatitis?
Glasgow criteria
What indicates severe acute pancreatitis within 24hrs of admission?
- Glasgow criteria score >3
- CRP>150mg/l
What are the points in the Glasgow criteria assessment?
-WCC >15x10^9/l
-Blood glucose >10mmol/l
-Blood urea>16mmol/l
-AST>200iu/l
-LDH>600iu/l
-Serum albumin <32g/l
-Serum calcium<2mmol/l
Arterial PO2 <7.5kPa
What is the general management for acute pancreatitis?
- Analgesia
- IV fluids
- Blood transfusion if Hb<10g/dl
- Monitor urine output
- NG tube
- Oxygen
- Insulin if required
- Nutrition-
What is the specific management of acute pancreatitis if there is pancreatic necrosis?
- CT guided aspiration
- Antibiotics
- Surgery if required
What is the specific management of acute pancreatitis if there is gallstones?
- EUS/MRCP/ERCP
- Cholecystectomy
What is the specific management of acute pancreatitis if there is an abscess?
- Antibiotics
- Drainage
Pseudocyst
Fluid collection without an epithelial lining resulting in persistent hyperamylasaemia with or without pain
How is a pseudocyst diagnosed?
- Ultrasound
- CT
What are the complications of a pseudocyst?
- Jaundice
- Infection
- Haemorrhage
- Rupture
When will a pseudocyst resolve spontaneously?
<6cm diameter
What is the treatment for a pseudocyst if there is persistent pain or complications?
- Endoscopic drainage
- Surgery
What are the different outcomes of acute pancreatitis?
- Mild AP mortality<2%
- Severe AP mortality 15%
- Subsequent course dependent on removal of aetiological factor
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?
- M>F
- Age 35-50 years
- Incidence 3.5/100,000 per year
What is the aetiology of chronic pancreatitis?
- Alcohol
- Cystic fibrosis
- Congenital anatomical abnormalities
- Hereditary pancreatitis (rare autoimmune dominant)
- Hypercalcaemia
- Diet
What anatomical abnormalities can result in chronic pancreatitis?
- Annular pancreas
- Pancreas divisum
What genes are associated with chronic pancreatitis?
- PRSS1
- SPINK1
- CFTR
What is the pathogenesis of chronic pancreatitis?
- Duct obstruction (calculi, inflammation, protein plugs)
- Abnormal sphincter of Oddi function (spasm raising intrapancreatic pressure, relaxation causing 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, tortous and strictured
- Inspissated secretions may calcify
- Exposed nerves due to loss of perineural cells
- Splenic, superior mesenteric and portal veins may thrombose leading to portal hypertension
What are the clinical features of chronic pancreatitis?
- Early disease is asymptomatic
- Abdominal pain
- Weight loss
- Exocrine insufficiency
- Endocrine insufficiency
- Jaundice
- Portal hypertension
- GI haemorrhage
- Pseudocysts
- Pancreatic carcinoma
Describe the exocrine insufficiency in chronic pancreatitis.
- Fat malabsorption leading steatorrhoea
- Decrease in fat soluble vitamins
- Decrease in Ca and Mg
- Protein malabsorption leading weight loss and decrease in vitamin B12
What does the endocrine insufficiency in chronic pancreatitis lead to ?
Diabetes
What investigations should be carried out in chronic pancreatitis?
- Plain AXR
- Ultrasound
- EUS
- CT
- Blood tests
- Pancreatic function tests
What may be found in blood tests of chronic pancreatitis?
- Serum amylase increased in acute exacerbations
- Decrease in albumin, Ca, Mg, vit B12
- Increase in LFTs, prothrombin time, glucose
What is involved in pain control management for chronic pancreatitis?
- Avoid alcohol
- Pancreatic enzyme supplements
- Opiate analgesia
- Celiac plexus block
- Referral to pain clinic/psychologist
- Endoscopic treatment of pancreatic duct stones and strictures
- Surgery in selected cases
What is involved in the management of the endocrine and exocrine problems associated with chronic pancreatitis?
- Low fat diet
- Pancreatic enzyme supplements (may need acid suppression to prevent hydrolysis in stomach)
- Insulin for diabetes mellitus
What is the prognosis for chronic pancreatitis?
- Death from complications of acute on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
- Continued alcohol intake 50% 10yr survival
- Abstinence 80% 10yr survival
What is the epidemiology of carcinomas of the pancreas?
- Incidence 11/100,000 per year
- M>F
- More common in Western countries
What are the pathological types of pancreatic carcinomas?
- Duct cell mucinous adenocarcinomas
- Carcinosarcoma
- Cystadenocarcinoma
- Acinar cell
What are the clinical features of pancreatic carcinomas?
- Upper abdominal pain
- Painless obstructive jaundice
- Weight loss
- Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
- Tender subcutaneous fat nodules
- Thrombophlebitis migrans
- Ascites, portal hypertension
What are the physical signs of pancreatic carcinomas?
-Hepatomegaly
-Jaundice
-Abdominal mass
-Abdominal tenderness
-Ascites, splenomegaly
-Supraclavicular lymphadenopathy
PRESENCE OF ABOVE SIGNS USUALLY INDICATES AN DUNRESECTABLE TUMOUR
-Palpable gallbladder (with ampullary cancer)
What imaging is used in pancreatic carcinomas?
- USS
- CT
- MRI
- EUS
What are the management options for pancreatic carcinoma?
- Radical surgery
- Palliation of jaundice
- Pain control
- Chemotherapy only in controlled trials
What is the radical surgery in pancreatic carcinoma?
- Pancreatoduodenectomy (Whipple)
- Patient is fit, tumour <3cm, no metastases
What is available for palliation of jaundice?
- Stent
- palliative surgery (cholechoduodenotomy)
What pain control is there for pancreatic carcinoma?
- Opiates
- Coeliac plexus block
- Radiotherapy
What is the prognosis for pancreatic carcinoma?
- Inoperable cases mean survival <6months with 1% 5yr survival
- Operable cases 15% 5yr survival
