Pancreatic Disease Flashcards
define acute pancreatitis
acute inflammation of the pancreas
what is elevated in acute pancreatitis?
serum amylase
what is the aetiology of acute pancreatitis?
> alcohol abuse > gallstones > trauma >drugs > viruses > carcinoma > metabolic > autoimmune > idiopathic
describe the parthenogenesis of acute pancreatitis
the primary insult results in the release of activated pancreatic enzymes which create auto-digestion releases pro-inflammatory cytokines and reactive oxygen species creating oedema, fat necrosis, haemorrhage
what are the clinical features of acute pancreatitis?
> jaundice if there is biliary obstruction
> bruising of abdominal wall
what does ercp stand for?
Endoscopic
Retrograde
Cholangio
Pancreatography
what blood tests should be carried out in acute pancreatitis?
> amylase/lipase > FBC > U+E's > LFT's > glucose > arterial blood gases > lipids > coagulation screen
what investigations should be carried out in acute pancreatitis?
> blood tests
AXR and CXR
abdominal ultrasound
CT scan
what Glasgow score means there is severe pancreatitis?
> 3
what is the general management for acute pancreatitis?
> analgesia > intravenous fluids > blood transfusion > monitor urine output > naso-gastric tube > oxygen > (insulin) > (calcium supplements) > Nutrition
what is the management in acute pancreatitis if there is pancreatic necrosis?
ct guided aspiration then antibiotics (maybe surgery)
what is the specific management for gallstones in acute pancreatitis?
> EUS/MRCP/ERCP
> cholecystectomy
what complications can arise from acute pancreatitis?
> abscess
> pseudocyst
what is a pseudocyst?
fluid collection without an epithelial lining creating persistent hyperamylasaemia and pain. it can go on to cause jaundice, infection, haemorrhage or rupture.
what is the management of pseudocyst?
endoscopic drainage or surgery if there is persistent pain or complications
what is the mortality in severe acute pancreatitis?
15%
define chronic pancreatitis
continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction, typically causing pain/permanent loss of function.
describe the epidemiology of chronic pancreatitis
> males affected more than females
> ages 35-50 years
what is the aetiology of chronic pancreatitis?
> alcohol > cystic fibrosis > congenital anatomical abnormalities > hereditary pancreatitis > hypercalcaemia
name three genes that are most well recognised as being susceptible to pancreatitis
> PRSS1
SPINK1
CFTR
describe the parthenogenesis of chronic pancreatitis
> duct obstruction causes inflammation and protein plugs
spasming sphincter of oddi increases the intra-pancreatic pressure
relaxation of the sphincter of oddi causes duodenal contents to reflux
genetic polymorphisms: abnormal trypsinogen activation
describe the pathology of chronic pancreatitis
> glandular atrophy and replacement with fibrous tissue
ducts are dilated, tortous and strictured
inspissated secretions may calcify
nerves are exposed as perinueral cells is lost
splenic, superior mesenteric and portal veins may thrombose
what are the clinical features of chronic pancreatitis?
> asymptomatic in early disease > abdominal pain > weight loss > exocrine insufficiency > endocrine insufficiency > (jaundice, portal hypertension, gi haemorrhage, pseudocysts)
what investigations are carried out for chronic pancreatitis?
> plain AXR > ultrasounds > EUS > CT > blood tests > pancreatic function tests
how may blood tests results be changed by chronic pancreatitis?
> increased serum amylase
decreased albumin, calcium, magnesium and vit b12 levels
increased LFT’s, prothrombin time, glucose
how is pain managed in chronic pancreatitis?
> avoidance of alcohol > pancreatic enzyme supplements > opiate analgesia > coeliac plexus block > referral to pain clinic > endoscopic treatment of pancreatic duct stones and strictures >surgery
what is the management for exocrine and endocrine problems in chronic pancreatitis?
> low fat diet
pancreatic enzyme supplements
vitamin supplements
insulin for diabetics
how does alcohol intake change the survival rate in chronic pancreatitis?
> continued drinking: 50% 10 years
> abstinence: 80% 10 years
what pathological types of pancreatic carcinomas are there?
> adenocarcinoma (75%)
carcinosarcoma
cystadenocarcinoma
acinar cell
what are the clinical features of pancreatic carcinomas?
> upper abdominal pain > painless obstructive jaundice > weight loss > fatigue > diarrhoea/steatorrhoea > nausea/vomiting > tender subcutaneous fat nodules > ascites > thrombophlebitis migrans
what are the physical signs of pancreatic carcinomas?
> hepatomegaly > jaundice > abdominal mass > abdominal tenderness > ascites > splenomegaly > supraclavicular lymphadenopathy > palpable gallbladder
what investigations would you carry out in clinical suspicion of pancreatic carcinoma?
abdominal ultrasound (ct scan and EUS)
if there was mass and jaundice present after initial investigation of pancreatic carcinoma what investigation would you then carry out?
> ERCP (and maybe a stent)
> then an EUS/percutaneous needle biopsy
if a mass was found in the initial investigations of a carcinoma of the pancreas what investigations would be carried out?
> EUS/percutaneous needle biopsy
what investigations would you carry out to assess if a diagnosed carcinoma of the pancreas was operable?
> CT scan
EUS
laparoscopy
laparotomy
what are the criteria for pancreatoduodenectomy in pancreatic cancer?
> fit
tumour <3cm in diameter
no metastasis
(<10% are operable)
what is the management of pancreatic carcinomas?
> radical surgery: pancreatoduodenectomy
palliation of jaundice
pain control
chemo (only in controlled trails)
what is the survival rate in non-operable pancreatic carcinoma?
> 1% survival at 5years
mean survival rate is 6 months
what is the survival rate in operable cases of pancreatic carcinomas?
> 15% 5year survival
> ampullary tumours 30-50% 5 year survival
describe kausch-whipple pancreatic surgery
distal part of stomach, duodenum, head of pancreas and bile duct are removed. there are many variable ways of anastomosing back together. .
when could you offer palliative drainage?
> obstructive jaundice
> duodenal obstruction
what surgery would you carry out in acute pancreatitis id there is infected necrosis?
necrosectomy: laparotomy, minimally invasive
what interventional procedures could you provide for chronic pancreatitis where there is pancreatic duct stenosis and obstruction?
> endoscopic pancreatic duct sphincetortomy, dilation and lithotripsy
what interventional procedures could you provide for chronic pancreatitis?
> Cystic bile duct stenting/bypass
thoracoscopic splanchnectomy
caeliac plexus block (CT guided, EUS guided, fluoroscopy guided)
name two surgeries used to drain
> pancreatic duct sphincteroplasty
> puestow
name some resection surgeries
> beger > PPPD > whipple's pancreatico-duodenectomy > spleen preserving distal pancreatectomy > central pancreatectomy
in PPPD why do patients who’s pyloric region has been preserved generally do better?
their pacemakers have been preserved to it is functionally better
