Pancreatic Disease Flashcards by Sarah Anderson

What is the definition of acute pancreatitis

Acute inflammation of the pancreas

Recognised as upper abdominal epigastric pain occurring with no warning sign

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What is the biomarker for acute pancreatitis

Elevated serum amylase levels (>4)

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What may acute pancreatitis be associated with in severe cases

Multi organ failure

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What is the aetiology of acute pancreatitis

Alcohol Abuse

Gall Stones

Trauma: Blunt/postoperative/post
ERCP

Drugs (Steroids, azathioprine, diuretics)

Viruses

Pancreatic carcinoma

Metabolic changes:
Increased Calcium
Increased Triglycerides
Decreased Temperature

Autoimmune

Idiopathic

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What is the pathogenesis of acute pancreatitis

Primary insult happens to the pancreas, affecting the exocrine portion, this causes the release of activated pancreatic enzymes resulting in autodigestion to occur

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What are the outcomes of auto digestion due to acute pancreatitis

Pro-inflammatory cytokines 
Reactive oxygen species 
Oedema 
Fat necrosis 
Haemorrhage

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What is the symptoms of acute pancreatitis

Abdominal pain

Vomiting

Significant bruising

Pyrexia

Jaundice

Tachycardia

Olguria (small amount of urine - due to renal failure)

Hypoxia - extreme case

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What are the imaging techniques used for the diagnosis of acute pancreatitis

ERCP

Endoscopic ultrasound

Abdominal X ray

Chest X ray

Abdominal Ultrasound

CT scan (contrast enhanced)

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What is the blood tests in the investigation of acute pancreatis

amylase/lipase
FBC, 
U&amp;Es, 
LFTs, 
Ca2+, (Hypocalcaemia)
glucose, (Hyperglycaemia)
arterial blood gases,
lipids, coagulation screen

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How is the Severity of acute pancreatitis determined

If have a score >3 of the following:
White cell count >15 x 109/l
Blood glucose >10 mmol/l
Blood urea >16mmol/l
AST >200 iu/l
LDH >600 iu/l
Serum albumin <32 g/l
Serum calcium <2.0 mmol/l
Arterial PO2 <7.5 kPa

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What is the general management of acute pancreatitis

Analgesia (pethidine, indomethacin)

Intravenous fluids

Blood transfusion

Monitor urine output (catheter)

Naso-gastric tube

Oxygen

May require:
insulin
calcium supplements
Nutrition

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How is pancreatic necrosis investigated and how is it managed

CT guided aspiration

antibiotics and surgery

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What are two complications of acute pancreatitis

Abscess
Pseudocyst
(Fluid collection without an epithelial lining resulting in Hyperamylasaemia and pain)

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How is the complication of an abscess managed in acute pancreitis

antibiotics and drainage

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What is further complications caused by pseudocyst

Jaundice
Infection
Haemorrhage
Rupture

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How is a pseudocyst diagnosed from acute pancreatitis

Ultrasound

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What is the management of Pseudocyst in acute pancreatitis

<6cm resolve spontaneous

Endoscopic drainage
or

Surgery due to pain or complications

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What is the prognosis of acute pancreatitis and what does it depend upon

Mild AP mortality <2%

Severe AP - mortality 15%

Subsequent
course dependent on removal of aetiological factor(s)

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What is the definition of chronic pancreatitis

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

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What is the aetiology of chronic pancreatitis

Alcohol

Congenital anatomical abnormalities:

annular pancreas
Pancrease divsum

Hereditary pancreatitis

Hypercalcaemia

Diet

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What is annular pancreas and how does it result in

Caused by the second part of the duodenum being surrounded by a ring of pancreatic tissue continuous with the head of the pancreas.

This portion of the pancreas can constrict the duodenum and block or impair the flow of food to the rest of the intestines

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What is pancreas divisum

single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts which have failed to fuse together

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What are the 3 susceptibility genes associated with pancreatisis

PRSS1 – cationic trypsinogen,

SPINK1 – pancreatic secretory trypsin inhibitor,

CFTR – cystic fibrosis transmembrane conductance regulator

What genes can be diagnose through testing for pancreatitis

PRSS1

CFTR- through sweat test

What kind of gene is PRSS1

Autosomal dominant | with high penetrance

What kind of gene is SPINK1

Disease modifying rather than disease causing with high frequency and low penetrance

What are the 3 pathogenesiis of chronic pancreatitis

Duct obstruction Abnormal spinchter of Oddi Function Genetic polymorphisms - abnormal trypsin activation

What are three factors that can cause duct obstruction

Calculi (gallstones) Inflammation Protein Plugs

What is two abnormal spinchter of Oddi functions

Spasms - Increasing intrapancreatic pressure Relaxation - resulting in reflux of duodenal contents

What is the pathology of Chronic pancreatitis

1. Glandular atrophy & replacement by fibrous tissue 2. Ducts become dilated, tortous & strictured 3. Thicken secretions may calcify

What is the symptoms of chronic pancreatitis

Early stage - asymptomatic Abdominal pain Weight loss steatorrhea Malabsorption Diabetes

What exasberates abdominal pain in chronic pancreatitis

alcohol food (severity decreases with time)

What is the result of exocrine insufficiency in chronic pancreatitis

Fat malabsorption: stearrohea Decrease fat soluble vitamins (A,D,E,K) Decrease Ca2+/Mg2+ Protein malabsorption: Weight loss Decreased Vitamin B 12

What is the affect of endocrine insufficiency caused by

Diabetes

What is the further complications caused by chronic pancreatitis

Jaundice Portal Hypertension -Splenic , superior mesenteric & portal veins may thrombose GI haemorrhage, pseudocysts, pancreatic carcinoma

What is the imaging techniques sued for the investigations for chronic pancreatitis

Abdominal Xray Ultrasound Endoscopic Ultrasound CT scan

What does a ultrasound show you in the investigation of chronic pancreatitis

pancreatic size, cysts, duct diameter, tumours

What Do the Blood tests show in the investigation of chronic pancreatitis

Increased: LFT Prothrombin time/INR glucose Decreased; albumin, Ca2+/Mg2, Vitamin B12 +

What is increases in acute exasperations of chronic pancreatitis

Serum amylase

What is the name of the two pancreatic function tests

Lundh: Low trypsin levels pancreolauryl Both see if exocrine portion is functioning

How is pain controlled in the management of chronic pancreatitis

Avoid alcohol Opiate analgesia (dihydrocodeine, pethidine) Celiac plexus blocks (injections of pain medication) Endoscopic treatment of pancreatic duct stones and strictures Surgery

How is Exocrine insufficiency managed in chronic pancreatitis

Low-fat diet Pancreatic enzyme supplements (eg. Creon, Pancrex)

How is | endocrine insufficiency managed in chronic pancreatitis

Insulin

What improves the prognosis of chronic pancreatitis

Abstinence from alcohol

What is the pathological cell type of carcinoma of the pancreas

75% duct cell mutinous adenocarcinoma carcinosarcoma cystadenocarcinoma Acinar cell

What pathological cell type has the best prognosis

cystadenocarcinoma

What is the specific symptoms of carcinoma of the pancrease if located in the body and tail

Upper adominal pain

What is the specific symptom of carcinoma of the pancrease if located just in the head

Painless obstructive jaundice

What is the overall symptoms of carcinoma of the pancreas

``` Upper abdominal pain Weight loss anorexia fatigue diarrhoea/steatorrhoea Nausea/vomiting ```

What is the physical signs of carcinoma of the pancreas

Tender subcutaneous fat nodules Thrombophlebitis migrans (vessels inflammation due to blood clot) Hepatomegaly Portal hypertension Jaundice Abdominal mass/tenderness ascites splenomegally supravicular lymphadenopathy palpable gallbladder

What are the imaging techniques used for the investigations for carcinoma of the pancreas

Ultrasound scan CT MRI Endoscopic US

What is the management of carcinoma of the pancreas

Only <10% operable at advanced disease Surgery: Pancreatoduodenectomy (whipples procedure) Palliation of Jaundice pain control Chemotherapy

When can surgery occur in carcinoma of the pancreas

If patient is fit Tumour is <3cm No metastases

What happens in palliation of jaundice in carcinoma of pancreas

stent cholechoduodenostomy (surgical formation of a communication between the common bile duct and the duodenum)

What is examples of pain control given in carcinoma of the pancrease

opiates, | Celiac plexus blocks, radiotherapy

What improves your prognosis in carcinoma of the pancreas

If its operable 15% 5 year survival compared to 1% 5 year survival

Define ampullary tumour

rare malignant tumor originating at the ampulla of Vater, in the last centimeter of the common bile duct, where it passes through the wall of the duodenum and ampullary papilla. Patients typically present with symptoms related to biliary obstruction Prognosis 30-50% 5 year survival