Pancreatic disease Flashcards
Enzymes which stimulate the pancreatic
Secretin and CCK
Produced by s-cells of the duodenum, controls gastric acid secretion and buffering with HCO3-
Secretin
Stimulates digestion of fat and protein. Made by I-cells in the duodenum. Causes release of digestive enzymes
CCK
Islets of langerhans - alpha cells
Secrete glucagon which increases blood glucose
Islets of Langerhans - beta cells
Secrete insulin which decreases blood glucose
Islets of Langerhans - delta cells
Secrete somatostatin which suppresses insulin and glucagon release
Islets of Langerhans - PP cells
PP cells contain a unique pancreatic polypeptide, VIP, that exerts several gastrointestinal effects, such as stimulation of secretion of gastric and intestinal enzymes and inhibi- tion of intestinal motility.
Pancreatic polypeptide is also secreted and regulates pancreatic secretion activities alongside effects on hepatic glycogen metabolism and GI secretions.
Metabolic syndrome
Pro-inflammatory state ?triggered by cytokine release from adipocytes.
Associated with: Central obesity Fasting hyperglycaemia (>6mmol/l) BP > 140/90 Microalbuminaemia Dyslipidaemia (decreased HDL cholesterol <1mmol/L and increased triglycerides >2mmol/L)] Hyper-coaguable state
Diagnosis of diabetes mellitus
Fasting plasma glucose >7mmol/L
Random plasma glucose >11.1mmol/L
T1DM pathophysiology
AI destruction of beta cells in the islets of Langerhans by CD4+ and CD8+ T lymphocytes.
T2DM pathophysiology
A combination of peripheral resistance to insulin action and an inadequate compensatory response of insulin secretion by the pancreatic beta cells (relative insulin deficiency).
Signs of diabetes
Polyuria (osmotic diuresis), polydipsia (raised plasma osmolality), hyperglycaemia predisposing to recurrent infections
Macrovascular complications of diabetes
Cardiac - MI
Renal - glomerulonephritis, pyelonephritis
Cerebral - CVA (cerebrovascular accident)
Microvascular complications of diabetes
Ocular - diabetic retinopahty
Peripheral vascular system - claudication, change in colour/temp, poor healing ulcer
Causes of acute pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia, hypercalcaemia, hypothermia ERCP Drugs (e.g. thiazides, steroids, sodium valproate)
Sudden severe epigastric pain radiating to back, relieved but sitting forward + vomiting
Acute pancreatitis
Periumbilical discolouration
Cullen’s sign in pancreatitis
Flank discolouration
Grey-turner’s sign in pancreatitis
Diagnosis of acute pancreatitis
Elevated serum lipase (more sensitive and specific than amylase, which is only raised for 1st 24 hours)
Histology in acute pancreatitis
Overall: coagulative necrosis Microvascular leakage - oedema Lipases - necrosis of fat Acute inflammatory reaction Proteolytic destruction of parenchyma Interstitial haemorrhage
Causes of chronic pancreatitis
Alcoholism (80%), CF, hereditary, pancreatic duct obstruction (stones/tumour), autoimmune (IgG4 sclerosing)
Chronic pancreatitis
Long-standing inflammation, fibrosis, and destruction of the exocrine pancreas. in its late stages, the endocrine parenchyma also is lost.
Irreversible impairment in function in chronic pancreatitis
Presentation of chronic pancreatitis
Epigastric pain radiating to the back (typically worse 15-30min post meal)
Steatorrhoea: pancreatic insufficiency (5 - 25 years after the onset of pain)
Weight loss due to malabsorption
DM develops in the majority of patients. Usually >20 years after symptom onset
Jaundice
Histology of chronic pancreatitis
Fibrosis and loss of exocrine tissue (acinar loss ubiquitous), duct dilation with thick secretions, calcification
Relative sparing of endocrine islets
Investigations in chronic pancreatitis
CT may show calcifications in pancreas
Faecal elastase may assess exocrine function if imaging inconclusive
Management of chronic pancreatitis
Pancreatic enzyme supplements and analgesia
Pseudocysts, diabetes, pancreatic cancer
Complications of chronic pancreatitis
Acinar cell carcinoma presentation
Non specific Sx; abdo pain, weight loss, nausea and diarrhoea.
10% get multifocal fat necrosis and polyarthragia due to lipase secretion
Neoplastic epithelial cells with esoinophilic granular cytoplasm. Positive imunoreactivity for lipase, trypsin and chymotrypsin.
Histology of acinar cell carcinoma
Schmid triad
Seen in acinar cell carcinoma
sc fat necrosis + eosinophilia + polyarthritis
Prognosis for acinar cell carcinoma
Median survival 18m
<10% 5 year survival
A 19 year old American student with bronchiectasis is on inhaled tobramycin for chronic Pseudomonal infection. The mutation delta F508 is identified. A. Carcinoma head of the pancreas B. Pseudocysts C. Gallstones D. Renal tubular acidosis E. Iatrogenic pancreatitis F. Hypercalcaemia G. Cystic fibrosis H. Haemochromatosis I. Insulinoma J. Gallstone pancreatitis K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Vibrio cholerae infection N. Carcinoma tail of the pancreas
Cystic fibrosis
A 68 year old smoker presents with jaundice and worsening abdominal and back pain. Scratch marks are seen on his arms and legs. He has lost 5kg in 2 months. Ultrasound shows dilated intrahepatic bile ducts. A. Carcinoma head of the pancreas B. Pseudocysts C. Gallstones D. Renal tubular acidosis E. Iatrogenic pancreatitis F. Hypercalcaemia G. Cystic fibrosis H. Haemochromatosis I. Insulinoma J. Gallstone pancreatitis K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Vibrio cholerae infection N. Carcinoma tail of the pancreas
Carcinoma of head of pancreas
A 39 year old Nepalese man presents with severe watery diarrhoea. He is found to have hypokalaemia and, surprisingly, a metabolic acidosis. A RUQ mass is detected by contrast-enhanced spiral CT scanning. Stool bicarb is high and urine anion gap is negative. A. Carcinoma head of the pancreas B. Pseudocysts C. Gallstones D. Renal tubular acidosis E. Iatrogenic pancreatitis F. Hypercalcaemia G. Cystic fibrosis H. Haemochromatosis I. Insulinoma J. Gallstone pancreatitis K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Vibrio cholerae infection N. Carcinoma tail of the pancreas
VIPoma (Werner Morrison syndrome)
A 59 year old widow complains of persistent back pain, loss of appetite and that she has dropped from dress size 18 to a size 14 in just 2 months. She was recently diagnosed with diabetes. A large central mass is palpable as well hepatosplenomegaly A. Carcinoma head of the pancreas B. Pseudocysts C. Gallstones D. Renal tubular acidosis E. Iatrogenic pancreatitis F. Hypercalcaemia G. Cystic fibrosis H. Haemochromatosis I. Insulinoma J. Gallstone pancreatitis K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Vibrio cholerae infection N. Carcinoma tail of the pancreas
Carcinoma of tail of pancreas
A 47 year old lecturer is referred to hospital clinic from his GP with worsening abdominal pain. He has a poor diet and weight loss. He has previously been prescribed Thiamine. A. Carcinoma head of the pancreas B. Pseudocysts C. Gallstones D. Renal tubular acidosis E. Iatrogenic pancreatitis F. Hypercalcaemia G. Cystic fibrosis H. Haemochromatosis I. Insulinoma J. Gallstone pancreatitis K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Vibrio cholerae infection N. Carcinoma tail of the pancreas
Chronic alcoholic pancreatitis
65 year old female with a large, cystic mass on tail of pancreas imaged using computed tomography. Further cytology reported the presence of epithelium A. Hyperlipidaemia B. Jaundice C. Cystadenoma D. Type 1 Diabetes E. Pancreas Divisum F. Agenesis G. Cystic Fibrosis H. Thrombophlebitis I. Scorpion Sting J. Pseudocyst K. Alcoholism L. Whipples' resection M. Gall Bladder N. Carcinoma of the Pancreas O. Trousseau’s Syndrome P. Pancreatitis
Cystadenoma
55 year old, diabetic, afro-Caribbean male presents with weight loss, poor diet and a gnawing pain in his back, which is sometimes felt ‘under his chest’ A. Hyperlipidaemia B. Jaundice C. Cystadenoma D. Type 1 Diabetes E. Pancreas Divisum F. Agenesis G. Cystic Fibrosis H. Thrombophlebitis I. Scorpion Sting J. Pseudocyst K. Alcoholism L. Whipples' resection M. Gall Bladder N. Carcinoma of the Pancreas O. Trousseau’s Syndrome P. Pancreatitis
Carcinoma of the pancreas
The commonest cause of acute pancreatitis in the UK. A. Hyperlipidaemia B. Jaundice C. Cystadenoma D. Type 1 Diabetes E. Pancreas Divisum F. Agenesis G. Cystic Fibrosis H. Thrombophlebitis I. Scorpion Sting J. Pseudocyst K. Alcoholism L. Whipples' resection M. Gall Bladder N. Carcinoma of the Pancreas O. Trousseau’s Syndrome P. Pancreatitis
Alcoholism
Inflammatory condition of the exocrine pancreas that results in injury to acinar cells. A. Hyperlipidaemia B. Jaundice C. Cystadenoma D. Type 1 Diabetes E. Pancreas Divisum F. Agenesis G. Cystic Fibrosis H. Thrombophlebitis I. Scorpion Sting J. Pseudocyst K. Alcoholism L. Whipples' resection M. Gall Bladder N. Carcinoma of the Pancreas O. Trousseau’s Syndrome P. Pancreatitis
Pancreatitis
ERCP finding due to incomplete fusing of pancreatic buds. A. Hyperlipidaemia B. Jaundice C. Cystadenoma D. Type 1 Diabetes E. Pancreas Divisum F. Agenesis G. Cystic Fibrosis H. Thrombophlebitis I. Scorpion Sting J. Pseudocyst K. Alcoholism L. Whipples' resection M. Gall Bladder N. Carcinoma of the Pancreas O. Trousseau’s Syndrome P. Pancreatitis
Pancreas divisum
Accounts for 85% of all pancreatic malignancies
Ductal adenocarcinoma of pancreas
RFs for carcinoma of pancreas
Smoking, pancreatitis, diet, age, genetic (e.g.. FAP, HNPCC)
Clinical features
Weight loss + anorexia = advanced disease
Upper abdo and back pain (chronic, persistent and severe)
Painless jaundice, pruritus, steatorrhoea (due to decreased exocrine function)
DM
Trousseau’s syndrome - superficial thrombophlebitis
Ascites
Abdominal mass
Virchow’s node
Courvoisier’s sign
Trousseau’s syndrome
Superficial thrombophlebitis
Investigations in suspected pancreatic cancer
High resolution CT modality of choice if diagnosis suspected
CT/MRI/ERCP
Bloods: increased bilirubin and calcium, decreased haemoglobin
Elevated CA19.9 (>70IU/ml) - not very sensitive or specific
Management of pancreatic cancer
Palliative chemotherapy (5-FU) Surgery (15% cases) - Whipple's procedure - surgical resection ERCP + stenting = palliation
Prognosis of ductal adenocarcinoma of the pancreas
<5% 5 year survival rate = very poor
