Pancreatic disease Flashcards
What is acute pancreatitis?
- Acute inflammation of the pancreas
- Upper abdominal pain
- Elevation of serum amylase (> 4 x 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 - Postoperative - Post-ERCP ○ Misc. - Drugs (steroids, azathioprine, diuretics) - Viruses (mumps, coxsackie B4, HIV, CMV) - Pancreatic carcinoma - Metabolic (raised calcium, raised triglycerides, raised temp) - Autoimmune ○ Idiopathic ~10%
What is the pathology of acute pancreatitis?
- Primary insult
- Release of activated pancreatic enzymes
- Autodigestion
- Proinflammatory cytokines and reactive oxygen species
- Oedema, fat necrosis and hemorrhage
What are the clinical features of acute pancreatitis?
○ Abdominal pain (may radiate to back)
○ Vomiting
○ Pyrexia
○ Tachycardia, hypovolemic shock
○ Oliguria, acute renal failure
○ Jaundice
○ Paralytic ileus
○ Retroperitoneal haemorrhage (Grey Turner’s & Cullen’s signs) (pic)
○ Hypoxia (respiratory failure in severe cases)
○ Hypocalcemia (tetany rare)
○ Hyperglycaemia (occasionally diabetic coma)
○ Effusions (ascites & pleural; high amylase)
What investigations are done for acute pancreatitis?
○ Blood tests: amylase/lipase, FBC, U&Es, LFTs, Ca2+, glucose, arterial blood gases, lipids, coagulation screen
○ AXR (ileus) & CXR (pleural effusion)
○ Abdominal ultrasound (pancreatic oedema, gallstones, pseudocyst)
○ CT scan (contrast enhanced)
How is the severity of acute pancreatitis assessed?
- White cell count >15 x 109/l
- Blood glucose >10 mmol/l
- Blood urea >16 mmol/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
What is the general management of acute pancreatitis?
- Analgesia (pethidine, indomethacin)
- Intravenous fluids
- Blood transfusion (Hb <10 g/dl)
- Monitor urine output (catheter)
- Nasogastric tube
- Oxygen
- May need insulin
- Rarely require calcium supplements
- Nutrition (enteral or parenteral) in severe cases
What is the specific management of acute pancreatitis?
- Pancreatic necrosis: CT guided aspiration → antibiotics ± surgery
- Gallstones
→ EUS/MRCP/ERCP
→ Cholecystectomy - No benefit: antiproteases, antibiotics, inhibitors of pancreatic secretion (glucagon, somatostatin), peritoneal lavage
What are the complications of acute pancreatitis?
- Abscess → antibiotics + drainage
- Pseudocyst
□ fluid collection without an epithelial lining
□ Persistent hyperglycemia and/or pain
□ Dx by ultrasound or CT scan
□ Complications: jaundice, infection, haemorrhage, rupture
□ <6 cm diameter = resolve spontaneously
□ Endoscopic drainage or surgery if persistent pain or complications
What is the outcome of acute pancreatitis?
○ Mild AP (75-80% of cases) - mortality <2%
○ Severe AP - mortality 15%
○ Subsequent course dependent on removal of aetiological factor(s)
What is the epidemiology of chronic pancreatitis?
○ Prevalence: 0.01% in Japan→5.4% in South India
○ Incidence: 3.5/100 000 pop./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 gene mutations in CP
○ Congenital anatomical abnormalities
○ Annular pancreas
○ Pancreas divisum (failed fusion of dorsal & ventral buds)
○ Hereditary pancreatitis: rare, auto. dom.
○ Hypercalcaemia
○ Diet: antioxidants in tropical pancreatitis?
What is the pathogenesis of chronic pancreatitis?
○ Duct obstruction - calculi - inflammation - protein plugs ○ Abnormal sphincter of Oddi function? - Spasm: raises intrapancreatic pressure - relaxation: reflux of duodenal contents ○ Genetic polymorphisms? - Abnormal trypsin activation
What is the pathology of chronic pancreatitis?
○ Glandular atrophy & replacement by fibrous tissue
○ Ducts become dilated, tortuous & strictured
○ Inspissated secretions may calcify
○ ‘Exposed’ nerves due to loss of perineural cells
○ Splenic, superior mesenteric & portal veins may thrombose which results in portal hypertension
What are the clinical features of chronic pancreatitis?
○ Early disease is asymptomatic
○ Abdominal pain (85-95%)
- exacerbated by food & alcohol; severity decreases with time
○ Weight loss (pain, anorexia, malabsorption)
○ Exocrine insufficiency
- fat malabsorption which results in steatorrhea
□ Decreased fat soluble vitamins (A,D,E,K), decreased Ca2+/Mg2+
- protein malabsorption which results in weight loss, decreased vitamin B12
○ Endocrine insufficiency which results in 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)
○ Ultrasound: pancreatic size, cysts, duct diameter, tumours
○ EUS
○ CT scan
○ Blood tests:
- Serum amylase: raised in acute exacerbations
- Lowered albumin, Ca2+/Mg2+, vitamin B12
- Raised LFTs, Prothrombin time (vitamin K), glucose
- Pancreatic function tests (Lundh, pancreolauryl)
What is done for pain control in chronic pancreatitis?
- 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
What is the management of the endocrine and exocrine functions in chronic pancreatitis?
- Low-fat diet (30-40 g/day)
- 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 (oral hypoglycemics usually ineffective)
What is the prognosis of chronic pancreatitis?
○ Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
○ Continued alcohol intake results in 50% 10 year survival
○ Abstinence results in 80% 10 year survival
What are the clinical features of 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 carcinoma of the pancreas?
○ Upper abdominal pain (75%) - Ca body & tail
○ Painless obstructive jaundice (25%) - Ca head
○ Weight loss (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 - PRESENCE OF ABOVE SIGNS USUALLY INDICATES AN UNRESECTABLE TUMOUR ○ Palpable gallbladder (with ampullary carcinoma)
What is the management of carcinoma of the pancreas?
○ Majority of patients have advanced disease at presentation and <10% are operable
○ Radical surgery - pancreatoduodenectomy
(Whipple’s procedure)
- Patient is fit, Tumour <3 cm diameter, No metastases
- Operative mortality ~5%
○ Palliation of jaundice
- stent, palliative surgery - cholechoduodenostomy
○ Pain control (opiates, coeliac plexus block, radiotherapy)
○ Chemotherapy only in controlled trials
What is the prognosis of carcinoma of the pancreas?
○ Inoperable cases: - mean survival <6 months - 1% 5yr survival ○ Operable cases: - 15% 5 year survival - Ampullary tumours 30-50% 5 year survival
