Pancreatic disease Flashcards
what is the basic pathophysiology of acute pancreatitis?
primary injury to pancreas causes release of pancreatic enzymes
this causes autodigestion
results in release of pro inflammatory cytokines and reactive 02 species
also fat necrosis, oedema and haemorrhage
what are the causes/aetiology of pancreatitis?
alcohol gallstones trauma - blunt, post op, post-ERCP drugs i.e. steroids viruses i.e. CMV and mumps autoimmune pancreatic carcinoma metabolic i.e. hypercalcaemia, hypertriglyceride, hypothermia)
what are the main symptoms of acute pancreatitis?
abdominal pain (may radiate to the back)
nausea/vomiting
collapse
dehydration
what can some people with acute pancreatitis present with? (clinical signs)
abdominal tenderness painful jaundice pyrexia hypocalcaemia/hypertriglyceride oliguria - acute renal failure retroperitoneal haemorrhage effusions - ascites and pleural, with high amylase circulatory failure
what investigations are used for detecting acute pancreatitis?
blood tests: FBC, U&E's, ABG, amylase, CRP, coagulation screen, Ca, lipids ERCP EUSS abdominal US (for ascites) CXR for pleural effusions/mets if cancer CT scan
what are the basic treatments for patients with acute pancreatitis?
analgesia 02 iv fluids blood transfusion calcium supplements if hypocalcaemia may need insulin if hypoglycaemic nutrition in severe cases monitor urine output
what main investigations are required and the treatment for acute pancreatitis with fat necrosis?
CT guided aspiration
Antibiotics
surgery
what are the main investigations and treatment for acute pancreatitis caused by gallstones?
ERCP/MRCP/EUS
cholecystectomy
why may a blood transfusion be required in someone with acute pancreatitis?
their Hb can fall <10g/dl
what criteria is used for measuring the severity of acute pancreatitis?
modified glasgow criteria
in the glasgow criteria, what indicates severe acute pancreatitis?
a score > or equal to 3
apart from a glasgow score above 3, what other indication is severe pancreatitis?
CRP >150mg/l
when investigating acute pancreatitis, why is a coagulation screen carried out?
disseminated inter vascular coagulation can occur as a result of acute pancreatitis
what individual markers may be used for indicating severity of acute pancreatitis?
CXR
CRP
IL 6
TAP
wat are the complications of acute pancreatitis?
pancreatic pseudocyst
pancreatic abscess
pancreatic necrosis
what are the complications of a pseudocyst as complication of acute pancreatitis?
haemorrhage
infection
jaundice
rupture
what is the prognosis for mild and severe acute pancreatitis?
mild AP - mortality <2%
severe AP - mortality 15%
what is the treatment for a pseudocyst?
endoscopic drainage
what is the pathophysiology of chronic pancreatitis?
continuing inflammation of the pancreas
irreversible glandular destruction
glandular atrophy
causes pain and permanent loss of function
ducts become dilated, tortuous and stricture
what sex is chronic pancreatitis most common in and what age group?
males > female
age 35-50
what is the aetiology of chronic pancreatitis?
Obstruction; - tumour - sphincter of oddi dysfcuntion - pancreatic divisum - duodenal diverticulum Autoimmune Toxins - alcohol - drugs - ethanol Idiopathic Genetic - PRSS1 - SPINK1 - CFTR Environmental - tropical CP Recurrent injury - billiary - hypercalcaemia - hyperlipidaemia
what is the clinical presentation of chronic pancreatitis?
most present asymptomatic
abdominal pain weight loss exocrine insuffiency - steattorhoea, protein malabsorption endocrine insufficiency - iabetes jaundice upper GI haemorrhage Portal hypertension duodenal obstruction pancreatic carcinoma pseuodcysts
what blood tests are carried out to diagnose chronic pancreatitis?
blood tests:
increase in amylase, Ca, Mg, Vit B12
decrease in LFT’s, INR, glucose
pancreatic function tests
apart from blood tests what other investigations are carried out for diagnosing chronic pancreatitis?
Abdominal XR CT scan MRCP/ERCP EUSS faecal elastase test pancreolauryl test
what genes are associated with chronic pancreatitis?
CFTR
SPINK1
PRSS1
what is the treatment for exocrine insufficiency due to chronic pancreatitis?
avoid high fat, high protein diet
pancreatic enzyme supplement i.e. creon, pancrex
when is surgery for chronic pancreatitis considered?
suspect malignancy intractable pain complications i.e. - pseudocysts - SM vein, splenic vein and portal vein thrombosis - gastric varices - biliary tract obstruction - duodenal stenosis - pancreatic duct stenosis - colonic stricture
what are the surgical options for treatment of pancreatic duct stenosis and obstruction due to chronic pancreatitis?
lithotripsy
dilatation
endoscopic pancreatic duct sphincetorotomy
what are the different procedures for resection of the pancreas?
whipple
freys procedure
PPPD
DPPHR (beger)
what is the prognosis of chronic pancreatitis?
mortality 50% over 20-25yrs
20% die of complications
what sex and age group is pancreatic carcinoma most common in?
males > females
most common in 60-80yrs
what are the different pathological types of pancreatic carcinomas?
duct cell mutinous adenocarcinoma
carcinosarcoma
cystadenocarcinoma
acinar cell
what are the risk factors for pancreatic carcinoma?
smoking
chronic pancreatitis
hereditary pancreatitis
inherited predisposition
what condition is periampullary cancer associated with?
FAP
what are the clinical features of pancreatic carcinoma?
painless obstructive jaundice abdominal/back pain weight loss anoreia vomiting diarrhoea steattorhoea recurrent blunts of pancreatitis
what are some of the physical signs of pancreatic carcinoma?
hepatomegaly splenomegaly abdominal mass jaundice ascites supraclavicular lymphadenopathy tender subcutaneous fat nodules portal hypertension thrombophlebitis migrant
what investigations are carried out to diagnose pancreatic cancer?
EUSS CT/MRI MRCP/ERCP percutaneous needle biopsy CXR
what tumour marker is tested for pancreatic carcinoma?
CA 19-9
WHAT SIZE DOES THE TUMOUR HAVE TO BE IN ORDER TO BE OPERATABLE?
< 3cm
what is the prognosis of inoperable and operable pancreatic cancer?
5yr survival 1%
5yr survival 15% (operable)
what are the different treatments for pancreatic cancer?
pain control chemotherapy radio frequency ablation palliative bypass/stent surgery
what 2 surgical procedures are used for treating pancreatic cancer?
whipple
pylorus preserving pancreas duodectomy
if there is duodenal obstruction in someone with pancreatic cancer, how is this treated?
palliative bypass or duodenal stent
what are the procedure options for treating chronic pancreatitis ?
obstruction - endoscopic PD sphincterotomy, lithotripsy, stenting/bypass
drainage - Puestows, PD sphincteroplasty
resection- PPPD, DPPHR (Begers), Freys, Whipple
