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GI System > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

What are the features of acute pancreatitis?

A
  • Acute inflammation
  • Upper, central epigastric pain
  • Elevation of serum amylase
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2
Q

Describe mild acute pancreatitis

A

Associated with minimal organ dysfunction and uneventful recovery

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3
Q

Describe severe acute pancreatitis

A 
Associated with multi-organ failure or local complication:
• Acute fluid collections 
• Pseudocyst
• Pancreatic abscess  
• Pancreatic necrosis
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4
Q

What is the aetiology of acute pancreatitis?

A
  • Gallstones
  • Alcohol
• Trauma: blunt/post-operative/post-ERCP 
• Pancreatic carcinoma
• Drugs (steroids, diuretics)
• Viruses (mumps, HIV)
• Hypercalcaemia
• Lipid abnormalities 
Idiopathic
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5
Q

What is alcohols role in acute pancreatitis?

A
  • Direct invasion
  • Increased sensitivity to stimulation
  • Oxidation products (acetaldehyde)
  • Non-oxidative metabolism (fatty acid ethyl esters)
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6
Q

How does gallstones cause acute pancreatitis?

A
  • Passage of gallstones essential

* Raised pancreatic ductal pressure

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7
Q

How does ERCP cause acute pancreatitis?

A

Endoscope used to to examine the pancreatic and bile ducts - can increase pancreatic ductal pressure

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8
Q

Describe the pathophysiology of alcohol/gallstones/ERCP causing acute pancreatitis

A 
Primary insult -> release of activated pancreatic enzymes -> autodigestion:
• Pro-inflammatory cytokines
• Reactive oxygen species 
• Oedema 
• Fat necrosis 
• Haemorrhage
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9
Q

What are the symptoms of acute pancreatitis?

A
  • Abdominal pain (may radiate to back)
  • Nausea, vomiting
  • Collapse
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10
Q

What are the signs of acute pancreatitis?

A
  • Pyrexia
  • Dehydration (hypovolemic shock)
  • Abdominal tenderness
  • Circulatory failure
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11
Q

What investigations are used for acute pancreatitis?

A
  • Blood tests: U+Es, FBC, serum amylase, ABG, lipids, LFT, glucose, Ca
  • CXR (pleural effusion)
  • AXR (ileus)
  • USS (pan. Oedema, gallstones, pseudocyst)
  • CT Scan
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12
Q

What is used to assess the severity of the acute pancreatitis and state the ranges?

A 
Glasgow Criteria: severe > 3 
White cell count > 15x109/L
Glucose > 10 mmol/L
Urea > 16mmol/L
AST > 200 IU/L
LDH > 700 IU/L
Serum albumin < 32g/l
Serum calcium < 2mmol/l
Arterial PO2 < 60 mmHg

Clinical Assessment
CT Scanning
Individual markers: CXR, CRP, IL6 TAP

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13
Q

What is the managements of the different precipitating factors?

A
  • Cholelithaiasis: ERCP & ES, cholecystectomy (check for gallstones)
  • Alcohol: Abstinence, counselling
  • Ischaemia: careful support
  • Malignancy: resection or bypass
  • Hyperlipidaemia: diet, lipid lowering drugs
  • Anatomical abnormalities: correction if possible
  • Drugs: stop or change
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14
Q

What is the general management of acute pancreatitis?

A
  • Analgesia
  • IV fluid
  • Blood transfusion (if anaemia)
  • Monitor urine output (catheter)
  • Naso-gastric tube
  • Oxygen
  • May need insulin (diabetic)
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15
Q

What is the specific management for acute pancreatitis?

A 
Pancreatic necrosis: 
• CT guided aspiration 
• Antibiotics 
• May need surgery 
Infected necrosis: laparotomy (could cause haemorrhage, portal hypertension, pan. Duct stricture

Gallstones
• EUS/MRCP/ERCP
• Cholecystectomy

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16
Q

What are the two possible complications of acute pancreatitis?

A

Abscess and pseudocyst

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17
Q

How do you manage an abscess in acute pancreatitis?

A

Antibiotics and drainage

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18
Q

How do you investigate and manage a pseudocyst in acute pancreatitis?

A
  • USS or CT
  • < 6cm diameter -> revolve spontaneously
  • Endoscopic drainage or surgery if persistent pain or complications
19
Q

What is a pseudocyst and what are possible complications of it?

A
  • Fluid collection without an epithelial lining
  • Persistent hyperamylasemia (and pain)
  • Complications: jaundice infection, haemorrhage, rupture
20
Q

What is chronic pancreatitis?

A

Continuing inflammation of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function of the endo and exocrine glands of the pancreas

21
Q

What is the aetiology of chronic pancreatitis (O-A-TIGER)?

A
  • Obstruction of MPD
  • Autoimmune
  • Toxin - ethanol, smoking, drugs
  • Genetic - recessive CFTR gene mutation
  • Environment - tropical chronic pancreatitis
  • Recurrent injuries
22
Q

What are the recurrent injuries which can cause chronic pancreatitis?

A
  • Biliary
  • Hyperlipidaemia
  • Hypercalcaemia
23
Q

What can cause obstruction of MPD in chronic pancreatitis?

A

Tumour, sphincter of Oddi dysfunction, Pancreatic divisum, duodenal obstruction, trauma, structure (post necrotising radiation

24
Q

Describe the pathology of chronic pancreatitis

A
  • Glandular atrophy & replacement by fibrous tissue
  • Ducts become dilated, tortous & strictured
  • Inspissated secretions may calcify
  • Exposed nerves due to loss of perineural cells
  • Splenic, superior mesenteric & portal veins may thrombose -> portal hypertension
25
Q

What are the clinical features of chronic pancreatitis?

A
  • Abdominal pain
  • Weight loss (pain, anorexia, malabsorption)
  • Pancreatic exocrine insufficiency: fat malabsorption -> steatorrhoea
  • Endocrine insuffiency diabetes
  • Jaundice
  • Duodenal obstruction
  • Upper GI Haemorrhage
26
Q

What investigations are used for chronic pancreatitis?

A
  • CT scan: pancreatic size, cysts, ducts
  • Plain AXR
  • ERCP/MRCP
  • EUS
  • Serum amylase increase
  • Decrease albumin, Ca, Vit B12
  • Increase LFTs, glucose
27
Q

What is the management for chronic pancreatitis?

A
  • Abstinence of alcohol
  • Analgesia
  • Avoid high fat, high protein diet
  • Pancreatic enzyme supplements (for steatorrhoea)
  • Insulin for diabetics
  • Coeliac plexus block (stop pain)
28
Q

What types of surgery is used for chronic pancreatitis?

A

Drainage and resection

29
Q

What are five different types of resection surgeries available for chronic pancreatitis?

A
  • Duodenum-preserving pancreatic head resection (DPPHR)
  • Pylorus preserving pancreatoduodectomy (PPPD)
  • Whipple’s pancreatico-duodenectomy
  • Spleen-preserving distal pancreatectomy
  • Central pancreatectomy
30
Q

What complications can occur during surgery for chronic pancreatitis?

A
  • Pancreatic duct stenosis
  • Cyst / pseudocysts
  • Biliary tract obstruction
  • Splenic vein thrombosis / gastric varices
  • Portal vein compression / mesenteric vein thrombosis
  • Duodenal stenosis
  • Colonic stricture
31
Q

What is the treatment of chronic pancreatitis?

A
  • PD stenosis and obstruction: endoscopic PD sphincterotomy, dilateion and lithrotripsy
  • Management of chronic pseudocyst
  • CBD stening or bypass
  • Thorascopic splanchnectomy
  • Coeliac plexus block (inject ethanol to numb the nerves of the pancreas)
32
Q

Name five risk factors for pancreatic carcinoma

A
  • Smoking
  • Chronic pancreatitis
  • Adult onset DM of less than 2 years duration
  • Hereditary pancreatitis
  • Inherited predisposition (Periampullary cancer is a feature of FAP)
33
Q

Describe the pathology of pancreatic carcinoma

A

75% are duct cell mutinous adenocarcinoma (mostly head of p.)

Other pathological types:
• Carcinosarcoma
• Cystadenocarcinoma
• Acinar cell

34
Q

What are the clinical features of pancreatic carcinoma?

A
  • Abdominal pain (Ca of body & tail)
  • Painless obstructive Jaundice (Ca head)
  • Weight loss + anorexia
  • Vomiting
  • Tender subcutaneous fat nodules due to metastatic fat necrosis
  • Thrombophlebitis migrans
  • Ascites, portal hypertension
35
Q

What is Thrombophlebitis migrans?

A

Recurrent episodes of vessel inflammation due to blood clot

36
Q

What are the signs of pancreatic carcinoma?

A
  • Hepatomegaly
  • Jaundice
  • Abdominal mass
  • Abdominal tenderness
  • Ascites, splenomegaly
  • Supraclavicular lymphadenopathy

Signs above usually indicate unresectable tumour
• Palpable gallbladder (with ampullary carcinoma)

37
Q

What investigations are used for pancreatic carcinoma?

A 
General: blood tests and CXR
Tumour markers: CA19-9 
Imaging/Invasive:
• USS
• ?ERCP
• CT
• MR, MRCP
• Laparoscopy + Lap USS 
• Peritoneal cytology 
• Percutaneous needle biopsy 
• PET
38
Q

What is the best modality for staging pancreatic carcinoma?

A

CT

39
Q

What is the best modality for detecting liver metastases in pancreatic carcinoma?

A

Laparoscopy (if positive then its inoperable)

40
Q

What is the management of pancreatic carcinoma if there is liver metastases?

A

Give ERCP and stent to bypass duodenal structure and stop jaundice

41
Q

What is used to assess patient for surgery?

A 
• History and excamination 
• CXR, ECG 
• Respiratory function test 
• Physiological ‘scoring system’ 
  o None
  o Performance status 1-5
  o Lactate threshold 
• Fully informed consent is vital
42
Q

What is the palliative management of pancreatic carcinoma?

A

Drainage:
o Obstructive jaundice
o Duodenal obstruction

43
Q

What is the management of pancreatic carcinoma?

A
  • Most ptient present at late stage and <10% operable
  • Radical surgery: pancreatoduodenectomy (Whipples)
  • Palliation of jaundice: stent, palliative surgery (cholechoduodenostomy)
  • Pain control (opiates, coaeliac plexus block, radiotherpay)
  • Chemotherapy

GI System (28 decks)

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