Pancreatic Disease Flashcards
What are the features of acute pancreatitis?
- Acute inflammation
- Upper, central epigastric pain
- Elevation of serum amylase
Describe mild acute pancreatitis
Associated with minimal organ dysfunction and uneventful recovery
Describe severe acute pancreatitis
Associated with multi-organ failure or local complication: • Acute fluid collections • Pseudocyst • Pancreatic abscess • Pancreatic necrosis
What is the aetiology of acute pancreatitis?
- Gallstones
- Alcohol
• Trauma: blunt/post-operative/post-ERCP • Pancreatic carcinoma • Drugs (steroids, diuretics) • Viruses (mumps, HIV) • Hypercalcaemia • Lipid abnormalities Idiopathic
What is alcohols role in acute pancreatitis?
- Direct invasion
- Increased sensitivity to stimulation
- Oxidation products (acetaldehyde)
- Non-oxidative metabolism (fatty acid ethyl esters)
How does gallstones cause acute pancreatitis?
- Passage of gallstones essential
* Raised pancreatic ductal pressure
How does ERCP cause acute pancreatitis?
Endoscope used to to examine the pancreatic and bile ducts - can increase pancreatic ductal pressure
Describe the pathophysiology of alcohol/gallstones/ERCP causing acute pancreatitis
Primary insult -> release of activated pancreatic enzymes -> autodigestion: • Pro-inflammatory cytokines • Reactive oxygen species • Oedema • Fat necrosis • Haemorrhage
What are the symptoms of acute pancreatitis?
- Abdominal pain (may radiate to back)
- Nausea, vomiting
- Collapse
What are the signs of acute pancreatitis?
- Pyrexia
- Dehydration (hypovolemic shock)
- Abdominal tenderness
- Circulatory failure
What investigations are used for acute pancreatitis?
- Blood tests: U+Es, FBC, serum amylase, ABG, lipids, LFT, glucose, Ca
- CXR (pleural effusion)
- AXR (ileus)
- USS (pan. Oedema, gallstones, pseudocyst)
- CT Scan
What is used to assess the severity of the acute pancreatitis and state the ranges?
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
What is the managements of the different precipitating factors?
- 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
What is the general management of acute pancreatitis?
- Analgesia
- IV fluid
- Blood transfusion (if anaemia)
- Monitor urine output (catheter)
- Naso-gastric tube
- Oxygen
- May need insulin (diabetic)
What is the specific management for acute pancreatitis?
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
What are the two possible complications of acute pancreatitis?
Abscess and pseudocyst
How do you manage an abscess in acute pancreatitis?
Antibiotics and drainage
How do you investigate and manage a pseudocyst in acute pancreatitis?
- USS or CT
- < 6cm diameter -> revolve spontaneously
- Endoscopic drainage or surgery if persistent pain or complications
What is a pseudocyst and what are possible complications of it?
- Fluid collection without an epithelial lining
- Persistent hyperamylasemia (and pain)
- Complications: jaundice infection, haemorrhage, rupture
What is chronic pancreatitis?
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
What is the aetiology of chronic pancreatitis (O-A-TIGER)?
- Obstruction of MPD
- Autoimmune
- Toxin - ethanol, smoking, drugs
- Genetic - recessive CFTR gene mutation
- Environment - tropical chronic pancreatitis
- Recurrent injuries
What are the recurrent injuries which can cause chronic pancreatitis?
- Biliary
- Hyperlipidaemia
- Hypercalcaemia
What can cause obstruction of MPD in chronic pancreatitis?
Tumour, sphincter of Oddi dysfunction, Pancreatic divisum, duodenal obstruction, trauma, structure (post necrotising radiation
Describe the pathology of chronic pancreatitis
- 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
What are the clinical features of chronic pancreatitis?
- Abdominal pain
- Weight loss (pain, anorexia, malabsorption)
- Pancreatic exocrine insufficiency: fat malabsorption -> steatorrhoea
- Endocrine insuffiency diabetes
- Jaundice
- Duodenal obstruction
- Upper GI Haemorrhage
What investigations are used for chronic pancreatitis?
- CT scan: pancreatic size, cysts, ducts
- Plain AXR
- ERCP/MRCP
- EUS
- Serum amylase increase
- Decrease albumin, Ca, Vit B12
- Increase LFTs, glucose
What is the management for chronic pancreatitis?
- Abstinence of alcohol
- Analgesia
- Avoid high fat, high protein diet
- Pancreatic enzyme supplements (for steatorrhoea)
- Insulin for diabetics
- Coeliac plexus block (stop pain)
What types of surgery is used for chronic pancreatitis?
Drainage and resection
What are five different types of resection surgeries available for chronic pancreatitis?
- Duodenum-preserving pancreatic head resection (DPPHR)
- Pylorus preserving pancreatoduodectomy (PPPD)
- Whipple’s pancreatico-duodenectomy
- Spleen-preserving distal pancreatectomy
- Central pancreatectomy
What complications can occur during surgery for chronic pancreatitis?
- Pancreatic duct stenosis
- Cyst / pseudocysts
- Biliary tract obstruction
- Splenic vein thrombosis / gastric varices
- Portal vein compression / mesenteric vein thrombosis
- Duodenal stenosis
- Colonic stricture
What is the treatment of chronic pancreatitis?
- 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)
Name five risk factors for pancreatic carcinoma
- Smoking
- Chronic pancreatitis
- Adult onset DM of less than 2 years duration
- Hereditary pancreatitis
- Inherited predisposition (Periampullary cancer is a feature of FAP)
Describe the pathology of pancreatic carcinoma
75% are duct cell mutinous adenocarcinoma (mostly head of p.)
Other pathological types:
• Carcinosarcoma
• Cystadenocarcinoma
• Acinar cell
What are the clinical features of pancreatic carcinoma?
- 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
What is Thrombophlebitis migrans?
Recurrent episodes of vessel inflammation due to blood clot
What are the signs of pancreatic carcinoma?
- Hepatomegaly
- Jaundice
- Abdominal mass
- Abdominal tenderness
- Ascites, splenomegaly
- Supraclavicular lymphadenopathy
Signs above usually indicate unresectable tumour
• Palpable gallbladder (with ampullary carcinoma)
What investigations are used for pancreatic carcinoma?
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
What is the best modality for staging pancreatic carcinoma?
CT
What is the best modality for detecting liver metastases in pancreatic carcinoma?
Laparoscopy (if positive then its inoperable)
What is the management of pancreatic carcinoma if there is liver metastases?
Give ERCP and stent to bypass duodenal structure and stop jaundice
What is used to assess patient for surgery?
• 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
What is the palliative management of pancreatic carcinoma?
Drainage:
o Obstructive jaundice
o Duodenal obstruction
What is the management of pancreatic carcinoma?
- 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
