Pancreatic Disease Flashcards
Pancreas - anatomy
- sits across the back of the abdomen, behind the stomach. Is retroperitoneal
- The head on the right side of the abdomen and is connected to the duodenum through the pancreatic duct.
The narrow end, the tail, extends to the left side of the body.
Acute pancreatitis - definition
A disorder of the exocrine pancreas, with acinar cell injury with local and systemic inflammatory responses. Ranges from mild pancreatic oedema to severe systemic inflammatory response with pancreatic/peri-pancreatic necrosis, multiple organ failure, and death.
Pancreatitis - causes
• I: idiopathic • G: gallstones • E: ethanol (alcohol) • T: trauma • S: steroids • M: mumps (and other infections) / malignancy • A: autoimmune • S: scorpion stings/spider bites • H:hyperlipidaemia/ hypercalcaemia/ hyperparathyroidism • E: ERCP • D: drugs (eg furosemide, oestrogens, azathioprine, thiazide diuretics, sulfonamides, tetracyclines, valproate)
Pancreatitis - stages
3 phases of which the initial phase characterized by activation of intrapancreatic digestive enzyme and acinar cell damage followed by the second phase of an inflammatory reaction with acinar cell necrosis and finally, the last phase is the appearance of extrapancreatic changes where pulmonary damage occurs and ultimately leading to ARDS
Acute pancreatitis - clinical features
- Mid-epigastric or left upper quadrant pain that radiates to the back , can improve on leaning forward
- O/E tender and distended abdomen with guarding
- nausea and profuse vomiting
- anorexia
- signs of hypovolaemia - may include skin turgor, dry mucous membranes, hypotension, and sweating. In more severe cases, tachycardic and/or tachypnoeic.
Acute pancreatitis - characteristic signs
- Grey-Turner’s sign: bilateral flank blue discoloration indicating haemorrhagic pancreatitis.
- Cullen’s sign: peri-umbilical blue discoloration indicating haemorrhagic pancreatitis.
- Fox’s sign: ecchymosis over the inguinal ligament area
Acute pancreatitis - investigations
- serum lipase or amylase = very high
- LFTs = raised ALT/AST or obstructive pattern if stone in CBD
- FBC = leukocytosis
- CRP = high
- ABG - may be hypoxaemic, requiring oxygen
- 1st scan: abdominal ultrasound
- still inconclusive: contrast-enhanced CT scan: can show oedema, swelling or necrosis
- AXR - may find a sentinel loop (isolated dilatation of a segment of gut) adjacent to the pancreas
- CXR - may show atelectasis and pleural effusion (especially in the left side)
Serum amylase vs lipase
Serum lipase and amylase have similar sensitivity and specificity but lipase levels remain elevated for longer - up to 14 days after symptom onset vs 5 days for amylase
Acute pancreatitis - management
- resuscitation with IV fluids, oxygen
- analgesia (morphine sulfate or fentanyl)
- Abx - based on where infection is (GB, UTI, RTI etc)
- Early nutritional support — oral feeding (mild acute pancreatitis), enteral feeding is otherwise preferable
- catheterisation + fluid balance chart
- correction of electrolyte abnormalities (calcium or magnesium replacement)
- insulin for tight glucose control
- if caused by gallstone –> ERCP + sphincterotomy; early laparoscopic cholecystectomy
- infected necrosis: either radiological drainage or surgical necrosectomy
Acute pancreatitis - complications
- pseudocyst (encapsulated collections of fluid with high enzyme concentrations)
- pancreatic abscess (peri-pancreatic fluid collections become colonised and infected)
- pancreatic insufficiency
- chronic pancreatitis
- intestinal obstruction
- sepsis
- pancreatic necrosis (responsible for 80% of deaths. Infections eg E coli, Pseudomonas etc)
- haemorrhage
- acute lung injury/acute respiratory distress syndrome
- disseminated intravascular coagulation
- acute renal failure
Chronic Pancreatitis - main features
- most common cause is alcohol
- fibrosis, atrophy and calcification of pancreas
- chronic epigastric pain, steatorrhea, DM (loss of islet cells), obstructive jaundice, anorexia
- exacerbated by alcohol and relieved by sitting forward
- increased risk of pancreatic adenocarcinoma
- other causes = gallstones, tumours, CF in children, A1ATd, pancreatic divisium
- Dx: US/CT +/- MRCP
also check amylase (typically not raised), LFTs, glucose
faecal elastase may be used to assess exocrine function if imaging inconclusive
Mx
- analgesia
- treat undrlying cause, e.g. ERCP, alcohol cessation, statin
- enzyme replacement e.g. creon, ADEK
- glucose monitoring
Pancreatic Carcinoma - features
- > 95% exocrine (adenocarcinoma)
- RF: smoking, obesity, red meat, male, African, age 65-75, DM, chronic pancreatitis, cirrhosis (alcohol), FH
- N+V, fatigue, weight loss/anorexia, non-specific abdo pain or epigastric to back
- progressive jaundice (dark urine, pale stool)
- Trusseau sign of malignancy* = blood clots felt as small lumps under skin
- Courvoisier sign = GB enlarged and palpable
- can also occur in gastric and lung ca
Pancreatic adenocarcinoma - investigations
- serum amylase and lipase ↑
- tumour markers = ↑ CA19-9 and ↑ CEA
- LFTs - obstructive pattern
- abdo USS = mass, dilated bile ducts
- high resolution CT (gold standard) = dilated bile ducts
- ERCP = stricture of pancreatic duct
- brush cytology = malignant cells
- other way of getting histology is with Endoscopic ultrasound (EUS) to guide fine needle aspiration biopsy
Pancreatic adenocarcinoma - treatment
Resectable (stages 1 and 2)
- consider preoperative biliary stenting
- surgery = proximal pancreaticoduodenectomy with antrectomy (Kausch-Whipple procedure)
- Adjuvant chemotherapy prolongs survival
- Pancreatic enzyme replacement after surgery (pancreatin)
- For patients with tumours of the body or tail of pancreas, a distal pancreatectomy can often be performed
- Cx: pancreatic fistula, delayed gastric emptying, pancreatic insufficiency.
Non-resectable:
palliative treatment with endoscopic stent insertion into the bile duct, followed by chemotherapy or chemoradiotherapy.
Acute pancreatitis - Glasgow score
If the score ≥ 3, severe pancreatitis is likely- suggest refer to HDU/ICU and if the score < 3, severe pancreatitis is unlikely (each scores 1)
- PaO2< 7.9kPa
- Age > 55 years
- Neutrophils (WBC > 15)
- Calcium < 2 mmol/L
- Renal function: Urea > 16 mmol/L
- Enzymes LDH > 600IU/L (Lactate dehydrogenase) - sign of tissue damage
- Albumin < 32g/L (serum)
- Sugar: Blood glucose > 10 mmol/L
Other risk stratification scores that can be used scoring severity of acute pancreatitis include the APACHE II score, the Ranson Criteria, and Balthazar score (CT scoring system).
