Pancreatic Disease

Question 1

What is Acute Pancreatitis?

Answer 1

• Inflammation of the pancreas.
• Limited damage to the secretory function of the gland with no gross structural damage developing.
• Has increasing incidence and mortality ranges between 5-30% depending on severity

Question 2

What can cause Acute Pancreatitis?

Answer 2

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune disease such as SLE
• Scorpion venom
• Hypercalcaemia
• Endoscopic retrograde cholangiopancreatography
• Drugs such as Azathioprine, NSAIDs or Diuretics

Question 3

What is thought to be the pathophysiology of Acute Pancreatitis?

Answer 3

• Premature and exaggerated activation of digestive enzymes within the pancreas leading to inflammation
• This causes an increase in vascular permeability and subsequent fluid loss into third space
• Enzymes are released from the pancreas into the systemic circulation causing autodigestion of fats and blood vessels.
• Fat necrosis can cause the release of free fatty acids reacting with calcium to form chalky deposits in fatty tissue. Results in hypocalcaemia.
• End stage pancreatitis will eventually result in partial or complete necrosis of pancreas

Question 4

What are clinical features of Acute Pancreatitis?

Answer 4

• Sudden severe epigastric pain which can radiate through the back
• Nausea
• Vomiting
• Tetany may occur from hypocalcaemia secondary to fat necrosis

Question 5

What are examination findings of Acute Pancreatitis?

Answer 5

• Epigastric tenderness on examination
• Guarding and a rigid abdomen with potential circulatory instability
• Grey Turner’s sign which is bruising in the flank
• Cullen’s sign which is bruising around the umbilicus
• Gallstone pathology may lead to concurrent jaundice or cholangitis

Question 6

What is seen on investigation of Acute Pancreatitis?

Answer 6

• Serum amylase: Diagnostic of acute pancreatitis if 3X the upper limit of normal
  
  • (raised in bowel perforation, ectopic pregnancy, mesenteric ischaemia, DKA)
• LFTs to assess for any concurrent cholestatic element to the clinical picture
• Serum Lipase is more accurate for acute pancreatitis yet not available or routinely performed at every hospital

Question 7

What is seen on imaging of Acute Pancreatitis?

Answer 7

• Abdominal Ultrasound
  
  • ​Typically used to identify a possible gallstone by demonstrating dilation of the bile ducts
• AXR:
  
  • Shows ‘sentinel loop sign’. Dilated proximal bowel loop adjacent to the pancreas which occurs secondary to localised inflammation.
  • CXR should be undertaken to look for pleural effusion or signs of ARDs.
• Contrast-enhanced CT scan
  
  • Performed if clinical assessment and blood tests prove inconclusive.
  • If performed after 48hrs from initial presentation, it will often show area of pancreatic oedema and swelling as well as any potential complications that may have developed

Question 8

How is Acute Pancreatitis managed?

Answer 8

Management - No curative management for acute pancreatitis so supportive measure are the mainstay of treatment.

• Treat any underlying causes as necessary
• Supportive treatment includes:
  
  • High-Flow oxygen
  • IV fluid resuscitation
    
    • Recommended 250 – 500ml/hr of crystalloid solution to be given to all patient in initial period. Hartmann’s solution of preferred choice of fluid
  • Catheterisation
    
    • Accurate monitoring of urine output and start a fluid chart.
    • Aim for urine output at least >0.5ml/kg/hr and check U&Es.
  • Opioid analgesia
  • Nasogastric Tube
    
    • If patient has profuse vomiting, make them nil-by mouth
  • If Severe, managed in HDU or ITU
  • Broad-spectrum antibiotic should be considered for prophylaxis against infection in cases of confirmed pancreatic necrosis, as this has shown a decreased mortality with their use.
• Treat underlying cause once stabilised patient

Question 9

What are some systemic complications of Acute Pancreatitis?

Answer 9

• DIC
• Acute Respiratory Distress syndrome
• Hypocalcaemia
• Hyperglycaemia – secondary to disturbances of insulin metabolism
• Hypovolaemic shock
• Multiorgan failure

Question 10

What are some local complications of Acute Pancreatitis?

Answer 10

• Pancreatic Necrosis
  
  • Ongoing inflammation eventually leads to ischemic infarction of the pancreatic tissue hence this progression should be suspected in patient with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis. Confirmed with CT
  • Can lead to infection and should monitor for clinical deterioration with raised infection markers. Confirmed infection with fine needle aspiration of the necrosis
  • Any confirmed case treated by pancreatic necrosectomy
• Pancreatic Pseudocyst
  
  • Collection of the fluid containing pancreatic enzymes, blood and necrotic tissue typically located in the lesser sac. Typically formed weeks after the initial acute pancreatitis episode; they lack an epithelial lining, therefore termed pseudocyst, and instead have vascular and fibrotic wall surrounding the collection
  • Found incidentally on imaging or can present with symptoms of mass effect such as biliary obstruction or gastric outlet obstruction. Prone to haemorrhage or rupture and can become infected.
  • Cyst present for longer than 6 weeks unlikely to resolve spontaneously. Surgical debridement or endoscopic drainage

Question 11

What is Chronic Pancreatitis?

Answer 11

Chronic fibro-inflammatory disease of the pancreas with progressive and irreversible damage to the pancreatic parenchyma.

Question 12

What is the pathophysiology of Chronic Pancreatitis?

Answer 12

Large duct disease

• Dilatation and dysfunction of the large pancreatic ducts therefore visible on most diagnostic imaging.
• Pancreatic fluid changes composition and facilities the deposition of precursors to calcium carbonate stones and cause diffuse pancreatic calcification. Found more in males

Small duct disease

• Usually associated with normal imaging and no pancreatic calcification. Found more in females

Question 13

What are clinical features of Chronic Pancreatitis?

Answer 13

• Chronic pain in the epigastric region and radiating to the back. Partially eased patient leaning forward
• Nausea and vomiting
• Symptoms secondary endocrine dysfunction such as diabetes mellitus
• Symptoms secondary exocrine dysfunction such as steatorrhea or malabsorption

Question 14

What are laboratory investigations for Chronic Pancreatitis?

Answer 14

• BM to check for Raised Glucose, secondary to reduce endocrine dysfunction
• Serum Calcium to assess for any hypercalcaemia
• LFTs may be abnormal
• Serum Amylase and Lipase levels are rarely significantly raised in established disease.
• Markers of Nutrition: Magnesium, haemoglobin, and albumin may be low, but are not diagnostic.
• Faecal Elastase level: Abnormally low

Question 15

What are types of Pancreatic Cancer?

Answer 15

• Ductal carcinoma of the pancreas
• Exocrine tumours such as pancreatic cystic carcinoma
• Endocrine tumour derived from islet cells of the pancreas.

Question 16

What is the pathophysiology of Pancreatic Cancer?

Answer 16

• Most common type of pancreatic cancer is ductal carcinoma which spreads and invade local structures such as spleen, transverse colon and adrenal glands.
• Lymphatic metastases typically involves regional lymph nodes, liver, lungs and peritoneum.
• Metastasis is common at the time of diagnosis

Question 17

What are risk factors of Pancreatic Cancer?

Answer 17

• Smoking
• Chronic Pancreatitis,
• Recent onset of Diabetes Mellitus,
• Family History

Question 18

What are clinical features of Pancreatic Cancer?

Answer 18

• Cancer affecting the head of the pancreas classically presents with a combination of
  
  • Obstructive Jaundice – due to compression of the common bile duct
  • Abdominal pain due to invasion of the coeliac plexus or secondary pancreatitis. Painless jaundice however is head of pancreas cancer unless proven otherwise
  • Weight loss – due to metabolic effects of cancer or secondary to exocrine dysfunction
• Acute Pancreatitis
• Thrombophlebitis Migrans – caused by a paraneoplastic hypercoagulable state.
• Tumours of the tail of the pancreas have an insidious course and not generally symptomatic until a late stage

Question 19

What are examination signs of Pancreatic Cancer?

Answer 19

• Cachectic
• Malnourished
• Jaundiced
• Abdominal mass in the epigastric region as well as enlarged gallbladde

Question 20

What are some investigations of Pancreatic Cancer?

Answer 20

• Initial Blood Test
  
  • FBC: anaemia, thrombocytopenia)
  • LFTs: raised bilirubin, alkaline phosphatase, Gamma-GT
• CA19-9 is a tumour marker with high sensitivity and specificity for pancreatic cancer. Role in assessing treatment response rather than initial diagnosis

Question 21

How is Pancreatic Cancer managed?

Answer 21

• Surgery: curative management is radical resection
  
  • Tumours of the head of the pancreas is treatment with a pancreaticoduodenectomy or ‘Whipple’s procedure”
    
    • Removal of the head of pancreas, antrum of the stomach, 1st and 2nd part of the duodenum, common bile duct and the gallbladder. Removal due to their common arterial supply shared by the head of the pancreas and duodenum
    • Following this, the tail of pancreas and the hepatic duct are attached to the jejunum, allowing bile and pancreatic juices to drain into the gut, whilst the stomach is subsequently anastomosed with the jejunum allowing for the passage of food
  • Tumours of the body or tail of the pancreas, a distal pancreatectomy can be often performed
• Contraindications to Surgery is peritoneal, liver and distant metastases. Morbidity following the procedure is high and specific complication include formation of a pancreatic fistula, delayed gastric emptying and pancreatic insufficiency

Question 22

How is Pancreatic Cancer palliatively managed?

Answer 22

• Majority of pancreatic cancer patient undergo palliative care
• Obstructive jaundice and associated pruritis can be relieved with insertion of a biliary stent via ERCP or percutaneously
• Gemcitabine-based regime in patients with a reasonable performance status as palliation
• Exocrine insufficiency is common in advanced disease or those who have had signification excision of the pancreas and can lead to steatorrhea and malabsorption
  
  • Initially treated with enzyme replacement such as Creon who are typically administered with meals.
• Prognosis is less than 5% for 5-year survival rate

Question 23

How is Severity of Acute Pancreatitis determined?

Answer 23

• Modified Glasgow Criteria

Question 24

What are examination signs of Chronic Pancreatitis?

Answer 24

• Epigastric tenderness on palpation
• Fullness or mass can be felt in the epigastrium which suggest presence of pseudocyst or inflammatory mass.
• Patients with exocrine dysfunction may show signs relating to malsorption

Question 25

What is Courvoisier’s Law?

Answer 25

• In presence of jaundice and an enlarged/palpable gallbladder, malignancy of the biliary tree or pancreas should be strongly suspected as the cause is unlikely to be gallstones.
• Sign may be present if the obstructing tumour is distal to the cystic duct.

Question 26

What are some imaging techniques of Pancreatic Cancer?

Answer 26

• Abdominal Ultrasound which may demonstrate a pancreatic mass or a dilated biliary tree
• Pancreatic protocol CT Scan is important for diagnosis and stage disease progression.
• Chest-abdo-pelvis CT scan will be further required once pancreatic cancer has been diagnosed for staging.
• PET-CT may be warranted in those with localised disease on CT
• Endoscopic Ultrasound used to guide fine needle aspiration biopsy to histologically evaluate the lesion.

Question 27

What are some medical mangement techniques for Pancreatic Cancer?

Answer 27

• Adjuvant chemotherapy generally with 5-flouracil is recommended after surgery as it has been demonstrated to improve survival.
• In metastatic disease, use of FOLFIRINOX regime is advised in those with good performance status but has only modest improvement in survival. Gemcitabine therapy can be considered alternatively