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Gastrointestinal Pathology > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

What is acute pancreatitis?

A

Acute inflammation of the pancreas

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2
Q

Presentation of acute pancreatitis

A

Upper abdominal pain

Elevation of serum amylase (>4x upper limit of normal)

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3
Q

Causes of acute pancreatitis

A 
Alcohol abuse (60-75%)
Gallstones (25-40%)
Trauma
- blunt
- post op 
- post ERCP
Drugs (steroids, azathioprine, diuretics)
Pancreatic carcinoma
Mumps, coxsackie, HIV, CMV
Metabolic
- increased calcium 
- increased triglycerides
- decreased temp 
Autoimmune
Idiopathic 10%
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4
Q

Pathology of acute pancreatitis

A 
Primary insult
Release of activated pancreatic enzymes in the pancreas itself 
Autodigestion 
Proinflammatory cytokines
Reactive oxygen species
Oedema
Fat necrosis 
Haemorrhage
Systemic inflammation
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5
Q

Presentation of acute pancreatitis

A 
Abdominal pain 
Pain may radiate to back 
Vomiting
Pyrexia
Tachycardia
Hypovolaemic shock 
Oliguria 
Acute renal failure
Jaundice
Paralytic ileus
Retroperitoneal haemorrhage ( grey turners and cullens signs) 
Hypoxia (resp failure in severe cases)
Hypocalcaemia
Hyperglycaemia 
Effusions 
- ascites
- pleural 
- high amylase
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6
Q

What is paralytic ileus?

A

Destruction of normal propulsive ability of the GI tract

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7
Q

Definition of oliguria

A

Low output of urine

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8
Q

Investigations for acute pancreatitis

A 
Amylase/lipase
FBC
U and Es
LFTs
Ca2+
Glucose
ABGs
lipids 
Coagulation screen
AXR (ileus) and CXR (pleural effusion)
AUSS
CT scan
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9
Q

What indicates severe pancreatitis?

A

Score > 3 or the Glasgow criteria within 48 hours of admission
CRP > 150mg/l
Still unwell at the end of the first week

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10
Q

Treatment of acute pancreatitis

A 
Analgesia
IV fluids
Blood transfusion (Hb <10)
NG tube 
O2 
May need insulin 
Treat cause
Nutritional support in severe cases
Surgery
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11
Q

Complications of acute pancreatitis

A

Abscess

Pseudocyst

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12
Q

What is a pseudocyst?

A

Fluid collection without an epithelial lining

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13
Q

Presentation of a pseudocyst

A

Persistent hyperamylasaemia and/or pain

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14
Q

Diagnosis of pseudocyst

A

USS

CT scan

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15
Q

Complications of pancreatic pseudocyst

A

Jaundice
Infection
Haemorrhage
Rupture

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16
Q

Treatment of pseudocyst

A

< 6cm - resolve spontaneously

Endoscopic drainage or surgery if persistent pain or complications

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17
Q

What % of patients have mild acute pancreatitis?

A

75-80%

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18
Q

Mortality of severe acute pancreatitis

A

15%

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19
Q

What is chronic pancreatitis?

A

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

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20
Q

Which gender gets chronic pancreatitis more?

A

M > F

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21
Q

Which ages get chronic pancreatitis?

A

35 - 50

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22
Q

Causes of chronic pancreatitis

A 
Alcohol (80%)
CF 
Congenital 
- annular pancreas
- pancreas divisum 
Hereditary pancreatitis 
Hypercalcaemia 
Diet - possibly antioxidants decrease in topical pancreatitis
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23
Q

Assosiated genes with chronic pancreatitis

A

PRSS1 - cationic trypsinogen
SPINK1 - pancreatic secretory trypsin inhibitor
CFTR - CF gene

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24
Q

Pathogenesis of chronic pancreatitis

A

Duct obstruction
- calculi
- inflammation
- protein plugs
Possibly abnormal sphincter of oddi function
- spasm; increase in intrapancreatic pressure
- relaxation; reflux of duodenal contents
Possibly genetic polymorphisms
- abnormal trypsin activation
Glandular atrophy and replacement by fibrous tissue
Ducts become dilated, tortous and strictured
Inspissated secretions may calcify
Exposed nerves due to loss of perineural cells
Splenic, superior mesenteric and portal veins may thrombose -> portal HTN

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25
Q

Presentation of chronic pancreatitis

A 
Early disease asymptomatic 
Abdominal pain (85-95%)
- exacerbated with food and alcohol 
Weight loss / Anorexia
Malabsorption 
Exocrine insufficiency 
- fat malabsorption -> steatorrhoea 
- decrease in fat soluble vitamins (A,D,E,K) leads to a decrease in Ca/Mg
- decreased vit B12
Endocrine insufficiency 
- DM in 30%
Jaundice
Portal HTN
GI haemorrhage 
Pseudocysts 
Possibly pancreatic carcinoma
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26
Q

Investigations of chronic pancreatitis

A 
Plain AXR (30% have calcification of pancreas)
USS
EUS 
CT
Serum amylase 
Albumin 
U and Es 
Vit B12
LFTS
Prothrombin time
Glucose 
Pancreatic function tests
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27
Q

When is serum amylase increased in chronic pancreatitis?

A

In acute exacerbations

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28
Q

In chronic pancreatitis, what blood results will be decreased?

A

Albumin
Ca2+/Mg2+
Vitamin B12

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29
Q

In chronic pancreatitis, what blood results will be increased?

A

LFTs
Prothrombin Time (Vit K)
Glucose

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30
Q

What are the pancreatic function tests?

A

Lundh

Pancreolauryl

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31
Q

Pain control in chronic pancreatitis

A

Avoid alcohol
Pancreatic enzyme supplements
Opiate analgesia (dihydrocodeine, penthidine)
Coeliac plexus block
Endoscopic treatment of pancreatic duct stones / strictures
Surgery

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32
Q

What is the pain in chronic pancreatitis exacerbated by?

A

Alcohol

Food

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33
Q

Management of endocrine and exocrine issues in chronic pancreatitis

A 
Low fat diet (30 - 40g a day)
Pancreatic enzyme supplements 
- creon, pancrex
May need acid suppression to prevent hydrolysis in the stomach of the enzyme supplements
Insulin if DM
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34
Q

Prognosis (10 year survival) of chronic pancreatitis with continued alcohol intake

A

50%

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35
Q

Prognosis (10 year survival) of chronic pancreatitis with abstinence

A

80%

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36
Q

Which gender gets more pancreatic carcinomas?

A

M > F

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37
Q

Where has the highest rates of pancreatic carcinomas?

A

Maoris

Hawaiians

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38
Q

Where are the affected areas of the pancreas that gets carcinomas and their %s?

A

Head 60%
Body 13%
Tail 5%
Multiple sites 22%

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39
Q

Types of pancreatic carcinomas

A

75% duct cell mucinous adenocarcinoma
Carcinosarcoma
Cystadenocarcinoma
Acinar cell

40
Q

Which type of pancreatic carcinoma has the best prognosis?

A

Cystadenocarcinoma

41
Q

Presentation of pancreatic carcinoma

A 
Upper abdominal pain (75%)
Painless obstructive jaundice (25%)
Weight loss (90%)
Anorexia
Fatigue
Diarrhoea / steatorrhoea
Nausea / vomiting
Tender subcutaneous fat nodules due to metastatic fat necrosis
Thrombophlebitis migrans
Ascites
Portal HTN
42
Q

Signs of pancreatic carcinoma

A 
Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites
Splenomegaly
Supraclavicular lymphadenopathy 
Palpable gallbladder if ampullary carcinoma
43
Q

Where would the pancreatic cancer most likely be if there was upper abdominal pain?

A

Body and tail

44
Q

Where would the pancreatic cancer most likely be with painless obstructive jaundice?

A

Head

45
Q

Investigations of pancreatic cancer

A
  1. AUSS +/ CT +/- EUS
  2. If jaundice +/- mass, then ERCP +/- stent
    If there is a mass without jaundice;
  3. EUS / Percutaneous needle biopsy
  4. If carcinoma, CT / EUS/ Laparscopy/laparotomy to find out if inoperable or operable
46
Q

Treatment of pancreatic carcinoma

A 
Radical surgery -> pancreatoduodenectomy (Whipple's procedure) 
If palliation of jaundice
- stent 
- cholechudodenostomy 
Pain control
47
Q

Prognosis of inoperable cases of pancreatic carcinoma

A

Mean survival < 6 months

1% 5 year survival

48
Q

Prognosis of operable cases of pancreatic carcinoma

A

15% 5 year survival

Ampullary tumours 30-50% 5 year survival

49
Q

Most common causes of acute pancreatitis

A

40 % gallstones
40% alcohol
3% post ERCP

50
Q

Investigations to find the cause of acute pancreatitis

A
  1. USS to see if gallstones
  2. If cannot find cause, check
    - calcium
    - lipid profile
    - drug cardex
51
Q

What type of enzymes are one of the most potent enzymes?

A

Pancreatic enzymes

52
Q

What can pancreatic enzymes digest?

A

Fat
Carbohydrate
Proteins

53
Q

What are cytokines?

A

Inflammatory mediators - augmenting the inflammatory process

54
Q

What can acute pancreatitis also affect when its affects become systemic?

A

Heart
Lung
Kidney

55
Q

Does acute pancreatitis also have an infection?

A

No

56
Q

If the acute pancreatitis has been a mild attack, then how long should the patient be in hospital for?

A

2 days - 1 week

57
Q

What serious complication may occur in severe pancreatitis?

A

Organ failure

58
Q

What does pancreatic necrosis lead to?

A

Dead pancreatic tissue

59
Q

Is necrosis reversible?

A

No

60
Q

What does necrosis look like?

A

Batches

Thrombosis of the small vessels

61
Q

Is necrosis infected?

A

Starts off sterile

Can become infected

62
Q

Treatment of ANC

A

No intervention is possible
Localised necrosis
Need to wait 4 weeks so that the necrosis can collect then we can do something about it

63
Q

What is the worse complications of a patient from acute pancreatitis?

A

Infected necrosis

64
Q

Where is the lesser sac found?

A

Between the stomach and the pancreas

65
Q

Where is the foramen of Winslaw found?

A

Between the greater and lesser sacs

66
Q

How can inflammation of the pancreas lead to 3rd space loss?

A

Fluid can leak into the lesser sac which can then go into the greater sac

67
Q

Sources of third space loss in AP

A
  1. Acute fluid collection

2. Ileus

68
Q

Definition of a cyst

A

Fluid collection in the body lined by epithelium

69
Q

Definition of pseudocyst

A

A collection lined by fibrous or granulation tissue

70
Q

If a psuedocyst lasts > 6 weeks, what is this called?

A

Chronic pseudocyst

71
Q

Features of the pain in AP

A

Reaches its maximum within a few hours

Associated symptoms of vomiting and retching due to upper GI upset

72
Q

Features of the pain in a perforated PU

A

Sudden severe pain then stays at the same intensity

73
Q

What do cytokines cause?

A

Vasodilation

74
Q

Peritonisation of the pancreas

A

Retroperitoneal

75
Q

Would AP cause rigidity? Why?

A

No, as for rigidity something needs to irritate the peritoneum, and the pancreas is retroperitoneal

76
Q

Why should Ax be started when have AP?

A

At risk of ascending cholangitis

77
Q

What can severe pancreatitis cause?

A

Ileus in the proximal small bowel and transverse colon which leads to dilated bowel with loads of fluid in it

78
Q

As well as autodigestion in AP, what else do the enzymes digest?

A

Small blood vessels around the pancreas in the retroperitoneal tissue

79
Q

Are cullens and grey turners sign specific to AP?

A

No

80
Q

Causes of retroperitoneal haemorrhage

A

Ruptured AAA
Poorly controlled warfarin
Ectopic pregnancy

81
Q

What are patients with retro peritoneal haemorrhage at risk of?

A

Acute renal failure

82
Q

As patients with AP are at risk of acute renal failure, what must be done when the patients are admitted?

A

Catheter to monitor output

Fluid chart

83
Q

In patients who are very unwell with AP, why must an ABG be done?

A

Can get resp complications in AP

Looking for evidence of severe metabolic acidosis which would make you worry about ischaemic bowel

84
Q

How long does it take for serum amylase to rise in AP?

A

Up to 6 hours after onset of pain

85
Q

Is serum amylase prognostic for AP?

A

No

86
Q

Does serum amylase need to be repeated once diagnosed?

A

No

87
Q

Why would a CXR when looking for a perforated bowel?

A

Free air in the chest

88
Q

Definition of sentinel loop

A

Dilated small bowel loop next to an inflammed organ

89
Q

How long does it take to see necrosis of the pancreas on a CT scan?

A

3 days

90
Q

How can AP cause portal HTN?

A

Inflammation causes thrombosis of the veins that pass through the pancreas
Leading to portal HTN

91
Q

What veins pass through the pancreas?

A

Splenic vein
Superior mesenteric vein
Portal vein

92
Q

In AP if there is a sudden drop in haemoglobin, what would this indicate?

A

A pseudo-artery aneurysm

93
Q

What may be present on imaging in pancreatic cancer?

A

‘Double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts

94
Q

What hereditary condition can pancreatic cancer be associated with?

A

HNPCC

95
Q

What needs to be excluded in all patients presenting with painless jaundice?

A

Pancreatic carcinoma

Gastrointestinal Pathology (26 decks)

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