Pancreatic Disease Flashcards
1
Q
What is acute pancreatitis?
A
Acute inflammation of the pancreas
2
Q
Presentation of acute pancreatitis
A
Upper abdominal pain
Elevation of serum amylase (>4x upper limit of normal)
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%
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
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
6
Q
What is paralytic ileus?
A
Destruction of normal propulsive ability of the GI tract
7
Q
Definition of oliguria
A
Low output of urine
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
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
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
11
Q
Complications of acute pancreatitis
A
Abscess
Pseudocyst
12
Q
What is a pseudocyst?
A
Fluid collection without an epithelial lining
13
Q
Presentation of a pseudocyst
A
Persistent hyperamylasaemia and/or pain
14
Q
Diagnosis of pseudocyst
A
USS
CT scan
15
Q
Complications of pancreatic pseudocyst
A
Jaundice
Infection
Haemorrhage
Rupture
16
Q
Treatment of pseudocyst
A
< 6cm - resolve spontaneously
Endoscopic drainage or surgery if persistent pain or complications
17
Q
What % of patients have mild acute pancreatitis?
A
75-80%
18
Q
Mortality of severe acute pancreatitis
A
15%
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
20
Q
Which gender gets chronic pancreatitis more?
A
M > F
21
Q
Which ages get chronic pancreatitis?
A
35 - 50
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
23
Q
Assosiated genes with chronic pancreatitis
A
PRSS1 - cationic trypsinogen
SPINK1 - pancreatic secretory trypsin inhibitor
CFTR - CF gene
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
25
Presentation of chronic pancreatitis
```
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
```
26
Investigations of chronic pancreatitis
```
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
```
27
When is serum amylase increased in chronic pancreatitis?
In acute exacerbations
28
In chronic pancreatitis, what blood results will be decreased?
Albumin
Ca2+/Mg2+
Vitamin B12
29
In chronic pancreatitis, what blood results will be increased?
LFTs
Prothrombin Time (Vit K)
Glucose
30
What are the pancreatic function tests?
Lundh
| Pancreolauryl
31
Pain control in chronic pancreatitis
Avoid alcohol
Pancreatic enzyme supplements
Opiate analgesia (dihydrocodeine, penthidine)
Coeliac plexus block
Endoscopic treatment of pancreatic duct stones / strictures
Surgery
32
What is the pain in chronic pancreatitis exacerbated by?
Alcohol
| Food
33
Management of endocrine and exocrine issues in chronic pancreatitis
```
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
```
34
Prognosis (10 year survival) of chronic pancreatitis with continued alcohol intake
50%
35
Prognosis (10 year survival) of chronic pancreatitis with abstinence
80%
36
Which gender gets more pancreatic carcinomas?
M > F
37
Where has the highest rates of pancreatic carcinomas?
Maoris
| Hawaiians
38
Where are the affected areas of the pancreas that gets carcinomas and their %s?
Head 60%
Body 13%
Tail 5%
Multiple sites 22%
39
Types of pancreatic carcinomas
75% duct cell mucinous adenocarcinoma
Carcinosarcoma
Cystadenocarcinoma
Acinar cell
40
Which type of pancreatic carcinoma has the best prognosis?
Cystadenocarcinoma
41
Presentation of pancreatic carcinoma
```
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
Signs of pancreatic carcinoma
```
Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites
Splenomegaly
Supraclavicular lymphadenopathy
Palpable gallbladder if ampullary carcinoma
```
43
Where would the pancreatic cancer most likely be if there was upper abdominal pain?
Body and tail
44
Where would the pancreatic cancer most likely be with painless obstructive jaundice?
Head
45
Investigations of pancreatic cancer
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
Treatment of pancreatic carcinoma
```
Radical surgery -> pancreatoduodenectomy (Whipple's procedure)
If palliation of jaundice
- stent
- cholechudodenostomy
Pain control
```
47
Prognosis of inoperable cases of pancreatic carcinoma
Mean survival < 6 months
| 1% 5 year survival
48
Prognosis of operable cases of pancreatic carcinoma
15% 5 year survival
| Ampullary tumours 30-50% 5 year survival
49
Most common causes of acute pancreatitis
40 % gallstones
40% alcohol
3% post ERCP
50
Investigations to find the cause of acute pancreatitis
1. USS to see if gallstones
2. If cannot find cause, check
- calcium
- lipid profile
- drug cardex
51
What type of enzymes are one of the most potent enzymes?
Pancreatic enzymes
52
What can pancreatic enzymes digest?
Fat
Carbohydrate
Proteins
53
What are cytokines?
Inflammatory mediators - augmenting the inflammatory process
54
What can acute pancreatitis also affect when its affects become systemic?
Heart
Lung
Kidney
55
Does acute pancreatitis also have an infection?
No
56
If the acute pancreatitis has been a mild attack, then how long should the patient be in hospital for?
2 days - 1 week
57
What serious complication may occur in severe pancreatitis?
Organ failure
58
What does pancreatic necrosis lead to?
Dead pancreatic tissue
59
Is necrosis reversible?
No
60
What does necrosis look like?
Batches
| Thrombosis of the small vessels
61
Is necrosis infected?
Starts off sterile
| Can become infected
62
Treatment of ANC
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
What is the worse complications of a patient from acute pancreatitis?
Infected necrosis
64
Where is the lesser sac found?
Between the stomach and the pancreas
65
Where is the foramen of Winslaw found?
Between the greater and lesser sacs
66
How can inflammation of the pancreas lead to 3rd space loss?
Fluid can leak into the lesser sac which can then go into the greater sac
67
Sources of third space loss in AP
1. Acute fluid collection
| 2. Ileus
68
Definition of a cyst
Fluid collection in the body lined by epithelium
69
Definition of pseudocyst
A collection lined by fibrous or granulation tissue
70
If a psuedocyst lasts > 6 weeks, what is this called?
Chronic pseudocyst
71
Features of the pain in AP
Reaches its maximum within a few hours
| Associated symptoms of vomiting and retching due to upper GI upset
72
Features of the pain in a perforated PU
Sudden severe pain then stays at the same intensity
73
What do cytokines cause?
Vasodilation
74
Peritonisation of the pancreas
Retroperitoneal
75
Would AP cause rigidity? Why?
No, as for rigidity something needs to irritate the peritoneum, and the pancreas is retroperitoneal
76
Why should Ax be started when have AP?
At risk of ascending cholangitis
77
What can severe pancreatitis cause?
Ileus in the proximal small bowel and transverse colon which leads to dilated bowel with loads of fluid in it
78
As well as autodigestion in AP, what else do the enzymes digest?
Small blood vessels around the pancreas in the retroperitoneal tissue
79
Are cullens and grey turners sign specific to AP?
No
80
Causes of retroperitoneal haemorrhage
Ruptured AAA
Poorly controlled warfarin
Ectopic pregnancy
81
What are patients with retro peritoneal haemorrhage at risk of?
Acute renal failure
82
As patients with AP are at risk of acute renal failure, what must be done when the patients are admitted?
Catheter to monitor output
| Fluid chart
83
In patients who are very unwell with AP, why must an ABG be done?
Can get resp complications in AP
| Looking for evidence of severe metabolic acidosis which would make you worry about ischaemic bowel
84
How long does it take for serum amylase to rise in AP?
Up to 6 hours after onset of pain
85
Is serum amylase prognostic for AP?
No
86
Does serum amylase need to be repeated once diagnosed?
No
87
Why would a CXR when looking for a perforated bowel?
Free air in the chest
88
Definition of sentinel loop
Dilated small bowel loop next to an inflammed organ
89
How long does it take to see necrosis of the pancreas on a CT scan?
3 days
90
How can AP cause portal HTN?
Inflammation causes thrombosis of the veins that pass through the pancreas
Leading to portal HTN
91
What veins pass through the pancreas?
Splenic vein
Superior mesenteric vein
Portal vein
92
In AP if there is a sudden drop in haemoglobin, what would this indicate?
A pseudo-artery aneurysm
93
What may be present on imaging in pancreatic cancer?
'Double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
94
What hereditary condition can pancreatic cancer be associated with?
HNPCC
95
What needs to be excluded in all patients presenting with painless jaundice?
Pancreatic carcinoma
