pancreatic disease Flashcards
what is acute pancreatitis?
Acute inflammation of the pancreas
Upper abdominal pain
Elevation of serum amylase (> 4 x upper limit of normal)
May be associated with multi-organ failure in severe cases
aetiology of acute pancreatitis?
Alcohol Abuse (60-75%) Gallstones (25-40%)
Trauma - blunt/postoperative/post-ERCP
Misc. - Drugs (steroids, azathioprine, diuretics)
- Viruses (mumps, coxsackie B4, HIV, CMV)
- Pancreatic carcinoma
- Metabolic (calcium, triglycerides, temp)
- Auto-immune
Idiopathic ~10%
what is the pathology of acute pancreatitis?
primary insult –> release of activated pancreatic enzymes –>autodigestion–> pro-inflammatory cytokines, reactive oxygen species, oedema, fat necrosis, haemorrhage
investigations for acute pancreatitis
Blood tests: amylase/lipase, FBC, U&Es, LFTs, Ca2+, glucose, arterial blood gases, lipids, coagulation screen
AXR (ileus) & CXR (pleural effusion)
Abdominal ultrasound (pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced)
assessement of acute pancreatitis
White cell count >15 x 109/l Blood glucose >10 mmol/l Blood urea >16mmol/l AST >200 iu/l LDH >600 iu/l Serum albumin <32 g/l Serum calcium <2.0 mmol/l Arterial PO2 <7.5 kPa
glasgow criteria >3
CRP>150
management of acute pancreatitis
Analgesia (pethidine, indomethacin) Intravenous fluids Blood transfusion (Hb <10 g/dl) Monitor urine output (catheter) Naso-gastric tube Oxygen May need insulin Rarely require calcium supplements Nutrition (enteral or parenteral) in severe cases
management of pancreatic necrosis
CT guided aspiration
antibiotics ± surgery
management of gallstones
EUS/MRCP/ERCP
Cholecystectomy
complications of actue pancreatitis
Abscess antibiotics + drainage
Pseudocyst
fluid collection without an epithelial lining
Persistent hyperamylasaemia and/or pain
Dx by ultrasound or CT scan
Complications: jaundice, infection, haemorrhage, rupture
<6 cm diameter resolve spontaneously
Endoscopic drainage or surgery if persistent pain or complications
outcome of acute pancreatitis
Mild AP (75-80% of cases) - mortality <2%
Severe AP - mortality 15%
Subsequent course dependent on removal of aetiological factor(s)
what is chronic pancreatitis?
Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function’
whos more likely to get chronic pancreatitis?
males
chronic pancreatitis aetiology
Alcohol (80%)
Cystic Fibrosis (CP in 2%)
high frequency of CFTR gene mutations in CP
Congenital anatomical abnormalities
Annular pancreas
Pancreas divisum (failed fusion of dorsal & ventral buds)
Hereditary pancreatitis: rare, auto. dom.
Hypercalcaemia
Diet: ?antioxidants decrease in tropical pancreatitis
what are the genes associated with pancreatitis?
PRSS1
SPINK1
CFTR
pathogenesis of chronic pancreatitis?
Duct obstruction calculi inflammation protein plugs ?Abnormal sphincter of Oddi function spasm: increase of intrapancreatic pressure relaxation: reflux of duodenal contents ?Genetic polymorphisms Abnormal trypsin activation
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
clinical features of chronic pancreatitis?
Abdominal pain (85-95%) exacerbated by food & alcohol; severity decreases with time
Weight loss (pain, anorexia, malabsorption)
Exocrine insufficiency
fat malabsorption –> steatorrhoea
decrease in fat soluble vitamins (A,D,E,K), decrease in Ca2+/Mg2+
protein malabsorption -> weight loss, decrease in vit B12
Endocrine insufficiency – > Diabetes in 30%
Misc.: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma
investigations of chronic pancreatitis
Plain AXR (30% have calcification of pancreas)
Ultrasound: pancreatic size, cysts, duct diameter, tumours
EUS
CT scan
Blood tests:
Serum amylase increase in acute exacerbations
decrease albumin, Ca2+/Mg2+, vit B12
increase LFTs, Prothrombin time (vit K), glucose
Pancreatic function tests (Lundh, pancreolauryl)
how to control the pain of chronic pancreatitis
avoid alcohol
pancreatic enzyme supplements
opiate analgesia (dihydrocodeine, pethidine)
Coeliac plexus block
referral to pain clinic/psychologist
Endoscopic treatment of pancreatic duct stones and strictures
Surgery in selected cases
exocrine and endocrine management of chronic pancreatitis
Low-fat diet (30-40 g/day)
Pancreatic enzyme supplements (eg. Creon, Pancrex); may need acid suppression to prevent hydrolysis in stomach
Vitamin supplements usually not required
Insulin for diabetes mellitus (oral hypoglycaemics usually ineffective)
prognosis of chronic pancreatitis
Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
Continued alcohol intake 50% 10 yr survival
Abstinence 80% 10 yr survival
epidemiology of carcinoma of pancreas
Incidence: 11/100 000 pop/year (increasing) Males>Females 80% in 60-80 year age group More common in Western countries highest rates in Maoris & Hawaiians
pathology of carcinoma in pancreas
75% are duct cell mucinous adenocarcinoma (head 60%, body 13%, tail 5%, multiple sites 22%) Other pathological types: carcinosarcoma cystadenocarcinoma (better prognosis) Acinar cell
clinical features of carcinoma of the pancreas
Upper abdominal pain (75%) - Ca body & tail
Painless obstructive jaundice (25%) - Ca head
Weight loss (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans
Ascites, portal hypertension
