Pancreatic disease Flashcards
mortality rate associated with acute pancreatitis?
1 in 5 that get acute pancreatitis can die
What is acute pancreatitis
acute inflammation of the pancreas
sudden onset
upper abdominal pain - usually epigastric region
elevation of serum amylase due to inflammation
what does the serum amylase level have to be to make a diagnosis of acute pancreatitis?
4 times the normal level
common causes of acute pancreatitis
- excessive alcohol intake 60-75%
- gallstones 25-40%
not so common:-
trauma - road traffic accident, post op
misc - drugs, viruses (tend to be self limiting), pancreatic carcinoma
idopathic
Describe pathogenesis of acute pancreatitis
primary insult - alcohol, gallstone etc
causes a release of activated pancreatic enzymes
which can cause autodigestion leading to either oedema, fat necrosis, haemorrhage as a result or the release of reactive O2 species or pro-inflammatory cytokines
Clinical features of acute pancreatitis (7)
Abdominal pain (may radiate to back) Vomiting Pyrexia - fever Tachycardia, hypovolaemic shock (severe blood loss) Oliguria, acute renal failure Jaundice
what is an ERCP? what does it do?
endoscopic retrograde cholangio-pancreatography
an endoscope put through your mouth to your pancreas. It lets you examine the pancreatic and bile ducts
What other method other than ERCP is commonly used for acute pancreatitis
Endoscopic ultrasound
what investigations would a patient undergo to diagnose or assess for acute pancreatitis (4)
blood tests - amylase/lipase, FBC, LFT, U&E, Ca2+, arterial blood gases
AXR (abdominal x ray) or CXR
Abdominal ultrasound - looking for pancreatic oedema, gallstones, pseudocyst
CT scan
What does the Glasgow-Imrie criteria state for assessment of the severity of acute pancreatitis?
you need an overall score of >3 to diagnose within 48 hours of admission
it’s based on 8 lab values:-
- WCC > 15x10^9/L
- Blood glucose >10 mmol/L
- Blood urea >16 mmol/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
A CRP level of >150 mg/L also indicated what?
severe pancreatitis
General management of acute pancreatitis
Analgesia (pethidine, indomethacin) IV fluids Blood transfusion (Hb <10 g/dl) if anaemic etc
Monitor urine output (catheter) Naso-gastric tube O2 May need insulin Nutrition
Specific management when dealing with pancreatic necrosis?
CT guided aspiration
antibiotics and maybe surgery
Specific management when dealing with Gallstones
EUS/ERCP/MRCP
Cholecystectomy
What complications can arise when dealing with acute pancreatitis
abscess - antibiotics and drainage required
pseudocyst - fluid collection without an epithelial lining
- -> persistent pain or hyperamylasaemia
- -> jaundice, infection, haemorrhage
if collection is less than 6 cm diameter then resolves spontaneously
endoscopic drainage or surgery if persistent
Mortality difference between mild and sever ap
Mild AP - 75-80% of cases only have a mortality rate of 2%
sever AP has a mortality rate of 15%
what is chronic pancreatitis
continuing inflammatory disease of the pancreas
irreversible glandular destruction
pain
permanent loss of function perhaps
wall of pancreas gets destroyed over time
Causes of chronic pancreatitis (4)
alcohol 80%
Smoking
Autoimmune
cystic fibrosis - high freq. of CFTR gene mutations in chronic pancreatitis
congenital anatomical abnormalities - annular pancreas or pancreas divisum
hereditary pancreatitis - rare
hypercalcaemia
Key genes associated with pancreatitis (3)
PRSS1 - test
SPINK1 - no test
CFTR - sweat chloride test
Pathogenesis of chronic pancreatitis
duct obstruction - calculi (stones), inflammation, protein plugs
abnormal sphincter of oddi function
pathology of chronic pancreatitis (4)
Glandular atrophy & replacement by fibrous tissue
Ducts become dilated, tortous & strictured
‘Exposed’ nerves due to loss of peri-neural cells
Splenic, superior mesenteric & portal veins may thrombose leading to portal hypertension
Clinical features of chronic pancreatitis
Early disease is asymptomatic
Abdominal pain (85-95%) exacerbated by food & alcohol; severity decreases with time
Weight loss (pain, anorexia, malabsorption)
Exocrine insufficiency
fat malabsorption causing steatorrhoea
decrease in fat soluble vitamins (A,D,E,K)
protein malabsorption => weight loss - decreased vit B12
Endocrine insufficiency
Misc.: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma
investigations for chronic pancreatitis (6)
Plain AXR (30% have calcification of pancreas)
Ultrasound: pancreatic size, cysts, duct diameter, tumours
Endoscopic Ultrasound
CT scan
Blood tests
Serum amylase increases in acute exacerbations
decreased albumin, Ca2+/Mg2+, vit B12
increased LFTs, Prothrombin time (vit K), glucose
Pancreatic function tests (Lundh, pancreolauryl)
How can pain caused by chronic pancreatitis be controlled (5)
avoid alcohol
pancreatic enzyme supplements
opiate analgesia
coeliac plexus block
endoscopic treatment of pancreatic stones and strictures
surgery in some cases
Types of carcinoma of the pancreas
75% are duct cell mucinous adenocarcinoma
other types - carcinocarcoma, cystadenocarcinoma, acinar cell
Clinical features of pancreatic cancer (7+)
Upper abdominal pain (75%) -
Painless obstructive jaundice
Weight loss (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans (vessel inflammation)
Ascites, portal hypertension
Physical signs of pancreatic cancer (8)
hepatomegaly jaundice abdominal tenderness abdominal mass ascites, splenomegaly supraclavicular lymphadenopathy palpable gallbladder
Imaging used for carcinoma of the pancreas
USS
EUS
CT
MRI
Management of pancreatic cancer
most patients have advanced disease at presentation - less than 10% are operable
radical surgery - if patient is fit, tumour is <3cm, no metastases
palliation of jaundice - stent, palliative surgery
pain control - opiates, radiotherapy, coeliac plexus block
chemo
Prognosis for pancreatic cancer?
inoperable cases - <6 months, 1% 5 year survival
operable cases - 15% 5yr survival
