Pancreatic disease Flashcards
What is acute pancreatitis?
Inflammation of the pancreas with elevation of serum amylase (>4x) and multi-organ failure in severe cases
What is the incidence and mortality rate with acute pancreatitis?
Incidence of 20-300/million
Mortality of 6-12/million
What are the causes of acute pancreatitis?
(GETSMASHED)
Gallstones (25-40%)
Ethanol (60-75%)
Trauma
Steroids
Malignancy
Autoimmune
Scorpion sting
Hypertriglycerides / hypercalcaemia
ERCP
Drugs
(+ Idiopathic 10%)
Describe the pathology in acute pancreatitis
Primary insult causes the release of pancreatic enzymes
This causes Autodigestion leading to oedema, fat necrosis & haemorrhage
How does acute pancreatitis present (symptoms)?
Presents as acute emergency to hospital
Upper Abdominal pain (may radiate to back)
Nausea & Vomitting
Loss of appetite
Shivering
Fever
What are the clinical signs of Acute pancreatitis?
Epigastric tenderness (with gaurding)
Pyrexia
Tachycardia, hypovolaemic shock
Oliguria (acute renal failure)
Jaundice
Ascites / pleural effusions
Paralytic ileus
Retroperitoneal haemorrhage (Grey Turner’s & Cullen’s signs)
What investigations are done (first line) for a diagnosis of acute pancreatitis?
- Bloods: Serum amylase (> 4x), Serum Lipase (> 3x)
- Contrast enhanced CT scan
Source - BMJ
After diagnosis, investigations may be done to determine the cause.
What investigations could be done?
Gallstones - Abdo US + Liver function test
Bloods - FBC, Ca2+, Lipids, LFT^, Glucose, U&E’s
CXR - will identify pleural effusions
AXR - will identify ileus
What is the Glasgow criteria?
Criteria for assessng the severity of Acute pancreatitis, through analysis of several aspects of the Blood of the patient.
A score >3 = Severe pancreatitis
What are the cut off values for the Glasgow criteria?
White Blood cells >15x109/l
Glucose >10 mmol/l
Urea >16mmol/l
AST >200 iu/l
LDH >600 iu/l
Albumin <32 g/l
Calcium <2.0 mmol/l
PO2 <7.5 kPa
What CRP level indicates sever pancreatitis?
CRP > 150 mg/l
How should an acute pancreatitis patient be managed on admission?
Analgesia (morphine, pethidine, indomethacin)
IV fluids
Blood transfusion (Hb <10 g/dl)
Catheter (to monitor urine output)
Naso-gastric tube
Oxygen
Others: Insulin, Calcium supplements, Nutrition
Pancreatic necrosis is a complication of serious pancreatitis.
How is it managed?
CT guided aspiration
Followed by Antiobiotic treatment
Occasionally, surgery is required
Gallstones are a common cause of Acute pancreatitis.
How is this managed?
Gallstones usually identified by adbominal US scan
This is investigated using either EUS, MRCP or ERCP
Managed through Cholecystectomy
What is a cholycystectomy?
Surgical removal of the gallbladder
An abscess is a complication of Acute Pancreatitis
How is it treated?
Antibiotics
CT guided drainage
What is a pseudocyst (of the pancreas)?
Collection of Pancreatic fluids with a wall of fibrous tissue or granulation (but no epithelial lining)
What would indicate that a patient with Acute pancreatitis has developed a pseuodocyst?
Persistant Hyperamylaseaemia and/or Pain
How is a pseudocyst diagnosed?
Patient with symptoms is investigated using Abdominal Ultrasound or CT
What are the risks/complications of pseudocysts?
jaundice, infection, haemorrhage, rupture
Do all pseudocysts require surgical action?
Nah fam
If < 6cm - it will resolve
How is a pseudocyst managed?
Endoscopic drainage or surgery if persistent pain or complications
(Endoscopic is preffered)
What is the mortality of acute pancreatitis?
Mild < 2%
Severe - 15% (pretty high eh)
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’
How important is ethnicity/origin concerning someones likelihood of getting chronic pancreatitis?
Highly variable, for example:
in Japan there is a 0.01% prevalence
in S.India there is a 5.4% prevalence
In UK, 3.5 / 100,000 /year
Describe the Age and gender shit for chronic pancreatitis
Male > Female
Typical age is 35-50 years
What causes chronic pancreatitis?
Alcohol abuse (80%)
Cystic fibrosis
Congenital abnormalities
Hereditary pancreatitis
Hypercalcaemia
Diet
How likely is someone with Cystic fibrosis to develop chronic panc?
2% of CF patients have Chronic panc
High frequency of CFTR gene mutations in those with Chronic Panc
What genetic mutations are most strongly associated with Chronic pancreatitis?
PRSS1
SPINK1
CFTR (cystic fibrosis)
Describe the pathophysiology of Chronic pancreatitis
Duct obstruction
- Calculi (kidney stone), inflammation, protein plugs
Abnormal sphincter of Oddi function
–spasm: intrapancreatic pressure
–relaxation: reflux of duodenal contents
Genetic polymorphisms
–Abnormal trypsin activation
(just look this part up)
Describe the damage that takes place in the pancreatic ducts in chronic pancreatitis?
Pancreatic ducts blocked causing build up of pancreatic secretions
This basically destroys the ducts - causing glandular atrophy & replacement by fibrous tissue
Ducts become dilated, tortous & strictured - Inspissated secretions may calcify
How might nerves be exposed to damage in chronic pancreatitis?
Trapped Pancreatic juices may destroy perineural cells surrounding nerves
This may cause them to become destroyed
How would chronic pancreatitis lead to portal hypertension?
Splenic , superior mesenteric & portal veins may thrombose
This leads to portal hypertension
How does chronic pancreatitis tend to present?
Abdominal pain
Weight loss
Steatorhoea
Diabetes (30%)
Other: Jaundice, Portal hypertension, GI haemorrhage, pseudocysts & panc carcinoma
Why are symptoms like weight loss, Steatorrhoea and diabetes* present in chronic pancreatitis?
*not a symptom but shut up
Damage leads to Exocrine insufficiency
Fat malabsorption => Steatorrhoea
- Decreased fat soluble vitamins (ADEK)
- Decreased Ca2+ & Mg 2+
Protein malabsorption => Weight loss
Endocrine insufficiency => Diabetes in 30%
What investigations are done first line for chronic pancreatitis?
BMJ
Bloods: Amylase, Glucose, Albumin, Vit B12 , Ca2+, Mg2+, LFT, Prothrombin time
CT scan
AXR
Abdo Utrasound
What blood test results would indicate Chronic pancreatitis?
Serum amylase will increase in Acute exacerbations
Albumin, Ca2+, Mg2+, Vit B12 will be low
LFTs, prothrombin time (vit K), glucose will be High
What other investigations could be considered for Chronic pancreatitis?
EUS
Pancreatic function tests:
- Lundh
- Pancreolauryl
Why is Abdominal ultrasound a useful imaging modality for Chronic pancreatitis?
Will identify:
Pancreatic size, cysts, duct diameter, tumours
Why is Abdo X ray a useful imaging modality for chronic pancreatitis?
30% of CP patients have Calcification in their pancreas
Xrays are good for picking this up
Pain control is a key part of the management of CP. Describe what is included in it?
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
How is the exocrine and endocrine aspect of CP managed?
Diet = Low fat (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)
What is the prognosis for CP?
If they drink = 50% 10 year survival
Abstinence = 80% 10 year survival
What are the main causes of death in those with Chronic pancreatitis?
Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
Describe the epidemiology of pancreatic carcinoma
11/100 000 pop/year (increasing)
Males > females
80% in 60-80 y/o age group
More common in Western countries
–highest rates in Maoris & Hawaiians
Where in the pancreas does the carcinoma tend to be?
head 60%
body 13%
tail 5%
multiple sites 22%
What types of pancreatic carcinoma are there?
75% are duct cell mucinous adenocarcinoma
carcinosarcoma
cystadenocarcinoma (better prognosis)
Acinar cell
What are the symptoms of pancreatic carcinoma?
Upper abdominal pain (75%)
Jaundice (painless obstr. 25%)
Weight loss (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
What are the signs not on examination of pancreatic cancer?
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans (shown below)
Ascites
Portal hypertension
What are the physical signs of pancreatic cancer?
(ie signs on examination)
Hepatomegaly
Jaundice
Abdo mass
Abdo tenderness
Ascites, splenomegaly
Supraclavicular lymphadenopathy
Palpable gallbladder
How is pancreatic carcinoma firstly investigated?
- Abdominal US ± CT scan ± EUS
- (Mass identified): EUS/percutaneous needle biopsy
- (if biopsy = carcinoma): CT scan/EUS/Laparoscopy/Laparotomy to see if operable
How is the investigative approach for pancreatic carcinoma different if there is jaundice?
ERCP ± Stent
This is done as well as the other investigations
What is the general approach to managing pancreatic carcinoma?
< 10% operable
Management is usually palliative:
- stent
- palliative surgery - cholechoduodenostomy
Pain control (opiates, coeliac plexus block, radiotherapy)
What is the approach to surgery with pancreatic cancer?
< 10% operable
If patient is Fit, the tumour is < 3cm and there is no metastisis then a pancreatoduodenectomy (Whipple’s procedure) can be performed
Why is chemotherapy not available for treating pancreatic carcinoma?
It is only being used in controlled trials rn
Wha is the prognosis for pancreatic cancer?
Absolutely terrible
Inoperable:
- mean survival < 6 months
- 1% 5 year survival
Operable:
- 15% 5 year survival
- Ampullary tumours 30-50% 5 year survival
