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Yr2 GI Joe > Pancreatic disease > Flashcards

Pancreatic disease Flashcards

1
Q

What is acute pancreatitis?

A

Inflammation of the pancreas with elevation of serum amylase (>4x) and multi-organ failure in severe cases

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2
Q

What is the incidence and mortality rate with acute pancreatitis?

A

Incidence of 20-300/million

Mortality of 6-12/million

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3
Q

What are the causes of acute pancreatitis?

(GETSMASHED)

A

Gallstones (25-40%)

Ethanol (60-75%)

Trauma

Steroids

Malignancy

Autoimmune

Scorpion sting

Hypertriglycerides / hypercalcaemia

ERCP

Drugs

(+ Idiopathic 10%)

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4
Q

Describe the pathology in acute pancreatitis

A

Primary insult causes the release of pancreatic enzymes

This causes Autodigestion leading to oedema, fat necrosis & haemorrhage

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5
Q

How does acute pancreatitis present (symptoms)?

A

Presents as acute emergency to hospital

Upper Abdominal pain (may radiate to back)

Nausea & Vomitting

Loss of appetite

Shivering

Fever

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6
Q

What are the clinical signs of Acute pancreatitis?

A

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)

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7
Q

What investigations are done (first line) for a diagnosis of acute pancreatitis?

A
  1. Bloods: Serum amylase (> 4x), Serum Lipase (> 3x)
  2. Contrast enhanced CT scan

Source - BMJ

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8
Q

After diagnosis, investigations may be done to determine the cause.

What investigations could be done?

A

Gallstones - Abdo US + Liver function test

Bloods - FBC, Ca2+, Lipids, LFT^, Glucose, U&E’s

CXR - will identify pleural effusions

AXR - will identify ileus

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9
Q

What is the Glasgow criteria?

A

Criteria for assessng the severity of Acute pancreatitis, through analysis of several aspects of the Blood of the patient.

A score >3 = Severe pancreatitis

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10
Q

What are the cut off values for the Glasgow criteria?

A

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

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11
Q

What CRP level indicates sever pancreatitis?

A

CRP > 150 mg/l

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12
Q

How should an acute pancreatitis patient be managed on admission?

A

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

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13
Q

Pancreatic necrosis is a complication of serious pancreatitis.

How is it managed?

A

CT guided aspiration

Followed by Antiobiotic treatment

Occasionally, surgery is required

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14
Q

Gallstones are a common cause of Acute pancreatitis.

How is this managed?

A

Gallstones usually identified by adbominal US scan

This is investigated using either EUS, MRCP or ERCP

Managed through Cholecystectomy

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15
Q

What is a cholycystectomy?

A

Surgical removal of the gallbladder

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16
Q

An abscess is a complication of Acute Pancreatitis

How is it treated?

A

Antibiotics

CT guided drainage

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17
Q

What is a pseudocyst (of the pancreas)?

A

Collection of Pancreatic fluids with a wall of fibrous tissue or granulation (but no epithelial lining)

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18
Q

What would indicate that a patient with Acute pancreatitis has developed a pseuodocyst?

A

Persistant Hyperamylaseaemia and/or Pain

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19
Q

How is a pseudocyst diagnosed?

A

Patient with symptoms is investigated using Abdominal Ultrasound or CT

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20
Q

What are the risks/complications of pseudocysts?

A

jaundice, infection, haemorrhage, rupture

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21
Q

Do all pseudocysts require surgical action?

A

Nah fam

If < 6cm - it will resolve

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22
Q

How is a pseudocyst managed?

A

Endoscopic drainage or surgery if persistent pain or complications

(Endoscopic is preffered)

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23
Q

What is the mortality of acute pancreatitis?

A

Mild < 2%

Severe - 15% (pretty high eh)

24
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’

25
Q

How important is ethnicity/origin concerning someones likelihood of getting chronic pancreatitis?

A

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

26
Q

Describe the Age and gender shit for chronic pancreatitis

A

Male > Female

Typical age is 35-50 years

27
Q

What causes chronic pancreatitis?

A

Alcohol abuse (80%)

Cystic fibrosis

Congenital abnormalities

Hereditary pancreatitis

Hypercalcaemia

Diet

28
Q

How likely is someone with Cystic fibrosis to develop chronic panc?

A

2% of CF patients have Chronic panc

High frequency of CFTR gene mutations in those with Chronic Panc

29
Q

What genetic mutations are most strongly associated with Chronic pancreatitis?

A

PRSS1

SPINK1

CFTR (cystic fibrosis)

30
Q

Describe the pathophysiology of Chronic pancreatitis

A

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)

31
Q

Describe the damage that takes place in the pancreatic ducts in chronic pancreatitis?

A

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

32
Q

How might nerves be exposed to damage in chronic pancreatitis?

A

Trapped Pancreatic juices may destroy perineural cells surrounding nerves

This may cause them to become destroyed

33
Q

How would chronic pancreatitis lead to portal hypertension?

A

Splenic , superior mesenteric & portal veins may thrombose

This leads to portal hypertension

34
Q

How does chronic pancreatitis tend to present?

A

Abdominal pain

Weight loss

Steatorhoea

Diabetes (30%)

Other: Jaundice, Portal hypertension, GI haemorrhage, pseudocysts & panc carcinoma

35
Q

Why are symptoms like weight loss, Steatorrhoea and diabetes* present in chronic pancreatitis?

*not a symptom but shut up

A

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%

36
Q

What investigations are done first line for chronic pancreatitis?

BMJ

A

Bloods: Amylase, Glucose, Albumin, Vit B12 , Ca2+, Mg2+, LFT, Prothrombin time

CT scan

AXR

Abdo Utrasound

37
Q

What blood test results would indicate Chronic pancreatitis?

A

Serum amylase will increase in Acute exacerbations

Albumin, Ca2+, Mg2+, Vit B12 will be low

LFTs, prothrombin time (vit K), glucose will be High

38
Q

What other investigations could be considered for Chronic pancreatitis?

A

EUS

Pancreatic function tests:

  • Lundh
  • Pancreolauryl
39
Q

Why is Abdominal ultrasound a useful imaging modality for Chronic pancreatitis?

A

Will identify:

Pancreatic size, cysts, duct diameter, tumours

40
Q

Why is Abdo X ray a useful imaging modality for chronic pancreatitis?

A

30% of CP patients have Calcification in their pancreas

Xrays are good for picking this up

41
Q

Pain control is a key part of the management of CP. Describe what is included in it?

A

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

42
Q

How is the exocrine and endocrine aspect of CP managed?

A

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)

43
Q

What is the prognosis for CP?

A

If they drink = 50% 10 year survival

Abstinence = 80% 10 year survival

44
Q

What are the main causes of death in those with Chronic pancreatitis?

A

Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide

45
Q

Describe the epidemiology of pancreatic carcinoma

A

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

46
Q

Where in the pancreas does the carcinoma tend to be?

A

head 60%

body 13%

tail 5%

multiple sites 22%

47
Q

What types of pancreatic carcinoma are there?

A

75% are duct cell mucinous adenocarcinoma

carcinosarcoma

cystadenocarcinoma (better prognosis)

Acinar cell

48
Q

What are the symptoms of pancreatic carcinoma?

A

Upper abdominal pain (75%)

Jaundice (painless obstr. 25%)

Weight loss (90%)

Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting

49
Q

What are the signs not on examination of pancreatic cancer?

A

Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis

Thrombophlebitis migrans (shown below)

Ascites

Portal hypertension

50
Q

What are the physical signs of pancreatic cancer?

(ie signs on examination)

A

Hepatomegaly

Jaundice

Abdo mass

Abdo tenderness

Ascites, splenomegaly

Supraclavicular lymphadenopathy

Palpable gallbladder

51
Q

How is pancreatic carcinoma firstly investigated?

A
  1. Abdominal US ± CT scan ± EUS​
  2. (Mass identified): EUS/percutaneous needle biopsy
  3. (if biopsy = carcinoma): CT scan/EUS/Laparoscopy/Laparotomy to see if operable
52
Q

How is the investigative approach for pancreatic carcinoma different if there is jaundice?

A

ERCP ± Stent

This is done as well as the other investigations

53
Q

What is the general approach to managing pancreatic carcinoma?

A

< 10% operable

Management is usually palliative:

  • stent
  • palliative surgery - cholechoduodenostomy

Pain control (opiates, coeliac plexus block, radiotherapy)

54
Q

What is the approach to surgery with pancreatic cancer?

A

< 10% operable

If patient is Fit, the tumour is < 3cm and there is no metastisis then a pancreatoduodenectomy (Whipple’s procedure) can be performed

55
Q

Why is chemotherapy not available for treating pancreatic carcinoma?

A

It is only being used in controlled trials rn

56
Q

Wha is the prognosis for pancreatic cancer?

A

Absolutely terrible

Inoperable:

  • mean survival < 6 months
  • 1% 5 year survival

Operable:

  • 15% 5 year survival
  • Ampullary tumours 30-50% 5 year survival
57
Q
A

Yr2 GI Joe (28 decks)

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