Pancreatic Disease Flashcards
Acute Pancreatitis Definition
- ACUTE INFLAMMATION OF PANCREAS (sudden onset + sig. mortality)
- Results in UPPER ABDOMINAL PAIN
- ELEVATED SERUM AMYLASE (>4x upper normal limit; normal = ~90)
- Could be ass. w/ MULTI-ORGAN FAILURE IN SEVERE CASES
prognosis dependant on sorting out aetiological factor
Acute Pancreatitis Presentation
Symptoms:
• ABDOMINAL PAIN
• NAUSEA, VOMITING, COLLAPSE
• OLIGURIA, ACUTE RENAL FAILURE
- JAUNDICE
- PARALYTIC ILEUS (ileus = lack of movement in intestines leading to build-up of intestinal contents & potentially intestinal obstruction - this can be due to paralysis of intestinal muscles)
- RETROPERITONEAL HAEMORRHAGE (Grey Turner’s & Cullen’s signs)
- HYPOXIA (REPIRAOTRY FAILURE if SEVERE)
- HYPOCALCAEMIA (TETANY RARE)
- HYPERGLYCAEMIA (occasionally DIABETIC COMA)
- EFFUSIONS (ASCITIC & PLEURAL, HIGH AMYLASE)
Signs: • PYREXIA • TACHYCARDIA, HYPOVOLAEMIC SHOCK • DEHYDRATION • ABDOMINAL TENDERNESS • CIRCULATORY FAILURE
Acute Pancreatitis Investigations
Bloods:
• FBC
• U+E
• LFT
- AMYLASE/LIPASE
- Ca2+
- GLUCOSE & LIPIDS
- ABG - systemically unwell
- COAGULATION SCREEN
Imaging:
• AXR (ileus) & CXR (pleural effusion) - may also show perforated abscess
- ABDOMINAL USS (pancreatic oedema, gallstones, pseudocyst)
- CT (contrast enhanced - useful for complications e.g. ~ 4 - 10 days for necrosis, severity + monitor pt. for disease)
- ERCP & ENDOCSCOPIC USS (jaundice & cholangitis)
- MRCP & EUSS = if stones don’t show up
- ERCP = only if pt. jaundiced, biliary obstruction, documented gallstone blockage
Acute Pancreatitis Managment
Assess severity: • WCC > 15x109/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 mmol/L • ARTERIAL PO2 < 7.5kPa
- GLASGOW CRITERIA = SCORE < 3 is SEVERE PANCREATITIS w/I 48 HRS of ADMISSION
- CRP > 150 mg/L also INDICATES SEVERE PANCREATITIS
General: • ANALGESIA = PETHIDINE, INDOMETHACIN • IV FLUIDS • BLOOD TRANSFUSION (if Hb < 10 g/dL) • MONITOR URINE OUTPUT = CATHETER • NGT • O2 • INSULIN (may req.) • Ca2+ SUPPLEMENTS (rarely req.) • NUTRITION (ENTERAL - better/PARENTERAL) IN SEVERE CASES
Specific:
• PANCREATIC NECROSIS = CT GUIDED ASPIRATION = ANTIBIOTICS ± SURGERY (try to avoid pt. going into surgery)
* May be STERILE/INFECTED = NECROSECTOMY * GALLSTONES = EUSS/MRCP/ERCP = CHOLECYSTECTOMY
Precipitating Factors:
• CHOLELITHIASIS = ERCP & ES, CHOLECYSTECTOMY
- ALCOGOL = ABSTINENCE, COUNSELLING
- ISCHAEMIA = CAREFUL SUPPORT, CORRECT CAUSE
- MALIGNANCY = RESECTION/BYPASS
- HYPERLIPIDAEMIA = DIET, LIPID LOWERING DRUGS
- ANATOMICAL ABNORMALITIES = CORRECT if POSS.
- DRUGS = STOP/CHANGE
Complications:
• ABSCESS = ANTIBIOTICS + DRAINAGE
- PSEUDOCYST:
- FLUID COLLECTION w/o EPITHELIAL LINING
- PERSISTENT HYPERAMYLASAEMIA ± PAIN
- DIAGNOSIS/INVESTIGATIONS = USS/CT
- COMPLICATIONS = JAUNDICE, INFECTION, HAEMORRHAGE, RUPTURE
- < 6cm in diameter = SPONTANEOUSLY RESOLVE
PERSISTENT PAIN/COMPLICATIONS = ENDOSCOPIC DRAINAGE/SURGERY
Acute Pancreatitis Aetiology
• I = IDIOPATHIC
* G = GALLSTONES, GENETIC - CF * E = ETHANOL * T = TRAUMA * S = STEROIDS * M = MUMPS (& OTHER INFECTIONS)/MALIGNANCY * A = AUTOIMMUNE * S = SCORPION STINGS/SPIDER BITES * H = HYPERLIPIDAEMIA/HYPERCALCAEMIA/HYPERPARATHYROIDISM (METABOLIC DISORDERS) * E = ERCP * D = DRUGS (TETRACYCLINES, FUROSEMIDE, AZATHIOPRINE, THIAZIDES, MANY OTHERS)
ANATOMICAL ABNORMALITIES, ISCHAEMIC, PANCREATINC CARCINOMA
Chronic Pancreatitis Definition
- CONTINUING INFLAMMATORY DISEASE of the PANCREAS
- Characterised by IRREVERSIBLE GLANDULAR DESTRUCTION
- Typically PAIN ± PERMANENT LOSS of FUNCTION
Chronic Pancreatitis Epidemiology
MALES > FEMALES
AGE = 35 - 50yrs
Chronic Pancreatitis Prognosis
- DEATH from COMPLICATIONS of ACUTE-ON-CHRONIC ATTACKS, CV COMPLICATIONS of DM, ASS. CIRRHOSIS, DRUG DEPENDANCE, SUICIDE
- CONTINUED ALCOHOL INTAKE = 50% 10yr SURVIVAL
- ABSTINENCE = 80% 10yr SURVIVAL
Chronic Pancreatitis Presentation
• EARLY DISEASE = ASYMPTOMATIC
• ABDOMINAL PAIN = EXACERBATED by FOOD & ALCOHOL, SEVERITY DECREASES w/ TIME ○ DEBILITATING PAIN, ass. w/ BINGES - BECOME MORE FREQ. & LESS TREATABLE by ABSTINENCE * WGT. LOSS (PAIN, ANOREXIA, MALABSORPTION) * EXOCRINE INSUFFICIENCY = STEATORRHOEA (fat malabsorption), reduced fat soluble vitamins & Ca2+/Mg2+, WGT. LOSS (protein malabsorption) * ENDOCRINE INSUFFICIENCY = DIABETES, reduced vitamin B12 * MISCELLANEOUS = JAUNDICE, PORTAL HYPERTENSION, GI HAEMORRHAGE, PSEUDOCYSTS, PANCREATIC CARCINOMA, DUODENAL OBSTRUCTION (uncommon)
Chronic Pancreatitis Investigations
Bloods
* SERUM AMYLASE (increase in acute exacerbations) * REDUCED AMYLASE, Ca2+/Mg2+, VITAMIN B12 * INCREASED LFTs, PROTHROMBIN TIME (vitamin K), GLUCOSE * PANCREATIC FUNCTION TESTS (not anymore)
Imaging
* PLAIN AXR - pancreatic calcification * USS - pancreatic size, cysts, duct diameter, tumours * CT * ERCP/MRCP
Chronic Pancreatic Management
Pain Control
- AVOID ALCOHOL!!! + COUNSELLING
- PANCREATIC ENZYME SUPPLEMENTS
- OPIATE ANALGESIA = DIHYDROCODEINE, PETHIDINE
- COELIAC PLEXUS BLOCK
- REFERRAL to PAIN CLINIC/PSYCHOLOGIST
- ENDOSCOPIC TREATMENT of PANCREATIC DUCT STONES & STRICTURES
- SURGERY in SELECTED CASES (suspicious of MALIGNANCY, INTRACTABLE PAIN) = DRAINAGE/RESECTION - has complications e.g. cysts/pseudocysts, pancreatic duct stenosis, colonic strictures
Exocrine & Endocrine Control
- LOW FAT DIET = 30 - 40 g/day (& LOW PROTEIN as well)
- PANCREATIC ENZYME SUPPLEMENTS = CREON, PANCREX
- ACID SUPPRESSION to prevent HYDROLYSIS in STOMACH
- INSULIN = for DM (oral hypoglycaemics ineffective - pancreatic damage)
- Vitamin supplements not usually req.
Chronic Pancreatitis Aetiology
O = OBSTRUCTION of MPD
○ TUMOUR = ADENOCARCINOMA, IPMT
○ SPHINCTER of ODDI DYSFUNCTION
○ PANCREATIC DIVISUM
○ DUODENAL OBSTRUCTION = TUMOUR, DIVERTICULUM
○ TRAUMA
○ STRUCTURE = POST-NECROTISING RADIATION
A = AUTOIMMUNE
T = TOXIN
○ ETHANOL - related to amount & length of consumption
○ SMOKING
○ DRUGS
I = IDIOPATHIC
G = GENETIC
○ AUTOSOMAL DOMINANT (Condon 29 & 122)
○ AUTOSOMAL RECESSIVE (CFTR, SPINK1, Codon A etc.)
E = ENVIRONMENTAL
○ TROPICAL CHRONIC PANCREATITIS
R = RECURRENT INJURIES
○ BILIARY
○ HYPERLIPIDAEMIA
○ HYPERCALCAEMIA
CONGENITAL ANATOMICAL ABNORMALITIES, HERDITARY PANCREATITIS
mainly ALCOHOL
Chronic Pancreatitis Pathogenesis + Pathology
PATHOGENESIS
- DUCT OBSTRUCTION = CALCULI, INFLAMMATION, PROTEIN PLUGS
- ABNORMAL SPHINCTER of ODDI FUNCTION ? = SPASM resulting in INCREASED INTRAPANCREATIC PRESSURE, RELAXATION resulting in REFLUX of DUODENAL CONTENTS
- GENETIC POLYMORPHISMS ? = ABNORMAL TRYPSIN ACTIVATION
PATHOLOGY
- GLANDULAR ATROPHY & REPLACEMENT by FIBROUS TISSUE
- DUCTS become DILATED, TORTUOUS & STRICTURES
- INSPISSATED SECRETIONS may CALCIFY
- EXPOSED NERVES due to LOSS of PERINEURAL CELLS
- SPLENIC, SMV & PORTAL VEINS may THROMBOSE = PORTAL HYPERTENSION
Pancreatic Carcinoma Epidemiology
MALES > FEMALES
80% in 60 - 80yrs
MORE COMMON in WESTERN COUNTRIES (highest rates in Maoris & Hawaiians)
Pancreatic Carcinoma Prognosis
- INOPERABLE = MEAN SURVIVAL < 6 MONTHS, 1% 5yr SURVIVAL
* OPERABLE = 15% 5yr SURVIVAL, AMPULLARY TUMOURS 30 - 50% 5yr SURVIVAL