Pancreatic Disease

Question 1

Causes of acute pancreatitis (remember I GET SMASHED)

Answer 1

• Idiopathic
• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps/malignancy
• Autoimmune
• Scorpion sting
• Hyperlipidaemia/hypercalcaemia
• ERCP/EUS
• Drugs (azathioprine)

Question 2

Features of acute pancreatitis

Answer 2

• Pancreatic enzymes (amylase/lipase) attack the pancreatic tissue
• Acute severe upper abdominal pain, 50% radiates to back and partially relieved by bending forwards
• Cullen’s sign (bruising on umbilical region)
• Grey Turner’s sign (bruising on flanks)

Question 3

Diagnosis of acute pancreatitis

Answer 3

• Diagnosed clinically
• Elevated serum amylase >3x ULN
• Amylase half-life short so may be on way back down by time measured
• Serum lipase elevated for longer
• CT scan

Question 4

Glasgow score for pancreatitis (remember PANCREAS)

Answer 4

• PaO2 <60
• Age >55 years
• Neutrophils - WBC >15
• Calcium <2
• uRea >16
• Enzymes - LDH >600 or AST/ALT >200
• Albumin >32
• Sugar - glucose >10

Question 5

Causes of chronic pancreatitis (remember TIGARO)

Answer 5

• Toxic/metabolic (alcohol, tobacco, hyperlipidaemia, CKD)
• Idiopathic
• Genetic (PRSS1, CTFR, SPINK1)
• Autoimmune
• RAP/SAP associated (post-necrotic, vascular, post-irradiation)
• Obstriction

Question 6

Features of chronic pancreatitis

Answer 6

• Inflammatory condition
• Parenchyma replaced with fibrous tissue
• Pain
• Malnutrition
• Diabetes
• Increased risk of pancreatic cancer
• Erythema ab igne seen in patients using hot water bottle for pain

Question 7

Diagnosis of chronic pancreatitis

Answer 7

• Calcification on imaging (100% specific)
• Aspiration of duodenal secretions post secretin/CCK at ERCP
• Secreting enhanced MRCP
• EUR (Rosemount criteria)
• Labelled carbon breath test (test for PEI)
• Wedge biopsy or section of resected pancreas

Question 8

Management of pancreatitis

Answer 8

• Escalate care according to Glasgow score
• Careful monitoring as can deteriorate quickly
• IV fluids
• Analgesia
• Endoscopic drainage of large pseudocysts
• Antibiotics if evidence of infected pancreatic necrosis
• Address exocrine and endocrine needs in chronic cases
• Surgery to remove infected pancreatic necrosis

Question 9

Complications of pancreatitis

Answer 9

• Pseudocysts (no epithelial lining, high concentration of pancreatic enzymes, may resolve spontaneously or can be drained into stomach)
• Pancreatic necrosis
• Infection in nectoric areas (avascular haemorrhagic pancreas food culture medium, drainage or necrosectomy plus antibiotics)
• Chronic pancreatitis

Question 10

Pathogenesis of pancreatic exocrine insufficiency

Answer 10

• Reduced secretion due to pancreatic disease
• Low CCK due to duodenal disease
• Acidic duodenal pH due to gastric hypersecretion or low bicarbonate secretion
• Abnormal transit due to surgery

Question 11

Presentation of pancreatic cancer

Answer 11

• 90% are adenocarcinomas of head of pancreas
• Present late as do not cause symptoms until blocking biliary system causing painless jaundice
• Other symptoms include:
  
  • Unintentional weight loss
  • Non-specific upper abdominal/back pain
  • Pale stools
  • Steatorrhoea
  • Dark urine
  • Palpable mass in epigastric region
• Typically metastasise to peritoneum, lungs and bones
• Peak incidence in 70s and 80s
• Genetic factors include PRSS1, BRCA2, Peutz-Jeughers, HNPCC and FAP

Question 12

Diagnosis and management of pancreatic cancer

Answer 12

• Diagnosis
  
  • CA19-9 tumour marker
  • CT CAP for staging
  • Endoscopic US with biopsy
• PDAC grading
  
  • A and B are resectable
  • C are borderline
  • D1, D2 and E are irresectable
• Management
  
  • Whipple’s procedure (removes head of pancreas, gallbladder, duodenum and pylorus)
  • Distal pancreatectomy for tumour in body/tail
  • Adjuvant chemotherapy
  • Palliative stenting/chemotherapy in late disease