Pancreatic Disease Flashcards
What is the definition of acute pancreatitis?
Acute inflammation of the pancreas
Upper abdominal pain
Elevation of serum amylase (> 4 x upper limit of normal)
May be associated with multi-organ failure in severe cases
What are the different aetiologie of acute pancreatitis?
Alcohol Abuse (60-75%)
Gallstones (25-40%)
Trauma - blunt/postoperative/post-ERCP
Misc. - Drugs (steroids, azathioprine, diuretics)
- Viruses (mumps, coxsackie B4, HIV, CMV)
- Pancreatic carcinoma
- Metabolic (increased calcium, increased triglycerides, decreased temp)
- Auto-immune
Idiopathic ~10%
What is the pathogenesis of acute pancreatitis?
Primary insult - release of activated pancreatic enzymes - autodigestion
Resultant: Pro-inflammatory cytokines, reactive oxygen species
Oedema, fat necrosis, haemorrhage
Who is ERCP offered to?
Those with biliary obstruction and acute pancreatitis
What are the relevatn investigations for pancreatitis?
Blood tests: amylase/lipase, FBC, U&Es, LFTs, Ca2+, glucose, arterial blood gases, lipids, coagulation screen
AXR (ileus) & CXR (pleural effusion)
Abdominal ultrasound (pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced)
What are markers of severe acute pancreatitis?
High white cell count
High blood glucose
High blood urea
High AST
Low serum albumin
Low serum calcium
Low arterial partial pressure oxygen
High CRP
What is management for acute pancreatitis?
Analgesia (pethidine, indomethacin)
Intravenous fluids
Blood transfusion (Hb <10 g/dl)
Monitor urine output (catheter)
Naso-gastric tube
Oxygen
May need insulin
Rarely require calcium supplements
Nutrition (enteral or parenteral) in severe cases
What is the specific management for acute pancreatitis?
Pancreatic necrosis - CT guided aspiration
- antibiotics ± surgery
Gallstones
EUS/MRCP/ERCP
Cholecystectomy
What are complications with acute pancreatitis?
Pancreatic necrosis
Abscess - antibiotics + drainage
Pseudocyst
–fluid collection without an epithelial lining
–Persistent hyperamylasaemia and/or pain
–Dx by ultrasound or CT scan
–Complications: jaundice, infection, haemorrhage, rupture
–<6 cm diameter ® resolve spontaneously
–Endoscopic drainage or surgery if persistent pain or complications
What is the outcome for acute pancreatitis?
Mild AP (75-80% of cases) - mortality <2%
Severe AP - mortality 15%
Subsequent course dependent on removal of aetiological factor(s)
What is the definition of chronic pancreatitis?
Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function
What are the aetiologies for chronic pancreatitis?
Alcohol (80%)
Cystic Fibrosis (CP in 2%)
–high frequency of CFTR gene mutations in CP
Congenital anatomical abnormalities
–Annular pancreas
–Pancreas divisum (failed fusion of dorsal & ventral buds)
Hereditary pancreatitis: rare, auto. dom.
Hypercalcaemia
Diet: ?antioxidants reduction in tropical pancreatitis
What is the effect of chronic pancreatitis on the glandular tissue of the pancrea?
Glandular atrophy and replacement by fibrous tissue
What is the effect of chronic pancreatitis on pancreas ducts?
Ducts become dilated, tortous and strictured
What happens to pancreatic secretions in chronic pancreatitis?
Inspissated (thickened or congealed) secretions may calcify
What happens to nerves in chronic pancreatitis?
Exposed nerves due to loss of perineural cells
How can chronic pancreatitis result in portal hypertension?
Splenic, superior mesenteric and portal veins may thrombose - portal hypertension
What are the 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 - steatorrhoea
¯ fat soluble vitamins (A,D,E,K), ¯ Ca2+/Mg2+
–protein malabsorption - weight loss, ¯vit B12
Endocrine insufficiency - Diabetes in 30%
Misc.: jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma
What are the investigations for chronic pancreatitis?
Plain AXR (30% have calcification of pancreas)
Ultrasound: pancreatic size, cysts, duct diameter, tumours
EUS
CT scan
Blood tests:
–Serum amylase increase in acute exacerbations
–Decreased albumin, Ca2+/Mg2+, vit B12
– Increased LFTs, Prothrombin time (vit K), glucose
Pancreatic exocrine function:
- faecal / serum enzymes (elastase)
- Pancreolauryl test (enzyme reponse to a stimulus)
- Diagnostic Enzyme replacement
What is management for pain control in chronic pancreatitis?
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 do you manage exocrine and endocrine function?
Low-fat diet (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 of chronic pancreatitis?
Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
Continued alcohol intake - 50% 10 yr survival
Abstinence - 80% 10 yr survival
What is the epidemiology of carcinoma of the pancreas?
Incidence: 11/100 000 pop/year (increasing)
Males>Females
80% in 60-80 year age group
More common in Western countries
–highest rates in Maoris & Hawaiians
What are the most common types of carcinoma of the pancreas?
75% are duct cell mucinous adenocarcinomas
(head 60%, body 13%, tail 5%, multiple sites 22%)
Other pathological types:
–carcinosarcoma
–cystadenocarcinoma (better prognosis) (malignant neoplasm derived from glandular epithelium, in which cystic accumulations of retained secretions are formed)
–Acinar cell
What are clinical features of carcinoma of the pancreas?
Upper abdominal pain (75%) - Ca body & tail
Painless obstructive jaundice (25%) - Ca head
Weight loss (90%)
Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting
Tender subcutaneous fat nodules (like erythema nodosum) due to metastatic fat necrosis
Thrombophlebitis migrans (inflammation of a vein related to a thrombus - when it occurs repeatedly in different locations)
Ascites, portal hypertension
What are physical signs of carcinoma of the pancreas?
Hepatomegaly
Jaundice
Abdominal mass
Abdominal tenderness
Ascites, splenomegaly
Supraclavicular lymphadenopathy
PRESENCE OF ABOVE SIGNS USUALLY INDICATES AN UNRESECTABLE TUMOUR
Palpable gallbladder (with ampullary carcinoma)
What imaging modalities can you use for carcinoma of the pancreas?
USS CT and MRI
Look
What is management of the pancreas?
Majority of patients have advanced disease at presentation and <10% are operable
Radical surgery - pancreatoduodenectomy
(Whipple’s procedure)
–Patient is fit, Tumour <3 cm diameter, No metastases
–Operative mortality ~5%
Palliation of jaundice
–stent, palliative surgery - cholechoduodenostomy
Pain control (opiates, coeliac plexus block, radiotherapy)
Chemotherapy only in controlled trials
What is theprognosis of carcinoma of the pancreas?
Inoperable cases - mean survival is less than 6 months
1% 5 year survival
Operable cases - 15% 5 yr survival
Ampullary tumours 30-50% 5 yr survival
