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Pancreatic Disease Flashcards

1
Q

What is the definition of acute pancreatitis?

A

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

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2
Q

What are the different aetiologie of acute pancreatitis?

A

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%

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3
Q

What is the pathogenesis of acute pancreatitis?

A

Primary insult - release of activated pancreatic enzymes - autodigestion

Resultant: Pro-inflammatory cytokines, reactive oxygen species

Oedema, fat necrosis, haemorrhage

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4
Q

Who is ERCP offered to?

A

Those with biliary obstruction and acute pancreatitis

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5
Q

What are the relevatn investigations for pancreatitis?

A

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)

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6
Q

What are markers of severe acute pancreatitis?

A

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

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7
Q

What is management for acute pancreatitis?

A

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

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8
Q

What is the specific management for acute pancreatitis?

A

Pancreatic necrosis - CT guided aspiration

  • antibiotics ± surgery

Gallstones

EUS/MRCP/ERCP

Cholecystectomy

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9
Q

What are complications with acute pancreatitis?

A

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

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10
Q

What is the outcome for acute pancreatitis?

A

Mild AP (75-80% of cases) - mortality <2%

Severe AP - mortality 15%

Subsequent course dependent on removal of aetiological factor(s)

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11
Q

What is the definition of chronic pancreatitis?

A

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

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12
Q

What are the aetiologies for chronic pancreatitis?

A

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

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13
Q

What is the effect of chronic pancreatitis on the glandular tissue of the pancrea?

A

Glandular atrophy and replacement by fibrous tissue

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14
Q

What is the effect of chronic pancreatitis on pancreas ducts?

A

Ducts become dilated, tortous and strictured

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15
Q

What happens to pancreatic secretions in chronic pancreatitis?

A

Inspissated (thickened or congealed) secretions may calcify

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16
Q

What happens to nerves in chronic pancreatitis?

A

Exposed nerves due to loss of perineural cells

17
Q

How can chronic pancreatitis result in portal hypertension?

A

Splenic, superior mesenteric and portal veins may thrombose - portal hypertension

18
Q

What are the clinical features of chronic pancreatitis?

A

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

19
Q

What are the investigations for chronic pancreatitis?

A

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
20
Q

What is management for pain control in chronic pancreatitis?

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

21
Q

How do you manage exocrine and endocrine function?

A

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)

22
Q

What is the prognosis of chronic pancreatitis?

A

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

23
Q

What is the epidemiology of carcinoma of the pancreas?

A

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

24
Q

What are the most common types of carcinoma of the pancreas?

A

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

25
Q

What are clinical features of carcinoma of the pancreas?

A

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

26
Q

What are physical signs of carcinoma of the pancreas?

A

Hepatomegaly

Jaundice

Abdominal mass

Abdominal tenderness

Ascites, splenomegaly

Supraclavicular lymphadenopathy

PRESENCE OF ABOVE SIGNS USUALLY INDICATES AN UNRESECTABLE TUMOUR

Palpable gallbladder (with ampullary carcinoma)

27
Q

What imaging modalities can you use for carcinoma of the pancreas?

A

USS CT and MRI

28
Q

Look

A
29
Q

What is management of the pancreas?

A

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

30
Q

What is theprognosis of carcinoma of the pancreas?

A

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

GI (38 decks)

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