Pancreatic Disease Flashcards by MLG .

What are examples of pancreatic disease?

Acute pancreatitis

Chronic pancreatitis

Pancreatic cancer

Neuroendocrine tumours

Cystic fibrosis

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What is acute pancreatitis?

Acute inflammation of the pancreas

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Where is the pain usually due to acute pancreatitis?

Upper abdominal pain

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How does acute pancreatitis change serum levels of amylase?

Elevation of serum amylase (4x upper limit of normal)

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What can acute pancreatitis be associated with in severe cases?

Multi-organ failure

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What is the incidence of acute pancreatitis?

20-300 cases/million

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What is the mortality of acute pancreatitis?

6-12/million

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What is the aetiology of acute pancreatitis?

Gallstones

Ethanol (Alcohol)- Mostly

Trauma

Steroids

Mumps

Autoimmune disease, such as SLE

Scorpion venom (a rare and unlikely cause in most countries)

Hypercalcaemia

Endoscopic retrograde cholangio-pancreatography (ERCP)

Drugs, such as Azathioprine, NSAIDs, or Diuretics

10% Idiopathic cause

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What are examples of drugs that can cause acute pancreatitis?

Steroids

Azathioprine

Diuretics

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What are examples of viruses that can cause acute pancreatitis?

Mumps

Coxsackie B4

HIV

CMV

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What are metabolic changes that can cause acute pancreatitis?

Increased calcium

Increased triaglycerides

Decreased temperature

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Explain the pathogenesis of acute pancreatitis?

1) Primary insult
2) Release of activated pancreatic enzymes
3) Autodigestion causing pro-inflammatory cytokines, reactive oxygen species, oedema, fat necrosis and haemorrhage

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What are the clinical features of acute pancreatitis?

Abdominal pain

Vomiting

Pyrexia

Tachycardia

Oliguria

Jaundice

Paralytic ileus

Retroperitoneal haemorrhage

Hypoxia (respiratory failure in most severe cases)

Hypocalcaemia

Hyperglycaemia (occsaionally diabetic coma)

Effusions

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What is paralytic ileus?

Obstruction of the intestine due to paralysis of the intestinal muscles

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What is oligouria?

Urine output less than:

1mL/kg/h in infants

0.5mL/kg/h in children

400ml or 500ml per 24 hours in adults

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What is strange about ERCP and acute panceatitis?

ERCP is a cause and a treatment of acute pancreatitis

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What investigations are done for acute pancreatitis?

Blood tests

Abdominal and chest x-ray

Abdominal ultrasound

CT scan (contrast enhanced)

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What is being looked for in an abdominal ultrasound for acute pancreatitis?

Pancreatic oedema

Gallstones

Pseudocyst

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What blood tests are done for acute pancreatitis?

Amylase

Lipase

FBC

LFTs

Calcium

Glucose

Arterial blood gases

Lipids

Coagulation screen

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What is used to assess the severity of acute pancreatitis?

Glasgow criteria

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Using the glasgow criteria, what is considered to be severe pancreatitis?

A score of 3 or more

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What is assessed with the glasgow criteria?

PANCREAS:

pO2 <8kPa,

Age >55yrs,

Neutrophils (/WCC) >15×109/L,

Calcium <2mmol/L,

Renal function (Urea) >16mmol/L,

Enzymes LDH>600U/L or AST>200U/L,

Albumin <32g/L,

Sugar (blood glucose) >10mmol/L

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What is LDH?

Lactate dehydrogenase

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What is another indicator for severe pancreatitis that is not included in the Glasgow criteria?

CRP>150mg/L

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What is the general management for acute pancreatitis?

Mainly supportive care: Treat underlying case: Analgesia IV fluids Blood transfusion (Hb\<10g/dL) Monitor urine output (catheter) Naso-gastric tube Oxygen May need insulin Rarely required calcium supplements Nutrition (enteral or parenteal) in severe cases

What is the specific management for acute pancreatitis if pancreatitic necrosis is occuring?

CT guided aspiration Antibiotics and surgery

What is the specific management for acute pancreatitis if gallstones are present?

EUS/MRCP/ERCP Cholecystectomy

What are possible complications of acute pancreatitis?

Abscess Pseudocyst

What is the management of an abscess due to acute pancreatitis?

Give antibiotics and drainge

What is a pseudocyst?

Fluid collection without an epithelial lining

What is a pseudocyst diagnosed by?

Ultrasound or CT scan

What are possible complications of a pseudocyst?

Jaundice Infection Haemorrhage Rupture

What is the treatment for pseudocyst?

If \<6cm resolves spontaneously If \>=6cm, persistent pain or complications then endoscopic drainage or surgery

What is the clinical presentation of a pseudocyst?

Persistent hyperamylasaemia and/or pain

What percentage of cases is mild acute pancreatitis compared to severe?

Mild (75-80% of cases)

What is the mortality of mild acute pancreatitis?

\<2%

What is the mortality of severe acute pancreatitis?

15%

What is chronic pancreatitis?

Pancreas has become permanently damaged due to inflammation

What is the prevalence of chronic pancreatitis?

Ranges from 0.01% in Japan to 5.4% in South India

What is the incidence of acute pancreatitis?

3.5/100000 population/year

How does the incidence of chronic pancreatitis compared between males and females?

Males \> females

What age group is chronic pancreatitis most common in?

35-50 years

What is the aetiology of chronic pancreatitis?

Alcohol (80%) Cystic fibrosis Congenital anatomical abnormalities Hereditary pancreatitis Hypercalcaemia Possibly diet, not yet proven

What are examples of congenital anatomical abnormalities that can cause chronic pancreatitis?

Annular pancreas Pancreas divisum (failed fusion of dorsal and ventral buds)

Is hereditary pancreatitis dominant or rescessive?

Autosomal dominant

What genes are associated with pancreatitis?

PRSS1 SPINK1 CFTR

What is the pathogenesi of chronic pancreatitis?

Duct obstruction due to inflammation

What is the pathology of chronic pancreatitis?

Glandular atrophy and replacement by fibrosis tissue Ducts become dilated, tortous and strictured Inspissated secretions may calcify Exposed nerves due to loss of perineural cells Splenic, superior mesenteric and portal veins may thrombose which leads to portal hypertension

What does atrophy mean?

Wasting away of a body tissue

What are clinical features of chronic pancreatitis?

Early diseases is asymptomatic Abdominal pain (85-05%) Weight loss Exocrine insufficiency Endocrine insufficiency Miscellaneous (jaundice, portal hypertension, GI haemorrhage, pseudocysts)

What are abdominal pains due to chronic pancreatitis exacerbated by?

Food and alcohol

How does the severity of abdominal pain due to chronic pancreatitis change with time?

Severity decreases over time

What are consequences of weight loss due to chronic pancreatitis?

Pain, anorexia, malabsorption

What are consequences of exocrine insufficiency due to chronic pancreatitis?

Fat malabsorption (steatorrhea) Low fat soluble vitamins Low calcium/magnesium levels Protein malabsorption causing weight loss and low vitamin B₁₂

What is a consequence of endocrine insufficiency due to chronic pancreatitis?

Diabetes in 30% of cases

What is steatorrhoea?

Excretion of abnormal amounts of fat with faeces due to fat malabsorption

What investigations are done by chronic pancreatitis?

Plain abdominal x-ray (30% have calcification of pancreas) Ultrasound (shows pancreatic size, cysts, ducts diameter, tumours) EUS CT scan Blood tests Pancreatic function tests

What is being checked in ultrasounds for chronic pancreatitis?

Pancreatic size Cysts Ducts diameter Tumours

What can be seen in blood tests for chronic pancreatitis?

Serum amylase increased in acute exacerbations Decreased albumin, calcium, magnesium and vitamin B₁₂

What doe management of chronic pancreatitis involve?

Pain control Managing exocrine and endocrine functions

What is done for pain control in chronic pancreatitis?

Avoid alcohol Pancreatic enzyme supplements Opiate analgesia Coeliac plexus block Referral to pain clinic/psychologist Endoscopic treatment of pancreatic duct stones and strictures Surgery in selected cases

What is done to manage exocrine and endocrine functions of the pancreas in chronic pancreatitis?

Low fat diet (30-40g/day) Pancreatic enzyme supplements Insulin for diabetes mellitus

Why does death usually occur due to chronic pancreatitis?

Acute on chronic attack Cardiovascular complications of diabetes Associated cirrhosis Drug dependence Suicide

What is the prognosis of chronic pancreatitis with and without continued alcohol use?

Continued alcohol intake causes 50% 10 year survival rate No alcohol has 80% 10 year survival rate

What is the incidence of carcinoma of the pancreas?

11/100000 population/year (increasing)

How does the incidence for carcinoma of the pancreas change between male and females?

Males \> females

What age group does carcinoma of the pancreas ussualy occur?

80% are in 60-80 year age group

What are the pathological types of carcinoma of the pancreas?

Duct cell mucinous adenocarcinoma (75%) Carcinosarcoma Cystadenocarcinoma Acinar cell

What are carcinosarcomas?

Malignant tumours that contain a mix of carcinoma (epithelial cancer) and sarcoma (cancer of mesenchymal/connective tissue)

What are cystadenocarcinoma?

Malignant form of cystadenoma and is derived from glandular epithelium in which cystic accumulations of secreted fluid are formed

What is a cystadenoma?

Benign tumour that develops from ovarian tissue

Out of head, body, tail and multiple sites where do most adenocarcinomas of the pancreas occur?

Head (60%) Multiple sites (22%) Body (13%) Tail (5%)

What are clinical features of carinoma of the pancreas?

Upper abdominal pain (75%) Painless obstructive jaundice (25%) Weight loss (90%) Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting Tender subcutaneous fat nodules due to metastatic fat necrosis Ascites, portal hypertension

What are physical signs for carcinoma of the pancreas?

Hepatomegaly Jaundice Abdominal mass Abdominal tenderness Ascites, splenomegaly Supraclavicular lymphadenopathy Palpable gallbladder

What investigations are done for carcinoma of the pancreas?

What is the management for carcinoma of the pancreas?

Pancreatoduodenectomy (if patient is fit, \<3cm diameter and no metastasis) Palliation of jaundice (stent, palliative surgery - choleduodenostomy) Pain control (opiates, coeliac plexus block, radiotherapy) Chemotherapy only in contolled trials

When can a pancreatoduodenectomy be done for carcinoma of the pancreas?

Patient is fit \<3cm diameter No metastasis

What is the operative mortality of a pancreatoduodenectomy?

What can be done for pain control in carcinoma of the pancreas?

Opiates Coeliac plexus block Radiotherapy

What can be done for palliation of jaundice in carcinoma of the pancreas?

Stent Palliative surgery (cholechoduodenostomy)

Why is the prognosis for carcinoma of the pancreas so bad?

Majority of patients present with advanced disease (\<10% are operable)

What percentage of carcinoma of the pancreas cases are operable?

\<10%

What is the prognosis for operable and inoperable cases of carcinoma of the pancreas?

Inoperable 5 year survival is 1% Operable 5 year survival is 15% (30-50% is ampullary tumours)

What is the mean survival time for inoperable cases of carcinoma of the pancreas?

\<6 months

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Pancreatic Disease Flashcards

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