Pancreatic Disease/Surgery of Pancreatic Disorders Flashcards
What is acute pancreatitis and how does it present?
Acute inflammation of the pancreas presenting with upper abdominal pain and elevation of serum amylase
What is the normal level of elevated serum amylase in acute pancreatitis?
4 times the normal upper limit
What are the two main causes of acute pancreatitis?
Alcohol abuse
Gallstones
Give the less common causes of acute pancreatitis
Trauma Drugs Viruses Pancreatic carcinoma Metabolic disorders Autoimmune disorders Idiopathic
Other than abdominal pain, what are the typical presentations of acute pancreatitis?
Nausea and vomiting Collapse due to fluid loss Pyrexia Dehydration Abdominal tenderness Circulatory failure
What is the first line treatment in suspected acute pancreatitis?
ERCP
What would an endoscopic ultrasound be useful for showing in acute pancreatitis?
Gallstones/obstruction of the bile or pancreatic ducts, pancreatic oedema or pseudocysts
Name 3 other investigations done in suspected acute pancreatitis
Amylase and lipase
Bloods - FBC, ABGs, U+Es, calcium, glucose, lipids, coagulations screen
AXR/CXR
Contrast CT
What scoring system is used to determine the severity of acute pancreatitis and what score would indicate severe pancreatitis?
The Glasgow Criteria Score
Severe if score > 3
What treatments are used in the general management of acute pancreatitis?
Analgesia IV fluids Blood transfusion Urine output monitoring Naso-gastric tube if unable to eat Nutrition Oxygen Occasionally insulin
If pancreatic necrosis is present in pancreatitis, what treatment is necessary?
CT guided aspiration, antibiotics and/or surgery
If the cause of acute pancreatitis is gallstones, what may be used to treat?
EUS, MRCP or ERCP
Cholecystectomy
What surgical treatment is indicated in acute pancreatitis presenting with jaundice or cholangitis?
Cholecystectomy
When would a necrosectomy be indicated?
In acute pancreatitis with necrosis
What treatment is indicated for a pseudocyst in acute pancreatitis?
Diagnosis via ultrasound or CT then endoscopic drainage or surgery if persistent pain or complications
At would diameter would a pseudocyst normally resolve without medical/surgical treatment?
< 6cm
What is chronic pancreatitis?
Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function
What is the major cause of chronic pancreatitis?
Alcohol abuse
What is the pathogenesis of chronic pancreatitis?
Duct obstruction leading to calculi formation, inflammation and protein plugs
What happens to the pancreatic ducts in chronic pancreatitis?
Become dilated, tortuous and strictured, calcification may occur
What veins may thrombose and cause portal hypertension as a result of chronic pancreatitis?
Splenic, superior mesenteric and portal veins
What is the typical presentation of chronic pancreatitis?
Upper abdominal pain and weight loss Endocrine and exocrine insufficiencies Jaundice Portal hypertension GI haemorrhage Pseudocysts Pancreatic carcinoma
What features of abdominal pain are indicative of chronic pancreatitis?
Pain aggravated by binge drinking
Pain more frequent and less treatable by abstinence
What investigations are done in suspected chronic pancreatitis?
Abdominal x-ray Ultrasound EUS CT Bloods Pancreatic function tests
What are the main treatments of chronic pancreatitis?
Pain control is central to management - opiates, coeliac plexus block, referral to pain clinic or psychologist
Abstinence from alcohol and cigarettes
Endoscopic treatment of stones and strictures
Treatment of endocrine or exocrine insufficiencies
Why should patients with chronic pancreatitis abstain from cigarettes?
Cigarettes won’t cause chronic pancreatitis but will aggravate it once it is established
Under what circumstances would surgical treatment of chronic pancreatitis be given?
Suspicion of malignancy
End stage disease with intractable pain
What is the prognosis of chronic pancreatitis in patients who continue to drink alcohol?
50% 10 year survival rate
What is the main histological type of pancreatic carcinoma?
Duct cell mucinous adenocarcinoma (75%)
What location in the pancreas is the most common site of carcinomas?
Head of the pancreas (60%)
What are the histological types of pancreatic carcinoma?
Duct cell mucinous adenocarcinoma
Carcinosarcoma
Cystadenocarcinoma
Acinar cell carcinoma
What histological type of pancreatic cancer has the best prognosis?
Cystadenocarcinoma
What are the three main common presentations of pancreatic carcinoma?
Upper abdominal pain (75%) Painless obstructive jaundice (25%) Weight loss (90%)
What are the possible physical signs of pancreatic carcinoma?
Hepatomegaly Jaundice Abdominal mass and/or tenderness Ascites Splenomegaly Supraclavicular lymphadenopathy Palpable gall bladder (ampullary carcinoma)
What investigations would be done if suspecting pancreatic carcinoma?
USS/EUS CT MRI ERCP Percutaneous needle biopsy Laparoscopic/laparotomy investigation
What percentage of pancreatic carcinomas are operable at the stage of presentation?
10%
What is are the main treatments of pancreatic carcinoma?
Palliative care for jaundice - stent, palliative surgery
Pain control - opiates, coeliac plexus block, radiotherapy
What is the mean survival of patients with inoperable pancreatic carcinoma?
< 6 months
What is the 5 year survival rate of patients with ampullary tumours?
30-50%
What are the surgical management options for pancreatic carcinoma?
PPPD
Palliative drainage via ERCP, PTC stenting, or palliative bypass
Palliative bypass or duodenal stent for duodenal obstruction
Palliative bypass at the time of surgery in the event of a failed resection
