Pancreatic Disorders Flashcards
In acute pancreatitis what blood test may confirm the condition?
Serum amylase >4x upper limit of normal
What are the risk factors for acute pancreatitis?
Alcohol abuse (60-75%) Gallstones (25-40%) Viral infection Tumours Anatomical abnormalities
Drugs
Lipid abnormalities
Scorpion venom
Autoimmune
What is the pathogenesis of acute pancreatitis?
Primary insult
> release of activated pancreatic enzymes
> autodigestion
> pro-inflammatory cytokines, ROS, oedema, fat necrosis, haemorrhage
What are the symptoms/signs of acute pancreatitis?
Abdominal pain (may radiate to back) Vomiting Pyrexia Collapse Tachycardia, hypovolaemic shock Dehydration Oliguria, acute renal failure Jaundice
Paralytic ileus Retroperitoneal haemorrhage Hypoxia Hypocalcaemia Hyperglycaemia Effusions
What investigations might be done in acute pancreatitis?
ERCP EUS/USS (pancreatic oedema, gallstones, pseudocyst) Blood tests (amylase/lipase, FBC, U+Es, LFTs, Ca2+, glucose, ABG, lipids, coagulation screen)
AXR (ileus) / CXR (pleural effusion) CT scan (contrast enhanced) - useful in severe disease
What monitoring may be done in acute pancreatitis?
Pulse/BP Urine output CVP Arterial Line HDU/ITU
What are markers of severity in acute pancreatitis?
WCC > 15x10^9/L Blood Glucose > 10mM Blood urea >16mM AST/ALT >200iu/L LDH >600iu/L Serum Albumin <32g/L Serum Calcium <2mM Arterial PO2 <7.5kPa
Glasgow Criteria Score at 48 hours
>3 = severe pancreatitis
Individual markers (CXR, CRP, IL-6, TAP) - CRP >250mg/L also indicates severe pancreatitis
How does treatment for pancreatitis compare dependent on cause?
Identification of precipitating factors
- cholelithiasis - ERCP and ES, cholecystectomy
- alcohol - abstinence, counselling
- ischaemia - careful support, correct cause
- malignancy - resection/bypass
- hyperlipidaemia - diet, lipid lowering drugs
- anatomical abnormalities - correction if possible
drugs - cease/change
What are the general treatments for acute pancreatitis?
General supportive
- analgaesia
- IV fluids
- CV, resp, renal support
Blood transfusions (Hb <10g/dL) Monitor urine output NG tube O2 May need insulin Rarely require calcium supplements Nutrition
More specific
- pancreatic necrosis > CT guided aspiration > antibiotics possibly with surgery
- gallstones > EUS/MRCP/ERCP > cholecystectomy
Consider sepsis
CT guided FNA of pancreatic necrosis
What are some examples of treatments that have no benefit in acute pancreatitis?
Antiproteases
Antibiotics
Inhibitors pancreatic secretion (glucagon, somatostatin)
Peritoneal lavage
What is the definitive management of acute pancreatitis?
Prevention of recurrent attacks
- management of gallstones
- investigations of non-gallstone pancreatitis
- alcohol abstinence
Fluid collection
- early collection
- pseudocyst
- pancreatic duct fistula
Management of Necrosis
- sterile necrosis
- infected necrosis
- abscess
Late complications
- haemorrhage
- portal hypertension
- pancreatic duct stricture
What is the general prognosis of acute pancreatitis? Possible complications?
Mild AP mortality <2%
Severe ~15%
Possible complications
- Abscess > antibiotics + drainage
- necrosis possible
- Pseudocyst
What are the causes of chronic pancreatitis?
O-A-TIGER
Obstruction of MPD
Autoimmune causes
Toxins (alcohol, smoking, drugs)
Idiopathic
Genetic (autosomal dominant and recessive genes)
Environmental (tropical chronic pancreatitis)
Recurrent injuries (biliary, hyperlipidaemia, hypercalcaemia)
What genes are associated with pancreatitis?
PRSS1
SPINK1
CFTR
How does the cause of pancreatitis relate to the area of pancreas affected?
Alcohol - tail/body/neck - some uncinate process
Idiopathic - head
Other - uncinate process/head
> pancreatic duct obstruction, CF, hyperlipidaemia, hereditary pancreatitis, tropical pancreatitis, hyperparathyroidism
What are the symptoms/signs of chronic pancreatitis?
Early disease is asymptomatic
Abdominal pain
Weight loss
Exocrine insufficiency (late)
- fat malabsorption
- protein malabsorption
Endocrine insufficiency - diabetes in 30%
Misc
- jaundice
- portal hypertension
- GI haemorrhage
- pseudocysts
- pancreatic carcinoma?
What investigations might be done in chronic pancreatitis?
Detailed history Plain AXR - 30% have calcification of pancreas USS/EUS CT ERCP/MRCP
Blood tests
- serum amylase in acute exacerbations
- decreased albumin, Ca/Mg, Vit B12
- increased LFTs, PTT, Glucose
Pancreatic function tests
- Lundh’s - exocrine
- Faecal/serum enzymes (elastase)
- Pancreolauryl test (enzyme response to stimulus)
- Diagnostic enzyme replacement
What is the treatment for chronic pancreatitis?
Pain control
Avoid alcohol
Endoscopic treatment of pancreatic duct stones/strictures
Surgery
Exocrine/Endocrine management
- low fat diet
- enzyme supplements
- insulin
Surgery only after full evaluation
What surgical procedures may be used in (chronic) pancreatitis/suspicion of malignancy?
Endoscopic spincterotomy, dilation and lithotripsy
- PD stenosis/obstruction
CBD stenting/bypass
Thorascopic splanchnectomy
Coeliac plexus block (CT, guided, EUS guided, fluoroscopy guided)
Drainage (PD sphincteroplasty, Rochelle modification)
Resection
- DPPHR
- PPPD
- Whipple’s
- Frey
- Spleen-preserving distal pancreatectomy
- central pancreatectomy
What is the prognosis of chronic pancreatitis? Complications?
Continued alcohol intake 50% 10YS
Abstinence 80% 10YS
20% of those that die, die from complications
- rest die from associated conditions
Complications include
- pancreatic duct stenosis
- cyst/pseudocyst
- biliary tract obstruction
- splenic vein thrombosis/gastric varices
- portal vein compression/mesenteric vein thrombosis
- duodenal stenosis
- colonic stricture
What is the detailed pathology of chronic pancreatitis?
Glandular atrophy and replacement by fibrous tissue
Ducts become dilated, tortuous and strictured
Inspissated secretions may calcify
Exposed nerves due to loss of perineural cells
Splenic, superior mesenteric and proatl veins may thrombose > portal hypertension
