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S2.1 Gastrointestinal > Pancreatic Disorders > Flashcards

Pancreatic Disorders Flashcards

1
Q

In acute pancreatitis what blood test may confirm the condition?

A

Serum amylase >4x upper limit of normal

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2
Q

What are the risk factors for acute pancreatitis?

A 
Alcohol abuse (60-75%)
Gallstones (25-40%)
Viral infection
Tumours
Anatomical abnormalities

Drugs
Lipid abnormalities
Scorpion venom
Autoimmune

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3
Q

What is the pathogenesis of acute pancreatitis?

A

Primary insult
> release of activated pancreatic enzymes
> autodigestion
> pro-inflammatory cytokines, ROS, oedema, fat necrosis, haemorrhage

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4
Q

What are the symptoms/signs of acute pancreatitis?

A 
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
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5
Q

What investigations might be done in acute pancreatitis?

A 
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
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6
Q

What monitoring may be done in acute pancreatitis?

A 
Pulse/BP
Urine output
CVP
Arterial Line
HDU/ITU
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7
Q

What are markers of severity in acute pancreatitis?

A 
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
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8
Q

How does treatment for pancreatitis compare dependent on cause?

A

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

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9
Q

What are the general treatments for acute pancreatitis?

A

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

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10
Q

What are some examples of treatments that have no benefit in acute pancreatitis?

A

Antiproteases
Antibiotics
Inhibitors pancreatic secretion (glucagon, somatostatin)
Peritoneal lavage

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11
Q

What is the definitive management of acute pancreatitis?

A

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
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12
Q

What is the general prognosis of acute pancreatitis? Possible complications?

A

Mild AP mortality <2%
Severe ~15%

Possible complications

  • Abscess > antibiotics + drainage
  • necrosis possible
  • Pseudocyst
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13
Q

What are the causes of chronic pancreatitis?

A

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)

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14
Q

What genes are associated with pancreatitis?

A

PRSS1
SPINK1
CFTR

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15
Q

How does the cause of pancreatitis relate to the area of pancreas affected?

A

Alcohol - tail/body/neck - some uncinate process

Idiopathic - head

Other - uncinate process/head
> pancreatic duct obstruction, CF, hyperlipidaemia, hereditary pancreatitis, tropical pancreatitis, hyperparathyroidism

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16
Q

What are the symptoms/signs of chronic pancreatitis?

A

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?
17
Q

What investigations might be done in chronic pancreatitis?

A 
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
18
Q

What is the treatment for chronic pancreatitis?

A

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

19
Q

What surgical procedures may be used in (chronic) pancreatitis/suspicion of malignancy?

A

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
20
Q

What is the prognosis of chronic pancreatitis? Complications?

A

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
21
Q

What is the detailed pathology of chronic pancreatitis?

A

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

S2.1 Gastrointestinal (12 decks)

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