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General Surgery > Pancreatic disorders > Flashcards

Pancreatic disorders Flashcards

1
Q

What are the functions of the pancreas?

A
  • Endocrine production:
    • Insulin
    • Glucagon
  • Exocrine production:
    • Pancreatic protease: trypsin; chymotrypsin
    • Amylase
    • Lipase
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2
Q

Name three causes of acute pancreatitis

A
  • Gallstone (60%)
  • Ethanol (30%)
  • Trauma (1.5%)
  • Steroids
  • Mumps; malignancy
  • Autoimmune
  • Scorpion (Tityus trinitatis) sting
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP (5%); emboli
  • Drugs: eg. azathioprine, oestrogen, thiazides, isoniazid

10-30%: Pregnancy, neoplasia, idiopathic

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3
Q

Which drugs are particularly associated with acute pancreatitis?

A
  • NSAIDs
  • Steroids
  • Azathioprine
  • Thiazides
  • Isoniazid
  • Oestrogen
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4
Q

How can acute pancreatitis be classified?

A
  • Oedematous: simple or associated with phlegmon
  • Severe/necrotising: sterile/infected necrosis; pseudocysts
  • Haemorrhagic: Grey Turner’s and Cullen’s sign
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5
Q

Name four presenting features of acute pancreatitis

A
  • Sudden severe epigastric abdominal pain
    • May radiate to back; worse with movement
    • Alcohol-related: less sudden; poorly localised
  • Severe NaV; anorexia
  • Peritonism; rebound tenderness; guarding
  • Abdominal distension; small bowel ileus
  • Cullen’s (periumbilical); Grey Turner’s sign (flank)
  • Tachycardia; hypotension
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6
Q

Name three differential diagnoses for acute pancreatitis

A
  • Perforated peptic ulcer; bowel obstruction; ischaemic bowl
  • Ruptured AAA
  • MI
  • Gallstones: biliary colic; acute cholecystitis; cholangitis
  • Viral hepatitis
  • Gastroenteritis
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7
Q

How is acute pancreatitis initially investigated?

A
  • Serum amylase: >1000U/ml or 3x upper limit of normal
    • Does not correlate with severity of disease
    • Levels begin to fall within 24-48hr
  • Serum lipase: more sensitive and specific for pancreatitis
  • Imaging:
    • USS within 48hr admission: Gallstones in CBD
    • AXR (non-specific)
    • CT: assess extent and complications
  • ABG; FBC; U+E; LFTs; glucose: assess severity
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8
Q

Name three non-pancreatitis causes of raised serum amylase

A
  • Intestinal ischaemia
  • Leaking AAA
  • Perforated peptic ulcer
  • Acute cholecystitis
  • Acute appendicitis
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Renal failure
  • DKA
  • Head injury
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9
Q

How is severe acute pancreatitis determined?

A

Glasgow-Imrie criteria

3+ criteria within 48hr of admission ➔ ITU/HDU transfer

  • PaO2 <8kPa
  • Age >55
  • Neutrophils/WCC >15,000 x109/L
  • Corrected Ca2+ <2mmol/L
  • Raised blood urea >16mmol/L
  • Enzymes: AST >200U/L, LDH >600U/L
  • Albumin <32g/L
  • Sugar (CBG) >10mmol/L (secondary diabetes)
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10
Q

Outline the management of acute pancreatitis

A
  • Fluid resuscitation
  • Do not make NBM unless clear reason eg. vomiting
    • Enteral nutrition if moderate-severe pancreatitis
    • Consider parenteral nutrition
  • Urgent ERCP + cholecystectomy: proven bile duct stones
  • Consider debridement or aspiration if refractory necrosis
  • Manage complications eg. insulin for type 3c diabetes
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11
Q

Name two early complications of acute pancreatitis

A
  • Shock; Pre-renal AKI
  • ARDS
  • Sepsis; DIC
  • Hypocalcaemia: soaponification of fats
  • Hyperglycaemia
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12
Q

Name three late complications of acute pancreatitis

A
  • Pancreatic necrosis
  • Pseudocysts; abscess
  • Haemorrhage; Thrombosis
  • Fistula
  • Oedematous pancreas; obstructive jaundice
  • Pancreatic encephalopathy due to hypoperfusion
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13
Q

Give four presenting features of chronic pancreatitis

A
  • Recurrent/persistent severe epigastric pain radiating into back
    • Relieved by sitting forward; hot water bottles
    • Worse with food and alcohol
  • NaV; anorexia
  • Exocrine insufficiency:
    • Malabsorption; weight loss
    • Diarrhoea
    • Steatorrhoea
    • Protein deficiency
  • Endocrine insufficiency:
    • Diabetes mellitus
    • Impaired glucose regulation
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14
Q

Describe the histology of chronic pancreatitis

A
  • Glandular atrophy
  • Duct ectasia
  • Microcalcification
  • Intraductal stone formation
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15
Q

What sign may be seen as a result of conservative management of chronic pancreatitis?

A

Erythema ab igne (hot water bottle rash)

Chronic exposure to infrared radiation (heat) causing localised reticulated erythema and hyperpigmentation

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16
Q

List three causes of chronic pancreatitis

A
  • Alcohol
  • Idiopathic chronic hepatitis
  • Smoking: inhibits exocrine pancreatic secretion
  • Recurrent acute pancreatitis: eg. alcoholic pancreatitis
  • Obstructive causes:
    • Pancreatic head tumours or cysts
    • Pancreatic duct strictures: post-op, ERCP, parasites
    • Congenital: eg. pancreas divisum, annular pancreas
    • Cystic fibrosis
  • Autoimmune: eg. Sjogren’s syndrome; IBD; PBC
17
Q

Request three investigations for suspected chronic pancreatitis

A
  • FBC; LFTs; U+Es
  • CBG; HbA1c
  • AXR: Pancreatic calcifications
  • Abdominal USS; Pancreatic CT
  • ERCP
  • DXA scan
18
Q

What investigation can be used to assess pancreatic function in chronic pancreatitis?

A

Faecal elastase

Synthesised and excreted by pancreas

19
Q

Outline the initial treatment for chronic pancreatitis

A
  • Lifestyle:
    • Alcohol and smoking cessation
    • Antioxidant rich diet; dietary advice
  • Adequate analgesia
  • Pancreatic enzyme supplements
  • Insulin if diabetes mellitus develops
20
Q

What are the surgical indications for chronic pancreatitis?

A
  • Treat underlying reversible causes
  • Severe intractable pain or multiple relapses
  • Complications:
    • Pseudocysts
    • Obstruction
    • Fistula
    • Infections
    • Portal HTN
21
Q

Name three complications of chronic pancreatitis

A
  • Maldigestion and malabsorption
    • Osteoporosis; pathological fractures
  • Diabetes mellitus
  • Chronic pain; opioid dependency
  • Pancreatic calcification
  • Pseudocysts
22
Q

What surgical management is initially available for chronic pancreatitis?

A

Remove causes or drain obstructed pancreas:

  • Pancreaticoduodenectomy (Whipple procedure)
  • Partial pancreatectomy of head or tail
  • Pancreaticojejunostomy (Puestow procedure)

General Surgery (23 decks)

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