Pancreatic Pathology Flashcards
What is acute pancreatitis?
Acute inflammation of the exocrine pancreas resulting in reversible destruction/auto digestion by it’s own digestive enzymes
What causes acute pancreatitis?
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Scorpio stings
Mumps
Autoimmune
Steroids
Hypercalcaemia, hypothermia
ERCP
Drugs
What drugs can cause acute pancreatitis?
Sodium valproate
Azathioprine
Mesalazine
Fuorsemide/thiazide diuretics
Tetracycline
Co-trimoxazole
How does acute pancreatitis present?
Acute epigastric pain
- Sitting forward relieves pain
- Radiation to the back
N&V
Fever
Tachycardia
Cullen’s sign
Grey Turner’s Sign
Jaundice
Palpable mass if pseudocyst present
What is Cullen’s sign?
Bruising around umbilicus due to retroperitoneal haemorrhage
What is Grey Turner’s sign?
Bruising around flanks due to retroperitoneal haemorrhage
What investigations are used in acute pancreatitis diagnosis and monitoring?
>Amylase and lipase
LFT
- Decreased albumin
- AST>ALT suggesting alcohol use
FBC
- >WCC
U&E
- >Urea
Hyperglycaemia
Hypocalcamemia
>CRP
LDH
Coagulation
US
CT
Is amylase or lipase better to use in acute pancreatitis diagnosis and why?
Lipase is more sensitive and specific
Serum amylase may rise and fall quite quickly and lead to a false negative result
What CT signs are present in acute pancreatitis?
Pseudocysts
What are we looking for on an US in acute pancreatitis?
Gallstones
Why does hypocalcaemia occur in acute pancreatitis?
Lipase uses Ca2+ up
Why is LDH present in acute pancreatitis?
Tissue damage
Why is coagulation assessed in acute pancreatitis?
DIC is a complication
What is the management of acute pancreatitis?
IV fluids
Analgesia
Ca
Insulin
Urinary catheter
Naso-jejunal feeding, to avoid pancreatic stimulation
Treat cause
Name some complications of acute pancreatitis?
Pseudocyst/peripancreatic fluid collections
Pancreatic cancer
DIC
Acute Respiratory Distress Syndrome
Pancreatic abscess
Chronic pancreatitis
Pancreatic necrosis
What is a pseudocyst?
Fluid collection in lesser sac
What blood test is pseudocyst associated with?
Raised amylase
When do pseudocysts become present?
No earlier than 4 weeks after acute pancreatic attack
How are pseudocysts managed?
Symptomatic cases may be observed for 12 weeks as half resolve
Cystogastrostomy or aspiration
What criteria assesses the severity of acute pancreatitis?
Modified Glasgow Criteria
What factors does the Modified Glasgow Criteria take into consideration?
PaO2 < 8
Age > 55
Neutrophilia x10^9
Calcium < 2 mmoles
Renal function, urea >16
Enzymes, LDH > 600
Albumin < 32
Sugar, glucose > 10
How many points does the Modified Glasgow Criteria say is mild acute pancreatitis?
0-1
How many points does the Modified Glasgow Criteria say is moderate acute pancreatitis?
2
How many points does the Modified Glasgow Criteria say is severe acute pancreatitis?
>3
What is chronic pancreatitis?
Persistent inflammation of the pancreas, characterised by glandular destruction and permanent loss of function/irreversible change of pancreatic structure
What are the causes of chronic pancreatitis?
AAAACC
Alcohol
Anatomical bbnormalities
Autoimmune pancreatitis
Reoccuring acute pancreatitis
CF
Hypercalcaemia
What congenital anatomical abnormalities can cause chronic pancreatitis?
Annular pancreas
Pancreas divisum
What mode of inheritence is congenital pancreatitis?
Autosomal dominant
How does chronic pancreatitis present?
Asymptomatic in early disease
Weight loss
Steatorrhoea
Epigastric pain
- Exacerbated by food/alcohol
- Severity decreases over time
Jaundice
Diabetes
What investigations are used in chronic pancreatitis diagnosis?
US
- Increased pancreatic size
- Cysts
- Dilated duct diameter
>Serum Amylase
- Acute exacerbation
Abdominal CT with IV contrast
- Calcification of pancreas
How is chronic pancreatitis managed?
Pancreatic enzyme supplements
Analgesia/coeliac plexus block
Insulin
Avoid alcohol and smoking
Stenting
Name some complications of chronic pancreatitis
Diabetes
Pseudocyst development
Pancreatic carcinoma
Describe diabetic screening in chronic pancreatitis
Annual Hb1Ac
When does diabetes occur in patients with chronic pancreatitis?
20 years after symptom onset
What is the most common histological type of pancreatic cancer?
Adenocarcinoma, mostly occuring at the head
What sex is pancreatic cancer more common in?
M>F
What age is pancreatic cancer most common?
Onset at 65
What is the prognosis of pancreatic cancer?
Poor, average survival upon diagnosis is 6 months as metastasise early
What are the causes of pancreatic cancer?
Chronic pancreatitis
Smoking
Obesity
Alcohol
Diabetes
HNPCC
Diet
- Red meat
How does pancreatic cancer present?
Epigastric pain, radiates to back
Weight loss
Fatigue
Diarrhoea
Steatorrhoea
N&V
Hepatomegaly
Supraclavicular lymphadenopathy
Courvoisier sign/palpable gallbladder
New onset diabetes
Trousseau’s sign/migratory thrombophlebitis
What is Courvoisier sign?
Palpable gallbladder not tender to touch along with jaundice, suggesting pancreatic cancer
What investigations are used in pancreatic cancer diagnosis?
CT pancreas
CT thorax, abdomen, pelvis for staging
EUS with percutaneous biopsy
Cholestatic LFTs
- Increased ALP
- Increased gamma GT
- Increased bilirubin
Tumour markers
- CA19-9
What pancreatic cancer sign can be seen in imaging?
Double duct sign, due to obstruction of pancreatic and common bile duct
How is pancreatic cancer managed?
Surgery
- Whipples pancreaticoduodenectomy or modified whipples (pylorus sparing)
- Total or distal pancreatectomy
Palliative radiotherapy or chemotherapy
Stenting to relieve symptoms
Describe stage 1 pancreatic cancer
<2cm
Describe stage 2 pancreatic cancer
>2cm
Describe stage 3 pancreatic cancer
Grown into neighbouring tissue
Describe stage 4 pancreatic cancer
Metastatic
What is a useful test of exocrine function in chronic pancreatits?
Faecal elastase
