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Week A13 - GI & Liver > Pancreaticobiliary Disease > Flashcards

Pancreaticobiliary Disease Flashcards

1
Q

What is the endocrine component of the pancreas? [1]

A

islet of Langerhans

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2
Q

Name the different cell types of Islet of Langerhan and state what each produce [3]

A
  1. beta cells → insulin
  2. alpha cells → glucagon
  3. delta cells → somatostatin
  4. gamma cells → pancreatic polypeptide
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3
Q

What are the 2 types of exocrine cells in the pancreas, what does each secrete and in response to what? [6]

A
  1. ductal cells
    • secrete alkaline fluid (NaHCO3)
    • in response to secretin
  2. acinar cells
    • secrete digestive enzymes
    • in response to:
      • CCK
      • secretin
      • substance P
      • VIP
      • ACh
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4
Q

What digestive enzymes are produced by acinar cells for:

  1. starch and glycogen breakdown? [1]
  2. triglyceride breakdown? [2]
  3. protein and polypeptide breakdown? [3]
A
  1. amylase
  2. lipase & co-lipase
  3. trypsinogen, chymotrypsinogen & pro-elastase
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5
Q

Gallstones (cholelithiasis):

  1. what type of pain does it cause? [1]
  2. what is the most common type of gallstone? [1]
A
  1. right upper quadrant pain
  2. cholesterol stones
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6
Q

What is biliary colic and how does it present? [4]

A
  1. acute onset severe pain in RUQ/epigastrium lasting 4-6hrs
  2. due to stone obstructing the gallbladder neckorcystic duct
  3. pain is relieved as stone either disimpacts from cystic duct or passes into the common bile duct
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7
Q

What are the risk factors for gallstones (acute cholecystitis)? [6]

A
  1. female
  2. fat
  3. fourty (increasing age)
  4. pregnancy
  5. drugs (hormonal therapy)
  6. rapid weight loss
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8
Q

What is Murphy’s sign? [1]

A

pain in RUQ/epigastrium that radiates to the right shoulder in acute cholecystitis

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9
Q

What are the typical LFT findings in acute cholecystitis? [4]

A
  1. elevated ALT/AST
  2. elevated Alk Phos
  3. mild hyperbilirubinaemia
  4. mild hyperamylasaemia
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10
Q

What are the possible complications of acute cholecystitis (gallstones)? [4]

A
  1. gallbladder empyema
  2. perforation
  3. gangrene (tissue death due to lack of blood supply)
  4. gallstone ileus
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11
Q

Name the 2 sets of symptoms in biliary sepsis and list the features of each [7]

A
  1. Charcot’s triad
    • fever
    • jaundice
    • RUQ pain
  2. Reynolds’ Pentad
    • mental confusion
    • septic shock
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12
Q

What are the causes of biliary sepsis? [4]

A
  1. gallstones
  2. ↑bilirubin
  3. biliary manipulation
  4. hepatobiliary malignancy
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13
Q

What are the treatment options for biliary sepsis? [3]

A
  1. broad spectrum antibiotics
  2. ERCP
  3. PTC (last resort → percutaneous needle through bile duct)
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14
Q

What are the signs and symptoms of acute pancreatitis? [7]

A
  1. acute severe upper abdo pain
    • some radiates to back
    • partially relieved by sitting or bending forward
  2. severe pancreatitis:
    • multiple organ failure
    • pleural effusions
    • ascites
  3. jaundice may be present in gallstone disease
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15
Q

What is the name of the clinical sign shown in the image? [1]

A
  • Cullen’s sign
    • a bluish bruiselike appearance around the umbilicus due to bleeding into the peritoneum
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16
Q

What is the name of the clinical sign shown in the image? [1]

A
  • Grey Turner sign
    • a bluish bruiselike appearance around the flanks, representing retroperitoneal bleeding in pancreatic necrosis
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17
Q

What investigations should you carry out in a patient with suspected acute pancreatitis and what findings would you see? [3]

A
  1. elevated serum amylase >3xULN
    • occurs within 6-12hrs
  2. elevated serum lipase
  3. CT scan
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18
Q

What are the causes of acute pancreatitis? [11]

A

I GET SMASHED

  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps/malignancy
  • Autoimmune
  • Scorpion sting
  • Hyperlipidaemia, hypercalcaemia
  • ERCP/EUS
  • Drugs (azathioprine)
19
Q

What are the 5 classifications of acute pancreatitis? [5]

A
  1. interstitial oedematous acute pancreatitis
  2. necrotising acute pancreatitis
  3. mild
    • no organ failure/complications
  4. moderate
    • organ failure <48 hours and/or
    • local complications
  5. severe
    • persistent organ failure >48 hours
20
Q

What are the management options for acute pancreatitis? [6]

A
  • supportive in mild cases
    1. fluid replacement
    2. pain control
    3. enteral nutrition
    4. antibiotics (only if sepsis)
  • treat underlying cause
    1. abstinence
    2. cholecystectomy
21
Q

Define chronic pancreatitis [2]

A

inflammatory condition in which the parenchyma is replaced with fibrous tissue

22
Q

What are the causes and risk factors for chronic pancreatitis? [6]

A

TIGAR-O Classification

  1. Toxin/metabolic
    • alcohol
    • tobacco
    • hyperlipidaemia
    • CKD
  2. Idiopathic
  3. Genetic
    • PRSS1, CFTR, SPINK1 (inhibits trypsin)
  4. Autoimmune
  5. RAP/SAP associated
    • post-necrotic
    • vascular
    • post-irradiation
  6. Obstructive
23
Q

How is CP diagnosed? [2]

A

calcification on imaging

24
Q

What are the treatment options for chronic pancreatitis? [5]

A
  1. potent analgesia
  2. duct drainage
  3. smoking cessation
  4. alcohol cessation
  5. surgery (pancreaticojejunostomy/distal pancreatectomy)
25
Q

Describe the pathophysiology of pancreatic exocrine insufficiency [4]

A
  1. pancreatic disease → reduced exocrine secretion
  2. duodenal disease → low CCK release (no stimulation for release)
  3. gastric hypersecretion or low HCO3 secretion → acidic duodenal pH
  4. surgery → abnormal transit (of exocrine enzymes) from pancreas to GI tract
26
Q

What are the causes of pancreatic exocrine insufficiency? [8]

A
  1. acute/chronic pancreatitis
  2. cystic fibrosis (CF)
  3. pancreatic cancer
  4. diabetes mellitus
  5. pancreatectomy/gastrectomy
  6. inflammatory bowel disease (IBD)
  7. coeliac disease
  8. Zollinger-Ellison syndrome
27
Q

What enzyme, when decreased points towards the diagnosis of PEI? [1]

A

faecal elastase

28
Q

What is the main clinical consequence of pancreatic exocrine insufficiency? [1]

A

malnutrition

29
Q

What is the aim of therapy in pancreatic exocrine insufficiency? [4]

A
  1. to avoid
    • steatorrhoea
    • weight loss
    • maldigestion-related symptoms
  2. to ensure a normal nutritional status
30
Q

What are the management options for pancreatic exocrine insufficency? [3]

A
  1. CREON© → pancrelipase
  2. PPI
  3. ↑enzyme dose
31
Q

What are the risk factors for pancreatic cancer? [7]

A
  1. smoking
  2. male sex
  3. alcohol
  4. chronic pancreatitis
  5. BMI
  6. family history
  7. genetics (FAP gene)
32
Q

What are the signs and symptoms of pancreatic cancer? [8]

A
  1. cancer in the head of pancreas
  2. jaundice (CBD obstruction or mets)
  3. abdominal pain
  4. back pain
  5. weight loss
  6. acute pancreatitis
  7. migratory thrombophlebitis
  8. double duct sign
33
Q

What is the double duct sign? [1]

A

presence of simultaneous dilatation of the common bile and pancreatic ducts

34
Q

What are the palliative measures for pancreatic cancer? [6]

A
  1. Chemotherapy → FOLFIRINOX
  2. Coealic axis neurolysis
  3. Stenting if jaundice
  4. Gastrojejunostomy if GOO
  5. PERT to minimise weight loss / stabilise
  6. Thoracoscopic splanchnicectomy (crushing of nerves – rare)
35
Q

Features of Normal Bile:

  1. how much bile is secreted by the liver a day? [1]
  2. how is cholesterol kept in bile solution? [2]
  3. what compound causes the colour of bile and is it formed form? [2]
A
  1. 500ml
  2. cholesterol secreted in bile is not water soluble and is kept in solution by micelles containing bile acids and phospholipids
  3. bilirubin - which is a breakdown product of haemoglobin
36
Q

What factors can cause bile to become lithogenic (stone forming)? [3]

A
  1. excessive secretion of cholesterol
  2. decreased secretion of bile salts
  3. excessive secretion of bilirubin (e.g. haemolytic anaemia) can cause its precipitation in concentrated bile in the gallbladder
37
Q

What is mucocoele of gallbladder? [1]

A

distension of gallbladder due to inappropriate accumulation of mucus

38
Q

What is a potential complication of fat necrosis in acute pancreatitis? [1]

A

enzymes can leak out into the abdominal cavity and digest the fat on the omentum which makes it look more yellow

39
Q

Pancreatitic Abcess:

  1. potential complication of what condition? [1]
  2. what is it? [1]
  3. treatment? [3]
A
  1. potential complication of acute pancreatitis
  2. infected pancreatic necrosis which results in avascular haemorrhagic pancreas
  3. drainage or necrosectomy + antibiotics
40
Q

What is a pseudocyst and how do you treat it? [2]

A
  1. cyst filled with enzyme-rich pancreatic juice that slowly expands causing episodes of abdominal pain accompanied by a rise in enzyme levels in the blood as a complication of acute pancreatitis
  2. treatment is by drainage, usually by joining the pseudocyst to the stomach
41
Q

Describe the differential diagnoses for pancreatic cyst [3]

A
  1. intraductal papillary mucinous neoplasm
    • found in continuity with main pancreatic duct or side branch duct, dysplastic papillary lining secreting mucin
  2. mucinous cystic neoplasm
    • mucinous lining
    • “ovarian-type” stroma
  3. serous cystadenoma
    • no mucin production
    • (almost always) benign
42
Q

What are the signs of carcinoma of the pancreas? [4]

A
  1. painless obstructive jaundice
  2. new onset diabetes
  3. abdo pain
    • due to pancreatic insufficiency or nerve invasion
      • peri-neural invasion (cancer surrounds nerves)
  4. tumours in the head by obstruct the pancreatic duct and bile duct leading to the “double duct” sign on radiology
43
Q

What is the treatment for pancreatic carcinoma? [2]

A
  1. Whipple’s resection - removal of the head of pancreas
  2. Chemo with folfirinox

Week A13 - GI & Liver (11 decks)

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