Pancreatitis and Pancreatic Cancer

Question 1

Acute pancreatitis

Answer 1

Acute pancreatitis is the sudden inflammation and haemorrhaging of the pancreas due to destruction by its own digestive enzymes.

Question 2

What are the leading causes of acute pancreatitis?

Answer 2

Gallstones

Alcohol abuse

Question 3

How does alcohol cause acute pancreatitis?

Answer 3

Alcohol increases zymogen secretion from acinar cells while decreasing fluid and bicarbonate production from the ductal epithelial cells. Causes pancreatic secretion to become thick and viscous - this can lead to formation of a plug which can block the duct - similar to the effect of gallstones.

Stimulate acinar cells to release inflammatory cytokines.

Question 4

How can acute pancreatitis lead to destruction of the pancreatic tissue?

Answer 4

In acute pancreatitis, there is pancreatic tissue destruction that results from the proteases and inflammatory response of the body, and this can cause tiny blood vessels to become leaky and sometimes rupture.

Ultimately, all of the extra fluid or edema causes the capsule of the pancreas to swell, and unfortunately there can be some activation of lipases which go on to destroy the fat around the pancreas, or peripancreatic fat.

All of the digestion and bleeding can actually liquify the pancreatic tissue, a process called liquefactive hemorrhagic necrosis.

Question 5

What can acute pancreatitis cause due to liquefactive hemorrhagic necrosis?

Answer 5

Pancreatic pseudocyst

Question 6

How does a pancreatic psuedocyst form?

Answer 6

A pancreatic pseudocyst forms when fibrous tissue surrounds liquefactive necrotic tissue of the pancreas, and this fibrous tissue develops a cavity that fills up with pancreatic juice.

Question 7

What are the symptoms of a pancreatic pseudocyst?

Answer 7

Abdominal pain
Palpable tender mass
Loss of appetite

Question 8

What are the complications of acute pancreatitis?

Answer 8

Pancreatic pseudocyst
Hemorrhage of damaged blood vessels
Disseminated intravascular coagulation
Acute respiratory distress syndrome

Question 9

Explain the effect of disseminated intravascular coagulation due to acute pancreatitis.

Answer 9

Systemic activation of coagulation factors leads to the formation of blood clots throughout the body.
Paradoxically using up this clotting factor makes it easier to bleed.

Question 10

How does acute pancreatitis lead to acute respiratory distress syndrome?

Answer 10

The massive pancreatic inflammation leads to leaky blood vessels throughout the body - making it hard to breathe.

Question 11

What are the signs and symptoms of acute pancreatitis?

Answer 11

Nausea 
Vomiting
Hypocalcemia
Bruising around the belly button in the umbilical region - 'Cullen's Sign'
Pain in the epigastric region
Increased serum amylase and serum lipase

Question 12

What investigations are done for acute pancreatitis?

- why are they done?

Answer 12

CT scan - to look for inflammation, necrosis and pseudocysts.
Ultrasound - may show gallstones.

Question 13

What is the treatment for acute pancreatitis?

Answer 13

Pain management
Provide fluid and electrolytes.
IV Nourishment in place of eating food.
Treat complications with oxygen therapy and antibiotics if needed.

Question 14

What causes hereditary pancreatitis?

Answer 14

Mutation to the trypsinogen molecule, which makes it much more easily activated.

Question 15

What are the causes of acute pancreatitis?

Answer 15

Idiopathic
Gallstones
Ethanol 
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion stings
Hypercalcemia, hyperlipidemia, hyperthermia
ERCP
Drugs

Question 16

What is the basic pathology of acute pancreatitis?

Answer 16

Influx of Ca2+ causes early activation of trypsinogen in the acinar cell leading to pancreatitis.

Question 17

Chronic pancreatitis

Answer 17

Chronic pancreatitis is the constant inflammation of the pancreas, often due to repeated bouts of acute pancreatitis.

Question 18

What causes chronic pancreatitis?

Answer 18

Chronic pancreatitis is inflammation due to irreversible changes to the pancreatic structure, like fibrosis, atrophy and calcification.

Question 19

What is the main cause of chronic pancreatitis in children?

Answer 19

Cystic fibrosis

Question 20

How does pain present in chronic pancreatitis?

Answer 20

Continuous / Intense intermittent abdominal pain in the epigastric region that sometimes radiates to the back.

Question 21

How is chronic pancreatitis diagnosed?

Answer 21

Reliance on imaging studies which can identify the structural changes to the pancreas.

• X-rays and CT scans may show calcification of the pancreas.
• ERCP

Question 22

ERCP

Answer 22

Endoscopic retrograde cholangiopancreatography - used to visualise the pancreatic ducts.

Question 23

What are the symptoms of chronic pancreatitis?

Answer 23

Epigastric pain that radiates to the back.
Pancreatic insufficiency - leading to weightloss and Vitamin deficiency.
Deficient in the fat soluble vitamins A, D, E and K - leads to fat not being digested and passing through the bowel causing steatorrhoea.

Question 24

What is a long term consequence of chronic pancreatitis?

Answer 24

Development of diabetes mellitus.
Pancreatic cancer.
Pseudocysts.
Brittle bones due to lack of vitamin D.

Question 25

How is chronic pancreatitis treated?

Answer 25

Controlling pain.
Controlling the risk factors - e.g drinking less alcohol, eating less meat and reducing obesity.
Pancreatic enzyme replacement therapy.

Question 26

95% of pancreatic tumours develop where in the pancreas?

Answer 26

The exocrine tissues.

• majority of cases occur in the epithelial cells lining the ducts.
• typically in the neck / head of the pancreas.

Question 27

What are some of the risk factors of pancreatic cancer?

Answer 27

Smoking
Obesity
Diet high in red meat
Diabetes
Chronic pancreatitis
Liver cirrhosis

Question 28

What are the symptoms of pancreatic cancer?

Answer 28

Nausea 
Vomiting 
Fatigue
Weight loss
Midepigastric pain - radiates to mid / lower back
Trousseau sign of Malignancy.
Courvoiser's sign
Darker urine and jaundice due to obstructed bile duct.

Question 29

Trousseau sign of malignancy

Answer 29

When blood clots, that can be felt as small lumps under the skin, appear unexpectedly in superficial veins, and then over time, migrate to different locations.

Question 30

Courvoiser’s sign

Answer 30

When the gallbladder is enlarged and palpable - yet not tender (unlike gallstones).

Question 31

What causes Courvoiser’s sign?

Answer 31

A tumour in the head of the pancreas, which obstructs the common bile duct.

Question 32

How is pancreatic cancer diagnosed?

Answer 32

Medical imaging and biopsy.

- note imaging can also help determine if the cancer is resectable.

Question 33

Whipple’s procedure

Answer 33

The Whipple procedure (pancreaticoduodenectomy) is an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.

Question 34

Grey Turners sign:

Answer 34

Grey Turner sign is a discoloration of the left flank associated with acute haemorrhagic pancreatitis.

Question 35

Cullen’s sign:

Answer 35

Cullen sign is a hemorrhagic discoloration of the umbilical area due to intraperitoneal hemorrhage from any cause; one of the more frequent causes is acute hemorrhagic panniculitis.