Pancreatitis and pancreatic tumours Flashcards
WHere is the pancreas anatomically?
Behind the stomach.
Head to the ancreas sits in duodenum D1, 2 and 3.
Formed in 2 parts, the dorsal and ventral buds.
What are the parts of the pancreas?
Head, neck, body, tail and uncinate process
WHat is the arterial supply to the pancreas?
1) Coeliac artery:
- Splenic artery => Dorsal pancreatic artery.
- Common hepatic artery => Gastroduodenal => anterior and posterior pancreatoduodenal artery
2) SMA:
- Anterior and posterior inferior pancreatoduodenal artery.
What is the venous drainage of the pancreas?
Inferior pancreatic vein into splenic vein and then portal vain.
Anterior and posterior inferior pancreatoduodenal veins drain into the SMV.
Anterior and posterior superior pancreatoduodenal veins drain into the protal vein.
Which part of the duodenum is the CBD posterior to?
D1
Where are the major and minor papila found and what do they drain?
Both in D2
Minor drains the accessory pancreatic duct (ventral bud)
Major drains the common bile duct (dorsal bud)
What are the 2 major functions of the pancreas?
Exocrine function: acinar cells secrete pancreatic enzymes.
Endocrine function: Islets of langerhans secrete hormones into the blood
What are the 4 groups f cells in the islets of langerhans and what do they secrete?
Alpha cells- glucagon
Beta cells- Insulin
Delta cells- somatostatin
F cells- pancreatic polypeptides
What controls sectetions from acinar cells?
Vagus nerve and gastrin levels
What is secreted from pancreatic duct cells?
Bicarbonate: base to neutralise the astric juice
What is pancreatitis?
Acute inflammatory process of the pancreas. Involves regional tissues and sometimes remote organs
80% of cases of pancreatitis are mild. How are they managed?
Analgesia and IV fluids
What are the causes of pancreatits? (I get smashed)
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps and other viral infections- hepatitis and coxackie B
Autoimmune
Scorpion bite
Hyercalcaemia/Hyerparathyroidism/Hyperlipidaemia (familial)
ERCP
Drugs (azathoprin)
What is the pathophysiology of pancreatitis?
Bile reflux therory:
Obstruction of the CBD/PD causing reflux of bile into pancreas which irritates the pancreas- occurs with many small stones.
Release of pancreatic enzyme precursors. Activaed enzymes autodigest the pancreas
What are the 4 main pathological stages of pancreatitis?
1) Oedema and fluid shift. Hypovolaemia. Fluids and enzymes in the peritoneal cavity autodigest fats affecting Ca++ binding => hypocalcaemia
2) Autodigestion of blood vessels => reteroperitoneal haemorrhage
3) Infarction due to compromised blood supply => Pancreatic necrosis
4) Necrotic tissue becomes infected => abscess formation.
What happens if toxic metabolites from the pancreas enter the blood?
Systemic effects: Shock Pulmonary compromise Acute renal failure Dinseminated intravascualr coagulation.
How does acute pancreatits present?
Trigger? Gallstones, alcohol, ERCP.
Acute onset epigastric pain radiating through to the back. Very severe (confused with MI)
Nausea and vomiting +++
Jaundice
What is found on exam in mild pancreatits?
Diffuse upper abdominal tenderness.
Soft
Normal bowel sounds
Fullness is epigastrium may be a pseudocyst
What may be found on exam in severe pancreatitis?
Like peritonitis with wide spread guarding and absent bowel sounds
What are the classical signs of pancreatitis?
Cullen’s sign: cloted blood around the umbilicus
Grey Turner’s sign: clotted blood in the flanks due to retroperitoneal haemorrhage
Erythema Abigne: Mottling of the skin (hot water bottle to relieve pain)
What are the initial investigations for pancreatits?
IV access
Bloods: FBC and coagulation, UE, LFT, Calcium, Glucose, Amylase, CRP and Lactate dehydrogenase.
ABGs if hypoxic
What is the diagnostic test for pancreatitis?
Serum amylase: 3 times upper limit of normal is diagnostic. Can be normal in 30% of cases esp. chronic
What imaging may be useful in pancreatitis?
USS- ALL patients- looking for gall sones and size of CBD (dlated?), free fluid.
CXR- pleural effusion
AXR- Sentinel loop- small dilation of small bowel around pancreas
CT: assess severity of pancreatitis at day 5, for interventions or looking for complications
On a normal AXR can you see small bowel?
No- its abnormal to see it.
When is ERCP used?
1) NOT as diagnostic tool.
2) To remove CBD stones with obstruction.
3) Cholangitis: emergency procedure
4) Acute biliary pancreatitis at 24-72 hours if index cholecystectomy is not possible.
What is the glasgow criteria for pancreatitis?
PANCREAS score.
NB: Ranson’s criteria is also used
PaO2 < 8kPa Age >55 Neutrophils: WBC > 15 Calcium < 2 Renal Function: Urea > 16 Enzymes: ALT >200 or LDH > 600 Albumin <32 Sugar: Glucose > 10
WHat glasgow criteria score indicates severe pancreatits?
> 3 consider critical care
Score on arrival and at 24 hours
What are the local complications of pancreatitis?
Fluid collection Pseudocysts Abscess Necrosis +/- infection Ascites Pleural effusion
What are the systemic complications of pancreatitis?
Pulmonary failure Renal failure Shock Sepsis Metabolic acidosis Hyperglycaemia Hypocalcaemia Multiple organ failure
What is the mortality of severe pancretitis?
10-20%
Should all patients with gallstone pancreatitis have a laproscopic cholecystectomy on first admission?
If mild yes.
If severe, no. Let the patient recover and allow inflammation to reduce. ERCP and sphincerectomy will allow any additional stones to pass in the meantimeElective Lap cholecystectomy planned.
Pseudocysts are a complication of pancreatitis. WHat causes them?
Some are due to a pancreatic duct communication. Can cause biliary obstruction, gastric outlet obstruction => Jaundice and vomiting. Little pain
How are pseudocysts treated?
Nothing or Endoscopic/surgical/ radiological drainage by creating a port between cyst and stomach to allow drainage.
Pancreatic abscesses are a complication of pancreatitis. How are they treated?
CT/US retroperitoneal or trans peritoneal drainage
Pancreatic necrosis is a complication of pancreatits. What is the treatment?
CT for assessment
Fine needle aspiration by endoscopic US guidance for micro
If infected must be drained- pericutaineous drain/ open/laproscopic
What is chronic pancreatitis?
Progressive and irreversible damage with loss of exocrine and endocrine function.
What are the risk factors for chronic pancreatitis?
Alcohol, smokers, drugs.
What imaging should be done for chronic pancreatitis?
Consider the following: CXR/AXR USS CT pancreas MRI ERCP
What is the cause of chronic pancreatitis?
Alcohol Idiopathic Pancreatic duct obstruction (pancreas divisium- congenital) Autoimmune CF or Alpha antitrypsin
How is chronic pancreatitis managed?
Creon and insulin for pancreatic insufficiency.
Surgery: Pustow Procedure or Frey procedure
WHat are the complications fo chronic pancreatitis?
Splenic Vein thrombosis Pseudoaneurysm of splenic artery Pleural Effusions Ascites Pancreatic cancer Pseudocysts Biliary obstruction Duodenal obstruction
How is duodenal obstruction managed?
Stent
Bypass
Resection
What is the most common type of exocrine pancreatic tumour?
Adenocarcinoma
What are the 3 types of endocrine pancreatic tumour?
1) Gastrinoma- produces gastrin, increase stomach acid => PUD
2) Insulinoma- produces insulin, encourages sugar uptake and storage. Hypoglycemia
3) Glucagonoma: produces glucagon, increases serum blood sugars => hyperglycemia and diabetes
What are the symptoms of a pancreatic tumour?
Jaundice (painless) Loose stools and staetorrhoea. Dark urine Weight loss Back pain
What are the risk factors for pancreatic tumour?
Smoking
Obesity
Diabetes type 1 or 2
What investigations are important for pancreatic tumours?
Endoscopic USS (biopsy head of pancreas)
Triple phase CT
MRI (liver mets)
MRCP- bilary drainage
How can inoperable pancreatic carcinoma be treated?
Palliative
ERCP and stent insertion to decompress obstructed biliary ducts
What operations are carried out for pancreatic carcinoma
Curative intent: Whipples procedure Distal pancreatectomy Total pancreatectomy Bypass- Biliary, gastric or double
