Pancreatitis, Pancreatic Ca

Question 1

What are the causes of acute pancreatitis?

Answer 1

I GET SMASHED:
I: Idiopathic
G: Gallstones
E: Ethanol
T: Trauma
S: Steroids
M: Mumps
A: Autoimmune
S: Scorpion venom
H: HyperL, hyperCa, hypothermia
E: ERCP
D: Drugs

Question 2

What is the clinical presentation of acute pancreatitis?

Answer 2

SEVERE epigastric pain, radiates to back, relieved by sitting forward
Pain worse w/OH-
Abdominal rigidity
Epigastric tenderness
↓Bowel sounds
Anorexia + Vomiting ++ → SHOCK 
↑HR ↓BP ↑Temp (mild)
Jaundice

Question 3

What are the classic late signs of pancreatitis?

Answer 3

Grey-Turners (flank)

Cullen’s (central)

Question 4

What are the investigations for pancreatitis?

Answer 4

1) Bloods: Amylase↑↑↑, Lipase↑↑, ↑WCC, ↑CRP, ↑Urea, ↑Glucose, ↓Ca2+, ↓Hb (bleed)
2) AXR- erect
3) MRCP- determine gallstones

Question 5

What is being looked for on AXR in pancreatitis?

Answer 5

Exclude perforation
Retroperitoneal fluid
Sentinel loop sign indicates gallstone ileus

Question 6

How high does Amylase need to be to be significant?

Answer 6

x3 upper limit

Question 7

How is acute pancreatitis managed?

Answer 7

IV fluids
Oxygen
Analgesia: Morphine
Nil by mouth
NG-tube
VTE prophylaxis- LMWH
ERCP + Gallstone removal
Cholecystectomy if due to gallstones

Question 8

How is mortality predicted in acute pancreatitis?

Answer 8

MODIFIED GLASGOW SCORE:
P: PaO2 <8
A: Age >55yo
N: Neutrophilia >15
C: Ca2+ <2
R: RF- Urea >16
E: Enzyme- LDH >600, AST >200
A: Albumin >32
S: Sugar >10
SCORE >3 = SEVERE

Question 9

How is the severity of acute pancreatitis diagnosed?

Answer 9

RANSON:
Criteria on admission:
-Age >55 years
-Glucose >11.1 mmols/L 
-WCC >16 x 10⁹/L 
-AST >250 units/L
-LDH >350 units/L

Criteria at 48hours:

• Haematocrit fall >10%
• BUN rise >5 mg/dL
• Ca <2 mmols/L
• PO2 <8 kPa

Question 10

What are the complications of acute pancreatitis?

Answer 10

Psuedocysts
Pancreatic abscess
Necrotising pancreatitis

Question 11

What are the majority of pancreatic cancers?

Answer 11

Adenocarcinoma

Question 12

What are the RFs for pancreatic Ca?

Answer 12

Male
>60yo
Smoking
Alcohol
DM
Chronic pancreatitis
Obesity

Question 13

What are the clinical features of pancreatic cancer?

Answer 13

Epigastric discomfort- dull ache
Anorexia & weight loss
Steatorrhoea
Nausea & vomting
Palpable gallbladder (Courvoisier's sign)
DM
Epigastric mass (LATE)

Question 14

What are the signs of pancreatic head Ca?

Answer 14

Painless, progressive, obstructive jaundice
Dark urine
Pale stools
Pruritis

Question 15

What are the signs of pancreatic body/tail Ca?

Answer 15

Weight loss

Non-specific pain

Question 16

How is a pancreatic Ca investigated?

Answer 16

Bloods: FBC (normochromic anaemia), LFTs (↑Bili, ↑↑ALP, ↑↑GGT), ↑Glucose, ↑Ca19-9
EUS- DIAGNOSTIC
Biopsy
ABDO CT- GOLD STANDARD

Question 17

How is a pancreatic Ca managed?

Answer 17

Radical: Pancreato-duodenectomy (WHIPPLE'S)
Chemo
Palliative- COMMON
ERCP w/stenting 
Analgesia & RT

Question 18

What are the causes & risk factors for chronic pancreatitis?

Answer 18

OH-
Obstruction 2o to stones/tumour
Smoking
CF, haemochromatosis
Drugs (Loop diuretics, Azathioprine)
Male

Question 19

What are the Sx of chronic pancreatitis?

Answer 19

Epigastric pain bores through to back
N&V
ENDOCRINE: DM Sx
EXOCRINE: Malabsorption

Question 20

How is chronic pancreatitis investigated?

Answer 20

Endo-USS & CT = DIAGNOSTIC show calcifications

Bloods: FBC, U&Es, LFTs, CRP, ↑Glucose, HbA1C, ↑Amylase, ↑Lipase

Question 21

How is chronic pancreatitis managed?

Answer 21

1) Diet modification
2) Analgesia, Creon, Insulin, Octreotide
3) Surgery: Pancreatectomy

Question 22

What are the indications for a Pancreatectomy in chronic pancreatitis?

Answer 22

Persistent pain
Narcotic abuse
Weight loss