Surgery for pancreatic disorders Flashcards
List 3 main types of pancreatic disease
- Pancreatic cancer
- Acute pancreatitis
- Chronic pancreatitis
How many people in the UK are diagnosed with cancer of the head of the pancreas every year?
100/million p/a in UK
Who are most commonly affected by cancer of the head of the pancreas?
- Commonest in 60-80y, though there are more younger patients recently
- M:F = 1.5-2
What are the risk factors for cancer of the head of the pancreas?
– Cigarette smoking: increases risk by 25–30%
– Chronic pancreatitis: 5–15 fold chance of developing cancer
– Adult onset DM of less than two years’ duration
– Hereditary pancreatitis (rare)
– Inherited predisposition
– Periampullary cancer is a feature of FAP
How do patients with cancer of the head of the pancreas present?
- Obstructive jaundice – very gradual change, often present too late
- Diabetes
- Abdominal pain/back pain – often occurs in late stage disease
- Anorexia
- Vomiting
- Weight loss
- Recurrent bouts of pancreatitis
- Incidental finding
What tumour marker is associated with pancreatic cancer?
CA19-9
What imaging or invasive investigations are used for pancreatic cancer?
– USS – ERCP – CT – MR, MRCP – Laparoscopy + Lap USS – Peritoneal cytology – EUS + FNA/ Bx – Percutaneous needle biopsy – PET
List the 2 types of surgery offered for pancreatic tumours
Kausch- Whipple: A pancreaticoduodenectomy or Kausch-Whipple procedure, is a major surgical operation involving the removal of the head of the pancreas, the duodenum, the proximal jejunum, gallbladder, and part of the stomach. This operation is most often performed to remove cancerous or pre-cancerous tumours of the head of the pancreas or one of the related structures (Ampulla of Vater, duodenum or bile duct). Less commonly, it may be used for the management of pancreatic or duodenal trauma, or chronic pancreatitis.
PPPD or pylorus preserving pancreatoduodectomy - same procedure except pylorus is preserved to maintain gastric emptying, though some doubt its effectiveness in adequacy for cancer removal therefore
Describe acute pancreatitis
An acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems
What are some local complications associated with acute pancreatitis?
- Acute fluid collections
- Pseudocyst
- Pancreatic abscess
- Pancreatic necrosis
Describe the aetiology of acute pancreatitis
- Gallstones - most common cause
- Alcohol – 2nd most common cause
- Viral Infection: CMV, mumps
- Tumours, especially of head of pancreas, blocks the pancreatic duct
- Anatomical abnormalities (P.D.)
- Lipid abnormalities
- Hypercalcaemia
- Postoperative trauma/general trauma
- Ischaemia
- Drugs
- Scorpion venom
- “Idiopathic” - 2% of cases, check there is no genetic link
- ERCP
I GET SMASHED
Idiopathic Gallstones Ethanol (alcohol) Tumours/trauma Scorpion venom Mumps/malignancy Autoimmune Steroids and other drugs Hypertriglycerides or hypercalcaemia ERCP Drugs
Describe the I GET SMASHED mnemonic for acute pancreatitis causes
I GET SMASHED
Idiopathic Gallstones Ethanol (alcohol) Tumours/trauma Scorpion venom Mumps/malignancy Autoimmune Steroids and other drugs Hypertriglycerides or hypercalcaemia ERCP Drugs
Describe the OATIGER mnemonic for chronic pancreatitis
Obstruction - tumour/trauma Autoimmune Toxin - alcohol, smoking Idiopathic Genetic - CF Environmental - tropical chronic pancreatitis Recurrent injury
How does alcohol cause acute pancreatitis?
Direct injury
Increased sensitivity to stimulation
Oxidation products (acetaldehyde)
Non-oxidative metabolism (fatty acid ethyl esters)
How does acute pancreatitis present - symptoms and signs?
Symptoms:
Abdominal pain
Nausea, vomiting
Collapse
Signs: Pyrexia Dehydration Abdominal tenderness Circulatory failure
Describe initial resuscitation and management of acute pancreatitis patients
- Analgesia
- Intravenous fluids
- Cardiovascular, respiratory and renal support
What should be monitored in acute pancreatitis?
- Pulse, BP
- Urine output
- CVP/central venous pressure
- Arterial line
- HDU / ITU
How is the severity of acute pancreatitis predicted?
Modified Glasgow criteria – must be carried out within 48hrs of admission for accurate prediction. Predicted severe if >3 of the following: o Glucose > 10 mmol/L o Serum [Ca2+] < 2.00 mmol o WCC > 15000/mm3 o Albumin < 32 g//L o LDH > 700 IU/L o Urea > 16 mmol/L o AST/ALT > 200 IU/L o Arterial pO2 < 60mmHg
Also based on individual markers: • CXR • CRP (>200, or persists >150) • IL-6 • Urinary trypsinogen activation peptide (TAP) – increased in pancreatitis patients
What biomarkers are associated with acute pancreatitis?
CXR
• CRP (>200, or persists >150)
• IL-6
• Urinary trypsinogen activation peptide (TAP) – increased in pancreatitis patients
How can the risk factors for acute pancreatitis be identified and managed in patients?
- Cholelithaiasis (gallstones) - ERCP and endoscopic sphincterotomy (ES), cholecystectomy
- Alcohol – abstinence, counselling
- Ischaemia – careful support, correct cause
- Malignancy – resection or bypass
- Hyperlipidaemia – diet, lipid lowering drugs
- Anat. Abnormalities – correction if possible
- Drugs – stop or change
What drug is commonly associated with acute pancreatitis?
Steroids
On what days should Its be carried out to check for necrosis?
Days 4-10
What are some late complications associated with acute pancreatitis?
- Haemorrhage
- Portal hypertension
- Pancreatic duct stricture
Define chronic pancreatitis
Continuing chronic inflammatory process of the pancreas, characterized by irreversible morphological changes leading to chronic pain and / or impairment of endocrine and exocrine function of the pancreas.
What can cause obstruction, leading to chronic pancreatitis?
Tumour
• Adenocarcinoma
• IPMT
Sphincter of Oddi dysfunction
Pancreatic divisum
• Inadequate accessory drainage
Duodenal obstruction
• Tumour
• Diverticulum
Trauma
Structure
• Post necrotizing radiation
What toxins are associated with chronic pancreatitis?
– Ethanol (related to amount and length of consumption)
– Smoking (odds ratio 8 to 17)
– Drugs
Describe some genetic causes of chronic pancreatitis and how they are inherited
Autosomal dominant (Codon 29 and 122)
Autosomal recessive/modifier genes
• (CFTR, SPINK1, Codon A etc)
Describe an environmental cause of chronic pancreatitis
Tropical chronic pancreatitis
Describe the clinical features of chronic pancreatitis
- Pain
- Pancreatic exocrine insufficiency (late stage)
- Diabetes
- Jaundice
- Duodenal obstruction (uncommon)
- Upper GI haemorrhage
How can pancreatic exocrine function be tested?
o Faecal/serum enzymes (elastase)
o Pancreolauryl test (enzyme response to a stimulus)
o Diagnostic Enzyme replacement
How is chronic pancreatitis managed?
Predominantly conservative management
- Counselling
- Abstinence from alcohol and smoking
- Management of acute attacks
- Analgesia
- ? Interventional methods of analgesia
- Avoid high fat, high protein diet
- Pancreatic supplementation - controversial for pain
- Anti-oxidant therapy
- Steatorrhoea: reduce fat intake + pancreatic supplements
- Diabetes management
What are some complications associated with chronic pancreatitis?
- Pancreatic duct stenosis
- Cyst / pseudocysts
- Biliary tract obstruction
- Splenic vein thrombosis / gastric varices
- Portal vein compression / mesenteric vein thrombosis
- Duodenal stenosis
- Colonic stricture
