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Systems: Alimentary AB > Surgery of Pancreatic Disorders > Flashcards

Surgery of Pancreatic Disorders Flashcards

1
Q

What is the epidemiology of head of pancreas carcinoma?

A
  • 100/million per year UK
  • Average age 60-80 yrs
  • F>M
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2
Q

What is the aetiology of pancreatic carcinoma?

A

Unknown

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3
Q

What are the risk factors for pancreatic carcinoma?

A
  • Smoking
  • Chronic pancreatitis
  • Adult onset diabetes
  • Hereditary pancreatitis
  • Inherited predisposition
  • Periampullary cancer as a feature of FAP
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4
Q

What is the hallmark feature of pancreatic carcinoma?

A

Painless obstructive jaundice

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5
Q

How does pancreatic carcinoma present

A
  • Diabetes
  • Abdominal pain
  • Back pain
  • Anorexia
  • Vomiting
  • Weight loss
  • Recurrent bouts of pancreatitis
  • Incidental finding
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6
Q

What general investigations should be carried out for pancreatic carcinoma?

A
  • Blood tests

- CXR

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7
Q

What tumour markers are there for pancreatic cancer?

A

CA19-9

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8
Q

What imaging/invasive investigations should be carried out for pancreatic carcinoma?

A
  • USS
  • ERCP
  • CT
  • MR, MRCP
  • Laparoscopy and Lap USS
  • Peritoneal cytology
  • EUS + FNA Bx
  • Percutaneous needle biopsy
  • PET
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9
Q

How is a patient assessed for fitness for major pancreatic resection?

A
  • Basic history and examination
  • CXR, ECG
  • Resp function tests
  • Physiological scoring system (none established, performance status, lactate threshold)
  • Fully informed consent
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10
Q

What can be done for a patient with pancreatic cancer deemed to be unfir/unresectable?

A

ERCP+stent

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11
Q

What investigations must be performed before a potentially resectable cancer is resected?

A
  • USS
  • ERCP + stent
  • Spiral CT/MRI
  • Laparoscopy/ Lap USS
  • Laparotomy
  • Resection
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12
Q

What is the name of the surgery performed fro pancreatic cancer?

A

Kausch-Whipple

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13
Q

How is palliative drainage achieved with obstructive jaundice?

A
  • Palliative bypass
  • ERCP
  • PTC stenting
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14
Q

How is palliative drainage achieved with duodenal obstruction?

A
  • Palliative bypass

- Duodenal stent

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15
Q

Acute pancreatitis

A

An acute inflammatory process of the pancreas with variable involvement of other regional tissue or remote organ systems

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16
Q

Mild AP

A

Associated with minimal organ dysfunction and uneventful recovery

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17
Q

Severe AP

A

Associated with organ failure or local complication

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18
Q

What are the local complications of acute pancreatitis/

A
  • Acute fluid collections
  • Pseudocyst
  • Pancreatic abscess
  • Pancreatic necrosis
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19
Q

What is the aetiology of acute pancreatitis?

A
  • Gallstones
  • Alcohol
  • Viral infection: CMV, mumps
  • Tumours
  • Anatomical abnormalities
  • ERCP
  • Lipid abnormalities
  • Hypercalcaemia
  • Postoperative trauma
  • Ischaemia
  • Drugs
  • Scorpion venom
  • Idiopathic
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20
Q

What is the pathophysiology of AP as a result of alcohol?

A
  • Direct injury
  • Increased sensitivity to stimulation
  • Oxidation products (acetaldehyde)
  • Non-oxidative metabolism
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21
Q

What is the pathophysiology of AP as a result of gallstones?

A
  • Passage of gallstones is essential

- Raised pancreatic ductal pressure

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22
Q

What is the pathophysiology of AP as a result of ERCP?

A

-Increased pancreatic ductal pressure

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23
Q

What are the symptoms of AP?

A
  • Severe abdominal pain
  • Nausea
  • Vomiting
  • Collapse
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24
Q

What are the signs of AP?

A
  • Pyrexia
  • Dehydration
  • Abdominal tenderness
  • Circulatory failure
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25
Q

What general supportive care should be provided in AP initial resuscitation and management?

A
  • Analgesia
  • IV fluids
  • CV support
  • Resp support
  • Renal support
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26
Q

What monitoring should be provided in AP initial resuscitation and management?

A
  • Pulse
  • BP
  • Urine output
  • CVP
  • Arterial line
  • HDU/ITU
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27
Q

What investigations should be carried out in AP initial resuscitation and management?

A
  • U+Es
  • Glucose
  • Serum amylase
  • FBC
  • Clotting
  • LFTs
  • ABG
  • CXR
  • AXR
  • USS
  • CT
28
Q

What are the criteria in the Glasgow criteria scoring system?

A
  • Glucose >10mmol/L
  • Serum Ca <2mmol
  • WCC >1500/mm^3
  • Albumin<32g/l
  • LDH>700IU/L
  • Urea>16mmol/L
  • AST/ALT>200IU/L
  • Arterial pO2 <60mmHg
29
Q

When is AP predicted severe ?

A

If Glasgow criteria scoring is >3 at 48 hrs

30
Q

How is a prediction of severity made for AP?

A
  • Clinical assessment
  • Modified Glasgow criteria
  • CT scan
  • CXR
  • CRP>200 or persistent >150
  • IL6
  • TAP
31
Q

AP Identification and Management of Precipitating Factors: Cholelithaiasis

A

ERCP and ES, cholescystectomy

32
Q

AP Identification and Management of Precipitating Factors: alcohol

A
  • Abstinence

- Counselling

33
Q

AP Identification and Management of Precipitating Factors: Ischaemia

A
  • Careful support

- Correct cause

34
Q

AP Identification and Management of Precipitating Factors: Malignancy

A
  • Resection

- Bypass

35
Q

AP Identification and Management of Precipitating Factors: Hyperlipidaemia

A
  • Diet

- Lipid lowering drugs

36
Q

AP Identification and Management of Precipitating Factors: Anatomical abnormalities

A

Correction if possible

37
Q

AP Identification and Management of Precipitating Factors: Drugs

A
  • Stop

- Change

38
Q

What are the specific aspects of management for AP?

A
  • CT
  • Antibiotics
  • Diagnosis of infection
  • ERCP in gallstone pancreatitis
  • Nutrition
  • Manipulation of the inflammatory response
39
Q

When can necrosis by AP be detected on CT?

A

Days 4-10

40
Q

What complications of AP is CT useful for identifying?

A
  • Acute fluid collections
  • Abscess
  • Necrosis
  • Monitoring progress of disease
41
Q

What infections are associated with AP?

A
  • Sepsis

- SIRS

42
Q

When is ERCP and ES definitely indicated in AP?

A

In those with jaundice and cholangitis

43
Q

Why is ERCP and ES still controversial in the treatment of AP?

A
  • Reduces complications in severe gallstones

- Associated with higher mortality

44
Q

What role does nutrition play in the treatment of AP?

A
  • Nutrition vitally important
  • Enteral feeding is superior to parenteral feeding
  • NG feeding is tolerable in most cases and is not associated with any increase in complications
45
Q

What is the definitive management for AP in the prevention of recurrent attacks?

A
  • Management of gallstones
  • Investigations of non-gallstone pancreatitis
  • Alcohol abstinence
46
Q

What is the definitive management for fluid collect in AP?

A
  • Early collection: sit it out
  • Pseudocyst: doesn’t have a capsule
  • Pancreatic duct fistula: manage pancreas accordingly
47
Q

What is the definitive management of necrosis in AP?

A
  • Sterile and infected necrosis

- Necrosectomy by laparotomy or minimally invasive

48
Q

What are late complications of AP?

A
  • Haemorrhage
  • Portal hypertension
  • Pancreatic duct stricture
49
Q

Chronic pancreatitis

A

Continuing chronic inflammatory process of the pancreas characterised by irreversible morphological changes leading to chronic pain and/or impairment of endocrine and exocrine function of the pancreas

50
Q

What is the epidemiology of chronic pancreatitis?

A
  • M>F

- Increasing in the Western World

51
Q

What are the causes of chronic pancreatitis?

A
  • Obstruction of MPD
  • Autoimmune
  • Toxin
  • Idiopathic
  • Genetic
  • Environmental
  • Recurrent injuries
52
Q

What can cause obstruction of the MPD?

A
  • Tumour
  • Sphincter of Oddi dysfunction
  • Pancreatic divisum
  • Duodenal obstruction
  • Trauma
  • Stricture
53
Q

What toxins can cause CP?

A
  • Ethanol
  • Smoking
  • Drugs
54
Q

What genes can cause CP?

A
  • Autosomal dominant (Condon 29 and 122)

- Autosomal recessive (CFTR, SPINK1,)

55
Q

What environmental factor can cause CP?

A

Tropical chronic pancreatitis

56
Q

What recurrent injuries can cause CP?

A
  • Biliary
  • Hyperlipidaemia
  • Hypercalcemia
57
Q

What are the clinical features of CP?

A
  • Pain
  • Pancreatic exocrine insufficiency
  • Diabetes
  • Jaundice
  • Duodenal obstruction
  • Upper GI haemorrhage
58
Q

Describe the pain linked to CP.

A
  • Most significant factor affecting quality of life
  • Linked to binges
  • Become more frequent and less treatable by abstinence
  • Pathogenesis unknown
59
Q

What investigations should be carried out for CP?

A
  • CT
  • ERCP/MRCP
  • Pancreatic exocrine function
  • Faecal/serum enzymes
  • Pancreolauryl test
  • Diagnostic enzyme replacement
60
Q

What conservative management is there for CP?

A
  • Counselling
  • Alcohol abstinence
  • Management of acute attacks
  • Analgesia
  • Avoid high fat, high protein diet
  • Pancreatic supplementation
  • Anti-oxidant therapy
61
Q

When should surgery be considered for CP?

A

-Suspicion of malignancy
-Intractable pain
-Complications that require surgical intervention
ONLY AFTER FULL EVALUATION

62
Q

What complications of CP require surgical intervention?

A
  • Pancreatic duct stenosis
  • Cyst, pseudocysts
  • Biliary tract obstruction
  • Splenic vein thrombosis/ gastric varicies
  • Portal vein compression/ mesenteric vein thrombosis
  • Duodenal stenosis
  • Colonic stricture
63
Q

What interventional procedures are there for CP?

A
  • PD stenosis and obstruction: endoscopic PS sphincetortomy, dilation and lithotripsy
  • Management of chronic pseudocyst
  • Thoracoscopic
  • Spanchnectomy
  • Celiac plexus block
64
Q

What surgery is available for drainage in CP?

A
  • Pancreatic duct sphincteroplasty

- Puestow

65
Q

What surgery is available for resection in CP?

A
  • DPPHR
  • PPPD
  • Whipple
  • Frey procedure
  • Spleen preserving distal pancreatectomy
  • Central pancreatectomy
66
Q

What is the prognosis for CP?

A
  • Mortality 50% over 20-25yr
  • 20% die of complications
  • Rest die as a result of associated conditions
  • Morbidity is still a major cause for concern

Systems: Alimentary AB (37 decks)

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