Surgery of Pancreatic Disorders Flashcards by Annie Caldwell

What age group is the most common to get cancer of the head of the pancreas?

60 - 80 y/o

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Which gender gets pancreatic head cancer more?

M:F 1.5:2

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Risk factors for head of pancreas cancer

Smoking 25-30%
Chronic pancreatitis 5-15x
Adult onset DM of less than 2 years duration 
Hereditary pancreatitis 
Inherited predisposition 
- periampullary cancer feature of FAP

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What is periampullary cancer?

Cancer that forms near the ampulla of vater

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Presentation of head of pancreas cancer

Obstructive jaundice
Diabetes 
Abdominal Pain
Back pain 
Anorexia
Vomiting
Weight loss
Recurrent bouts of pancreatitis 
Can also be an incidental finding

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Investigations for head of pancreas cancer

FBC
CXR
Tumour markers
- CA19-9
USS
Possible ERCP
CT
MRCP
EUS + FNA
Percutaneous needle biopsy 
PET scan 
Peritoneal cytology

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Treatment for head of pancreas cancer if patient is fit for surgery

USS then ERCP + stent
Spiral CT + MRI
Laparotomy
Resection

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Treatment for head of pancreas cancer if cancer is unresectable or patient is unfit for surgery?

USS then ERCP + stent
Spiral CT + MRI
Laparoscopic bypass
Can also do open bypass

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Types of surgery

Kausch-Whipple surgery

PPPD surgery

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Definition of chronic pancreatitis

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

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Which gender gets chronic pancreatitis more?

M > F

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Causes of chronic pancreatitis

Obstruction of main pancreatic duct
Autoimmune 
Toxins
- ethanol 
- smoking
- drugs 
Idiopathic
Genetic 
Environmental - tropical chronic pancreatitis 
Recurrent injuries 
- biliary 
- hyperlipidaemia
- hypercalcaemia

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Causes of obstruction of the main pancreatic duct

Tumour 
- adenocarcinoma
- IPMT 
Sphincter of oddi dysfunction 
Pancreatic divisum 
Duodenal obstruction 
- tumour
- diverticulum 
Trauma
Structure
- post necrotising radiation

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What does IPMT stand for?

Intraductal papillary mucinous tumour of the pancreas

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Pneumonic to remember the causes of chronic pancreatitis

O-A-TIGER

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What is pancreatic divisum?

Inadequate accessory drainage

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What are the genetic causes of chronic pancreatitis?

Autosomal dominant - codon 29 and 122

Autosomal recessive / modifier genes (CFTR, SPINK1, Codon A etc)

Presentation of chronic pancreatitis

Pain 
Pancreatic exocrine insufficiency (late manifestation)
Diabetes
Jaundice
Duodenal obstruction (uncommon) 
Upper GI Haemorrhage

What is pain in chronic pancreatitis linked to?

Binges

Investigations for chronic pancreatitis

CT
ERCP/MRCP
Pancreatic exocrine function

Treatment of chronic pancreatitis

Abstinence from alcohol 
Management of acute attacks
Analgesia 
Avoid high fat, high protein diet
Pancreatic supplementation 
Anti-oxidant therpat 
R
Treat DM
Surgery 
Interventional treatmentss

When would surgery be done in chronic pancreatitis?

Suspicion of malignancy

Intractable pain

Complications of surgery for chronic pancreatitis

Pancreatic duct stenosis
Cysts/pseudocysts 
Biliary tract obstruction 
Splenic vein thrombosis/gastric varices
Portal vein compression/mesenteric vein thrombosis
Duodenal stenosis
Colonic stricture

What are interventional treatments for chronic pancreatitis?

For pancreatic duct stenosis and obstruction; Endoscopic PD sphincterectomy, dilation and lithotripsy
CBD stenting or bypass
Thorascopy splanchnectomy
Coeliac plexus block

Prognosis of chronic pancreatitis

50% over 20 - 25 years | 20% die of complications

Definition of acute pancreatitis

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

Types of acute pancreatitis

Mild acute pancreatitis | Severe acute pancreatitis

What is mild acute pancreatitis?

Assosiated with minimal organ dysfunction and uneventful recovery

What is severe acute pancreatitis?

Assosiated with organ failure or local complications e.g. - acute fluid collections - pseudocyst - pancreatic abscess - pancreatic necrosis

Causes of acute pancreatitis

``` Gallstones Alcohol Viral infection; CMV, Mumps Tumours Anatomical abnormalities (P.D.) ERCP Lipid abnormalities Hypercalcaemia Post op trauma Ischaemia Drugs Scorpion venom idiopathic ```

What is the most common two causes of acute pancreatitis?

Gallstones | Alcohol

Why can gallstones cause acute pancreatitis?

Raised pancreatic ductal pressure

What effects does alcohol have on the pancreas to induce acute pancreatitis?

Direct injury Increased sensitivity to stimulation Oxidation products (acetaldehyde) Non oxidative metabolism (fatty acid ethyl esters)

Why can ERCP cause acute pancreatitis?

Increased pancreatic ductal pressure

Presentation of acute pancreatitis

``` Abdominal pain Nausea + vomiting Collapse Pyrexia Dehydration Abdominal tenderness Circulatory failure ```

Treatment of acute pancreatitis

``` Analgesia IV fluids Treat precipitating cause Prevention of recurrent attacks - management of gallstones - alcohol abstinence Management of necrosis Management of fluid collection ```

Investigations for acute pancreatitis

``` U and Es Glucose Serum amylase FBC, clotting LFTs ABG CXR AXR USS CT scanning ```

3 or more of this modified Glasgow criteria of acute pancreatitis at 48 hours indicates severe

a) Glucose > 10mmol/L b) Serum [Ca2+] <2.00mmol c) WCC > 15000/mm3 d) Albumin <32g/L e) LDH > 700 IU/L f) Urea > 16mmol/L g) AST/ALT >200 IU/L h) Arterial Po2 <60mmHg

What is done to predict the severity of acute pancreatitis?

``` Clinical assessment Modified Glasgow criteria (3 or more) CT scanning Individual markers - CXR - CRP ( >200 or perisists > 150) - IL 6 - TAP ```

Late complications of acute pancreatitis

Haemorrhage Portal HTN Pancreatic duct stricture