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systems- GI > surgery of pancreatic disorders > Flashcards

surgery of pancreatic disorders Flashcards

1
Q

whos more likely to get cancer to the head of pancreas

A

60-80 yr and women

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2
Q

what is the 6th killer cancer in uk

A

cancer of head of pancreas

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3
Q

risk factors of cancer head of pancreas

A 
Unknown
Risk factors:
cigarette smoking: 25–30%
chronic pancreatitis: 5–15 fold
Adult onset DM of less than two years’ duration
Hereditary pancreatitis
Inherited predisposition:
Periampullary cancer is a feature of FAP
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4
Q

presentation of cancer head of pancreas

A

Obstructive jaundice

Diabetes
Abdominal pain / Back pain
Anorexia
Vomiting
Weight loss
Recurrent bouts pancreatitis

Incidental finding

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5
Q

investigations of cnacer head of pancreas

A 
General investigations
Blood tests
CXR
Tumour markers
CA19-9
Imaging / Invasive Investigations
USS
?ERCP
CT
MR, MRCP
Laparoscopy + Lap USS
Peritoneal cytology
EUS + FNA/ Bx
Percutaneous needle biopsy
PET
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6
Q

patient assessment for head of pancreas cancer

A 
Basic history and examination
CXR, ECG
Respiratory function tests
Physiological “scoring system”
None established
Performance status
Lactate threshold
Fully informed consent is vital
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7
Q

when would you do palliative bypass for pancreatic cancer?

A

for obstructive jaundice and duodenal obstruction

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8
Q

what is the definition of acute pancreatitis?

A

An acute inflammatory process of the pancreas, with variable

involvement of other regional tissues or remote organ systems

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9
Q

when is acute pancreatitis mild and when is it severe

A

mild: Associated with minimal organ dysfunction and uneventful recovery
severe: Associated with organ failure or local complication

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10
Q

what are local complications of acute pancreatitis?

A

Acute fluid collections

Pseudocyst

Pancreatic abscess

Pancreatic necrosis

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11
Q

aetiology of acute pancreatitis

A 
Gallstones 
Alcohol 
Viral Infection: CMV, mumps 
Tumours 
Anatomical abnormalities (P.D.)
ERCP
Lipid abnormalities
Hypercalcaemia 
Postoperative Trauma 
Ischaemia 
Drugs	
Scorpion venom
“Idiopathic”
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12
Q

pathophysiology of acute pancreatitis

A

Alcohol
direct injury increased
sensitivity to stimulation

oxidation products (acetaldehyde)

non-oxidative metabolism (fatty acid ethyl esters)

Gallstones
passage of gallstone is essential

raised pancreatic ductal pressure

ERCP
increased pancreatic ductal pressure

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13
Q

symptoms of acute pancreatitis

A

Abdominal pain
Nausea, vomiting
Collapse

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14
Q

signs of pancreatitis

A

Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure

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15
Q

monitoring acute pancreatitis

A 
Pulse, BP
Urine output
CVP
Arterial line
HDU / ITU
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16
Q

general supportive care of acute pancreatitis

A 
Analgesia
Intravenous fluids
Cardiovascular	}
Respiratory	}  support
Renal		}
17
Q

investigations of acute pancreatitis

A 
U/E, glucose
serum amylase
FBC, clotting
LFT	ABG
CXR	AXR
USS
CT scanning
18
Q

prediction of severity of disease for acute pancreatitis

A 
Glucose > 10 mmol/L
Serum [Ca2+] < 2.00 mmol
WCC > 15000/mm3			Predicted severe ≥ 3
Albumin< 32 g//L
LDH > 700 IU/L
Urea > 16 mmol/L
AST/ALT > 200 IU/L
Arterial pO2 < 60mmHg

modified glasgow criteria >3

19
Q

how do you manage cholelithaisasis?

A

ERCP & ES, cholecystectomy

20
Q

how do you manage alcohol?

A

abstenence, counselling

21
Q

how do you manage ischaemia?

A

careful support, correct cause

22
Q

how do you manage malignancy?

A

Resection or bypass

23
Q

how do you manage hyperlipidaemia?

A

Diet, lipid lowering drugs

24
Q

how do you manage drugs

A

stop or change

25
Q

specific aspects of management for acute pancreatitis

A 
CT scanning
 Antibiotics 
 Diagnosis of infection
 ERCP in gallstone pancreatitis
 Nutrition
 Manipulation of the inflammatory response
26
Q

what is CT good for when investigating acute pancreatitis?

A 
Useful for complications
  Acute fluid collections
  Abscess
  Necrosis
  Monitoring progress of disease
27
Q

definitive management of acute pancreatitis

A

Prevention of recurrent attacks
Management of Gallstones
Investigations of non-gallstone pancreatitis
Alcohol abstinenece

Fluid collection:
Early collection
Pseudocyst
Pancreatic duct fistula

Management of Necrosis:
Sterile necrosis
Infected necrosis: Necrosectomy
Laparotomy
Minimally invasive
Abscess
Late complications:
Haemorrhage
Portal hypertension
Pancreatic duct stricture
28
Q

definition of chronic pancreatitis

A

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.

29
Q

whos more likely to get chronic pancreatitis?

A

males

30
Q

causes of chronic pancreatitis

A 
O- A -Tiger
Obstruction of MPD
Tumour
Adenocarcinoma
IPMT
Sphincter of Oddi dysfunction
Pancreatic divisum
Inadequate accessory drainage
Duodenal obstruction
Tumour
Diverticulum
Trauma
Structure
Post necrotizing radiation

Autoimmune

Toxin
Ethanol (related to amount and length of consumption)
Smoking (odds ratio 8 to 17)
Drugs

Idiopathic

Genetic
Autosomal dominant (Condon 29 and 122)
Autosomal recessive/modifier genes
(CFTR, SPINK1, Codon A etc)

Environmental
Tropical chronic pancreatitis

Recurrent injuries
Biliary
Hyperlipidemia
Hypercalcemia

31
Q

features of chronic pancreatitis

A

Pain
most significant factor wrt quality of life
linked to binges
become more frequent and less treatable by abstinence
pathogenesis unknown

Pancreatic exocrine insufficiency
Late manifestation

Diabetes

Jaundice

Duodenal obstruction
Uncommon

Upper GI haemorrhage

32
Q

investigations of chronic pancreatitis

A

Appropriate imaging:
CT scan: local anatomy and complications
ERCP / MRCP

Pancreatic exocrine function (used infrequently):
  faecal / serum enzymes (elastase)
  Pancreolauryl test (enzyme reponse to a stimulus)

Diagnostic Enzyme replacement

33
Q

management of chronic pancreatitis

A 
Conservative management
  Counselling
  Abstinence from alcohol
  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 supplementation
  Diabetes
34
Q

surgery for chronic pancreatitis

A 
Suspicion of malignancy 
  Intractable pain
  Complications
Pancreatic duct stenosis
Cyst / pseudocysts
Biliary tract obstruction
Splenic vein thrombosis / gastric varices
Portal vein compression / mesenteric vein thrombosis
Duodenal stenosis
Colonic stricture
35
Q

prognosis of chronic pancreatitis

A

Mortality 50% over 20-25y

20% die of complications

Rest die as a result of associated conditions

Morbidity is still a major cause for concern

36
Q

indication for resection

A

BD-IPMN
In elderly >3 cm without high risk stigmata (mural nodules, positive cytology): can be observed
In younger patients: >2 cm may be considered depending on location
MCN: all MCN in fit patients indicated
<4cm without mural nodules: lap. Spleen preservation

37
Q

methods of resection

A 
Pancreatectomy + LN’s 
Focal and LN or spleen sparing:
Laparoscopic
Robotic
Multifocal BD-IPMN: total pancreatectomy

systems- GI (40 decks)

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