tbl 3 clinical: acute pancreatitis, chronic pancreatitis and pancreatic cancer

Question 1

Pancreatitis – inflammation of pancreas and ___________ tissues, can be acute or chronic

Answer 1

peri-pancreatic

Question 2

Classical symptoms of acute pancreatitis (Features of Abdominal pain):

• Location: ______________ pain
• Nature: Dull steady pain
• Severity: Varies from mild tolerable to severe incapacitating pain
• Radiation Classically to the back. May also radiate to _______________
• Aggravating: ______ position, food, alcohol
• Relieving: Sitting up, leaning forward, knees flexed
• Associated symptoms: Nausea, vomiting, abdominal distension, fever

Answer 2

Epigastric to periumbilical; chest, lower abdominal flanks; Supine

Question 3

Symptoms –> Aetiologies

• Recurrent episodes may point towards aetiologies like _____, _________, familial causes, congenital (pancreatic divisum)
• Alcohol – amount, frequency and last episode –> Common cause of acute pancreatitis
• Biliary colic, jaundice, fever –> ____________ is the most common cause
• Biliary stones – biliary colic due to _____________ can present with fever and jaundice
• Recent procedures – _____________, double balloon enteroscopy (DBE) –> Post ERCP or DBE pancreatitis is not uncommon
• Drug history – current and new Statin, ACE- OCP/HRT, diuretics, ART, valproic acid, OHGAs, azathioprine
• Family history – certain genetic predispositions ____________________ gene
• Viral prodrome, ___________: Mumps – uncommon locally due to compulsory childhood vaccination. Other viral causes are possible e.g. coxackie, HSV. Salivary gland swelling may also be seen in autoimmune pancreatitis.
• Exposure to toxin or trauma: Scorpion bites, significant abdominal trauma

Answer 3

alcohol, biliary stones;

Gallstone pancreatitis ;

choledocholithiasis ;

endoscopic retrograde pancreatography (ERCP);

PRSS1, SPINK1, CFTR;

salivary gland swelling

Question 4

Mnemonic for aetiologies of pancreatitis – gallstone and alcohol cause 80% of pancreatitis

• G Gallstones
• E Ethanol
• T Trauma
• S _______
• M Mumps
• A ____________
• S ____________
• H ___________________________
• E ERCP
• D Drugs

Answer 4

Steroids; Autoimmune pancreatitis (IgG4); Scorpion sting

Hyperlipidaemia, hypothermia, hyperparathyroidism, hypercalcaemia

Question 5

Drug causes of pancreatitis (7 classes)

• _______
• ACE-I
• OCP, HRT (oral contraceptive pill, hormonal replacement therapy)
• Anti-retroviral treatment
• ________
• __________
• OHGAs

Answer 5

Statins; Diuretics; Valproic acid

Question 6

Physical signs of acute pancreatitis
- Vitals signs are essential – assess stability of patient
o Evaluate for tachycardia, _________
o Patient may also have ___________ and hypoxaemia

• Abdominal pain
  o Epigastric tenderness that may become ________________ if severe
  o Abdominal distension with hypoactive bowel sounds from ileus from the pancreatic inflammation
• In 3 percent of patients with acute pancreatitis, ecchymotic discoloration may be observed in the periumbilical region (________ sign) or along the flank (________ sign)
  o These findings, although nonspecific, suggest the presence of retroperitoneal bleeding in the setting of pancreatic necrosis

Other physical signs – helpful to determine aetiology
o Hepatomegaly – alcoholic pancreatitis
o _______ – hyperlipidaemic pancreatitis
o __________ – mumps induced pancreatitis

Answer 6

hypotension, tachypnoea;

diffuse and tender

Cullen’s, Grey Turner

Xanthomas, Parotidomegaly

Question 7

Diagnosis of pancreatitis: need 2/3 out of a triad of criteria to exclude.
- Symptoms: Acute onset of persistent, severe, _______ pain often radiating to the back – typical abdominal pain suggestive of pancreatitis
- Laboratory testing: Elevation in serum lipase or
amylase to ____________ than the upper limit of normal
- Imaging: Characteristic imaging findings on CT, MRI or
transabdominal U/S Imaging studies may have limited yield soon after onset of symptoms as radiological changes may not be apparent

Answer 7

epigastric; three times or greater

Question 8

Investigations to confirm diagnosis of acute pancreatitis

Blood test:
- Amylase or lipase – elevation of lipase occurs earlier and last longer for lipase compared with amylase, more useful for patient who presents ______ after onset of pain. Lipase is also more sensitive

Radiology:

• CT AP – focal or diffuse enlargement of the pancreas with __________ with IV contrast. Necrosis of pancreatic tissue is recognized as __________ after IV contrast
• MRI Abdomen: diffuse/ focal enlargement of pancreatic glands can be seein in patients with acute pancreatitis and margins can be blurred.

Answer 8

> 24 hours;

heterogeneous enhancement, lack of enhancement

Question 9

Investigations to evaluate for aetiology for acute pancreatitis

Blood tests

• calcium or albumin
• lipid panel
• __________

Radiological

• US HBS – pancreas appears diffusely enlarged and _________ on abdominal ultrasound. Gallstones may be visualized in the gallbladder or the bile duct.
• CT AP
• MRI abdomen

Procedural:

• ______ to collect bile for microscopic evaluation for cholesterol/ bilrubinate crystals
• ____ to measure pancreatic & billary pressure to evaluate for sphincter of oddi function or to perform biliary or pancreatic sphincteromy.

Answer 9

liver function tests;

hypoechoic;

EUS; ERCP

Question 10

Investigations to assess severity and complications of acute pancreatitis

Blood tests

• Calcium or albumin
• FBC
• Renal Panel
• _____________

Radiological

• AXR – unremarkable in mild disease to localized ileus of a segment of small intestine (sentinel loop) or __________ in more severe disease. The colon cut off sign reflects a paucity of air in the colon distal to the splenic flexure due to functional spasm of the descending colon secondary to pancreatic inflammation. A ground glass appearance may indicate the presence of an acute peripancreatic fluid collection . Approximately one-third of patients with acute pancreatitis have abnormalities visible on the chest roentgenogram such as elevation of a hemidiaphragm, pleural effusions, basal atelectasis, pulmonary infiltrates, or acute respiratory distress syndrome.
• CT AP.
• MRI abdomen

Procedural
- EUS

Answer 10

Troponin I, ECG;

colon cutoff sign

Question 11

The differential diagnosis of acute pancreatitis includes other causes of epigastric abdominal pain. Acute pancreatitis can be distinguished from these causes based on the clinical features and laboratory studies.

● Peptic ulcer disease – Patients may have a history of longstanding epigastric pain that is usually ____________. The pain does not radiate to the back. Patients may have a history of ______________ or prior infection with Helicobacter pylori. On laboratory testing, patients with peptic ulcer disease have a normal amylase and lipase.

● Choledocholithiasis or cholangitis – Patients with choledocholithiasis and cholangitis may have a history of gallstones or biliary manipulation such as endoscopic retrograde cholangiopancreatography (ERCP). Serum ___________ and ___________ concentrations are typically elevated early in the course of biliary obstruction. Later, patients have elevations in serum bilirubin, alkaline phosphatase, exceeding the elevations in serum ALT and AST. Serum amylase and lipase are normal.

●Cholecystitis – Patients with acute cholecystitis typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium that may radiate to the right shoulder or back. Unlike patients with acute pancreatitis, patients with acute cholecystitis commonly experience increased discomfort while the area around the gallbladder fossa is palpated and may have an associated inspiratory arrest (__________). Mild elevations in serum aminotransferases and amylase, along with hyperbilirubinemia may be seen but amylase or lipase elevations of greater than three times the upper limit of normal are not usually associated with cholecystitis. An abdominal CT scan shows gallbladder wall edema and pericholecystic stranding.

Answer 11

intermittent; nonsteroidal antiinflammatory drug (NSAID) use

alanine aminotransferase (ALT), aspartate aminotransferase (AST)

Murphy’s sign;

Question 12

Differential diagnosis for acute pancreatitis part 2
●Perforated viscus – Patients with a perforated viscus present with sudden onset abdominal pain and have peritoneal signs with ____________ that are not associated with acute pancreatitis. Patients may have an elevated amylase but elevations are unlikely to be three times the upper limit of normal. On upright chest film and abdominal films and abdominal CT scan, _____ can be seen. Other possible findings on abdominal CT include free fluid, phlegmon, and bowel wall pathology with adjacent inflammation.

●Intestinal obstruction – Patients with intestinal obstruction have abdominal pain with ______, emesis, obstipation, or constipation and elevation in serum amylase and lipase. These patients may have a history of prior abdominal surgeries or Crohn’s disease. On physical examination, patients may have prior surgical scars or hernias. On abdominal CT scan in addition to _______________, the etiology and site of obstruction (transition point) may be seen.

●Mesenteric ischemia – In patients with mesenteric ischemia, the pain is often periumbilical and out of proportion to findings on physical examination. Patients may have risk factors for mesenteric ischemia including advanced age, atherosclerosis, cardiac arrhythmias, severe cardiac valvular disease, recent myocardial infarction, and intra-abdominal malignancy. Although patients may have elevations in amylase or lipase these are usually less marked than elevations seen in acute pancreatitis. On abdominal CT scan there may be _____________ or intestinal pneumatosis with portal vein gas. In addition, arterial or _________ or hepatic or splenic infarcts may be seen.

●Hepatitis – Patients have acute right upper quadrant pain, anorexia, and general malaise. Patients may also note dark urine, acholic stool, jaundice, and pruritus. On physical findings, patients with acute hepatitis have _________ and tender hepatomegaly. Laboratory studies are notable for marked elevations of serum ________ (usually >1000 int. units/dL), serum total and direct bilirubin, and alkaline phosphatase with normal amylase and lipase.

Answer 12

guarding, rigidity and rebound tenderness; free air

anorexia; dilated loops of bowel with air fluid levels;

focal or segmental bowel wall thickening; venous thrombosis

scleral icterus; aminotransferases

Question 13

Determining severity of acute pancreatitis – multiple scoring systems that determines severity using ranges from clinical parameters, laboratory parameters and radiological parameters e.g. Glasgow score

• Some systems are complicated e.g. APACHE II, requiring multiple parameters
• The revised _____________ is commonly used due to its simplicity
• Mild: no organ failure, no local complications
• Moderate: transient organ failure < 48 hours, local complications +/-
• Severe: persistent organ failures

Answer 13

ATLANTA criteria

Question 14

Categories and complications of acute pancreatitis
- ____________ (85%) – characterized by an enlargement of the pancreas due to inflammatory oedema
- Necrotizing pancreatitis (15%) – necrosis of the pancreatic parenchyma, __________, or both
- In most patients with acute pancreatitis, the disease is mild in severity and patients recover in three to five days without complications or organ failure
o However, 20 percent of patients have moderately severe or severe acute pancreatitis with local or systemic complications or organ failure

Answer 14

Interstitial oedematous pancreatitis; peripancreatic tissue

Question 15

Complications of acute pancreatitis (local)

• Acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis
• ___________ and acute necrotic collections – may develop less than four weeks after the onset of pancreatitis
• Pancreatic pseudocyst and ____________ – usually occurs >4 weeks after onset of acute pancreatitis
• Both acute necrotic fluid collections and walled off necrosis may become infected
• __________________ develops in approximately 50 percent of patients with necrotizing acute pancreatitis and is rare in the absence of necrosis

Answer 15

Acute peripancreatic fluid collections ; walled off necrosis;

Portosplenomesenteric venous thrombosis (PSMVT)

Question 16

Complications of acute pancreatitis (systemic)

• A systemic complication of acute pancreatitis is defined as an exacerbation of an _________ (e.g. coronary artery disease or chronic lung disease)
• Acute kidney injury, acute liver failure, adult respiratory distress syndrome, disseminated intravascular coagulation, encephalopathy, gut ischemia, hypocalcaemia, paralytic ileus, shock
• Organ failure — In the Atlanta classification, organ failure is a distinct entity separate from a systemic
  complication
• Pancreatic inflammation results in the activation of a
  cytokine cascade that manifests clinically as a __________________ – patients with persistent SIRS are at risk for failure of one or more organs
• Organ failure (acute respiratory failure, shock, and
  renal failure) may be transient, resolving within 48 hours in patients with moderately severe pancreatitis or persistent for >48 hours in patients with severe acute pancreatitis

Answer 16

underlying comorbidity; systemic inflammatory response syndrome (SIRS)

Question 17

Management of acute pancreatitis (early phase)

Fluid resuscitation

• During initial phase – for survival benefit
• Lactated Ringer’s solution preferred unless in ______________ – lactated Ringer’s solution contains calcium and may exacerbate hypercalcemia (alternative will be normal saline)
• Lactated Ringer’s reduces the chance of _____________ from excessive normal saline usage (acidosis tends to worsen the pancreatitis)

Pain control

• ___________ is the priority as hypovolaemia from pancreatitis result in ischaemic pain and lactate acidosis
• Opioids (_______)

Close monitoring

• Clinical parameters - BP, PR, SpO2, Temp, urine output
• Lab parameters – electrolytes (calcium), _______

Nutrition
- Oral always preferred followed by _____ then parental (for persistent ileus)

Antibiotics
- Not routine, only when suspicious of infectious complications

Management of acute pancreatitis (late)

• Pancreatic pseudocyst – there is a chance of spontaneous resolution, ________ if symptomatic
• Walled off necrosis – __________ if possible
• May progress to chronic pancreatitis

Answer 17

hypercalcemia induced pancreatitis; hyperchloremic non-anion gap metabolic acidosis;

Adequate hydration; fentanyl

glucose;

enteral;

drainage;endoscopic necrosectomy

Question 18

Symptoms of chronic pancreatitis
- ____________ should be suspected in patients with chronic pancreatitis who develop a sudden worsening or changing pattern of symptoms

Pain

• Typically epigastric, often radiating to the back, occasionally associated with nausea and vomiting, may be partially relieved by sitting upright or leaning forward
• Pain is often worse 15 to 30 minutes after eating
• Early in the course of chronic pancreatitis, the pain may occur in ___________ – as condition progresses, pain tends to become more continuous

Exocrine pancreatic insufficiency

• Fat malabsorption – steatorrhea usually occurs prior to protein deficiencies since lipolytic activity decreases faster than proteolysis
• Deficiencies in vitamin ____________

Endocrine pancreatic insufficiency
- Pancreatic diabetes – usually insulin requiring, but characteristically different from T1DM as glucagon-secreting _________ are also affected, increasing the risk of hypoglycaemia

Pancreatic complications;
- Pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites or pleural effusion, splenic vein thrombosis, pseudoaneurysms and pancreatic cancer

Answer 18

Acute pancreatitis; intermittent discrete attacks;

A, D, E and K;

alpha cells;

Question 19

Diagnosis of chronic pancreatitis – can be challenging as laboratory studies and imaging procedures may be normal
Diagnosis confirmed if –
- ____________ within pancreas on CT scan
-Abnormal pancreatogram revealing beading of main pancreatic duct or ectatic (dilated) side branches
- Abnormal __________ pancreatic function test – decreased capacity to secrete fluid, bicarbonate and enzymes (indicating pancreatic damage)

Differentials

• _____________ (most important to exclude) – patients with classical symptoms of chronic pancreatitis may in fact have pancreatic cancer
• Autoimmune pancreatitis
• Lymphoma
• Pancreatic endocrine tumour

Answer 19

Calcifications; secretin;

Pancreatic cancer

Question 20

Aetiologies of chronic pancreatitis – TIGAR-O

• T __________
• I ________
• G _________
• A___________
• Recurrent and severe acute pancreatitis
• O_________
• Typical patient with chronic pancreatitis – abdominal pain after alcohol, fatty stools and develops diabetes

Answer 20

Toxic and metabolic; Idiopathic; Genetic; Autoimmune; Obstructive

Question 21

Investigations in chronic pancreatitis
- Amylase and lipase may be slightly elevated or normal in chronic pancreatitis – should only be reserved for diagnosis of acute (not chronic) pancreatitis
- ___________ – gold standard, but hard to collect
- _________ – test of choice, <200mcg/g is suggestive of pancreatic insufficiency
- HbA1C – regular monitoring for development of glucose intolerance and diabetes
- _________ is the imaging study of choice as there is no radiation risk, demonstrate calcifications, pancreatic duct obstruction
o Ultrasound, CT, EUS

Answer 21

72-hour faecal fat; Faecal elastase; MRCP

Question 22

Dietary modifications for chronic pancreatitis
- Restrict fat intake – degree of restriction depends upon the severity of fat malabsorption
o Generally, intake of 20 grams per day or less is sufficient – patients who continue to suffer from steatorrhea following fat restriction require medical therapy
- Recommended diet – low fat, fruits, vegetables, whole-grains, lean protein
o ____________, juice, coffee, tea or water as beverages
o 5 to 6 small meals a day instead of 3 large ones

Answer 22

Almond milk

Question 23

Pancreatic cancer
- Uncommon in people <40 years old with a median age of 70, more common in men with a high incidence of cancer mortality
o Not in the top 10 cancers for both males and females – in the top 10 cancers that causes death amongst Singaporeans

• Early pancreatic cancers are asymptomatic, especially at the body and tail – except those at ___________
  o Pancreatic cancers at the head present earlier due to the compressive effect on bile duct (may present as jaundice)

Answer 23

pancreatic head

Question 24

Most common symptoms of pancreatic cancer:

Most common symptoms –
o Abdominal pain
o Jaundice, \_\_\_\_\_\_ coloured urine
o Weight loss
o Lethargy
o Others – pale stools, steatorrhea and new onset or sudden poor control of diabetes

[Symptoms and location of pancreatic cancers]
Head and uncinate process: 
- Jaundice
- Tea coloured urine
- Pale stool
- \_\_\_\_\_\_\_\_

Body and tail:

• Back pain
• Weight loss
• Localised __________ pain

Answer 24

tea;

Pruritus; leftsided

Question 25

Risk factors for pancreatic cancer
- Smoking – linear association with risk of developing pancreatic cancer, related to amount and duration of smoking
o Smokers have 1 to 3x risk – risk persists beyond cessation of smoking
o Smoking is a causative factor but alcohol is only an __________
- _____________ – both a causal risk factor for pancreatic cancer and a clinical manifestation of pancreatic cancer inducing alterations in islet cell function and loss of β cell mass

• lifestyle & environmental: smoking, heavy alcohol, residential radiation factor
• known inherited genetic: familial pancreas CA, FAMMM, Hereditary pancreatis, BCRA2, Peutz Jegher syndrome, von Hippel Lindau, Li-Fraumeni
• high risk occupation: dry cleaning, chemical plant, sawmills, uranium miners, electrical equipment manufacturing workers

Answer 25

associative factor; Diabetes mellitus

Question 26

of pancreatic cancer
- Need high index of suspicion as tumours at the body and tail does not present with many symptoms
o Tumour markers (non-specific) – _________
- Imaging studies – ultrasound of the hepatobiliary system (US HBS), CT, MRI
- Fine needle aspiration or biopsy to confirm diagnosis if mass is seen within pancreas

Answer 26

Ca 19-9

Question 27

Treatment of pancreatic cancer – depends on the stage of the pancreatic cancer
- Stage I or II Surgically resectable pancreatic cancer
- Stage III: _________ or unresectable pancreatic
cancer
- Stage IV: Metastatic pancreatic cancer

Curative treatment:
- Surgery, adjuvant chemotherapy

Palliative treatment:
- ______ (if jaundice), gastric outlet stenting or bypass surgery (if GIT obstructed by tumour), pain management, symptomatic relief

Whipple procedure – common for tumours of the __________
o Conventional pancreaticoduodenectomy (i.e. Whipple procedure) involves removal of the pancreatic head, duodenum, ______ of the jejunum, ________, and gallbladder, and a partial gastrectomy

Answer 27

Locally advanced; Biliary stenting; pancreatic head; first 15 cm; common bile duct

Question 28

Prognosis of pancreatic cancer
- Only 15 to 20% of patients present at the
____________
- 70% of pancreatic cancer occurs at the head and uncinate process region with the remaining 20 to 30% occurring at the body and tail
- Prognosis of tumour at the ___________tends to be poorer as often patients present with metastatic disease or at an advanced stage

• In summary …
  o Pancreatic cancer usually presents late – only 15 to 20% of patients present at resectable state
  o High level of suspicion is needed for diagnosis
  o Limited response to treatment

Answer 28

resectable stage; body and tail