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07. Year 2: Alimentary System > Pancreatic Disease > Flashcards

Pancreatic Disease Flashcards

1
Q

What are examples of pancreatic disease?

A

Acute pancreatitis

Chronic pancreatitis

Pancreatic cancer

Neuroendocrine tumours

Cystic fibrosis

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2
Q

What is acute pancreatitis?

A

Acute inflammation of the pancreas

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3
Q

Where is the pain usually due to acute pancreatitis?

A

Upper abdominal pain

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4
Q

How does acute pancreatitis change serum levels of amylase?

A

Elevation of serum amylase (4x upper limit of normal)

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5
Q

What can acute pancreatitis be associated with in severe cases?

A

Multi-organ failure

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6
Q

What is the incidence of acute pancreatitis?

A

20-300 cases/million

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7
Q

What is the mortality of acute pancreatitis?

A

6-12/million

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8
Q

What is the aetiology of acute pancreatitis?

A

Alcohol abuse (60-75%)

Gallstones (25-40%)

Trauma (blunt/postoperative/post ERCO)

Miscellaneous (drugs, viruses, pancreatic carcinoma, metabolic, autoimmune)

Idiopathic (about 10%)

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9
Q

What are examples of drugs that can cause acute pancreatitis?

A

Steroids

Azathioprine

Diuretics

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10
Q

What are examples of viruses that can cause acute pancreatitis?

A

Mumps

Coxsackie B4

HIV

CMV

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11
Q

What are metabolic changes that can cause acute pancreatitis?

A

Increased calcium

Increased triaglycerides

Decreased temperature

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12
Q

Explain the pathogenesis of acute pancreatitis?

A

1) Primary insult
2) Release of activated pancreatic enzymes
3) Autodigestion causing pro-inflammatory cytokines, reactive oxygen species, oedema, fat necrosis and haemorrhage

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13
Q

What are the clinical features of acute pancreatitis?

A

Abdominal pain

Vomiting

Pyrexia

Tachycardia

Oliguria

Jaundice

Paralytic ileus

Retroperitoneal haemorrhage

Hypoxia (respiratory failure in most severe cases)

Hypocalcaemia

Hyperglycaemia (occsaionally diabetic coma)

Effusions

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14
Q

What is paralytic ileus?

A

Obstruction of the intestine due to paralysis of the intestinal muscles

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15
Q

What is oligouria?

A

Urine output less than:

1mL/kg/h in infants

0.5mL/kg/h in children

400ml or 500ml per 24 hours in adults

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16
Q

What is strange about ERCP and acute panceatitis?

A

ERCP is a cause and a treatment of acute pancreatitis

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17
Q

What investigations are done for acute pancreatitis?

A

Blood tests

Abdominal and chest x-ray

Abdominal ultrasound

CT scan (contrast enhanced)

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18
Q

What is being looked for in an abdominal ultrasound for acute pancreatitis?

A

Pancreatic oedema

Gallstones

Pseudocyst

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19
Q

What blood tests are done for acute pancreatitis?

A

Amylase

Lipase

FBC

LFTs

Calcium

Glucose

Arterial blood gases

Lipids

Coagulation screen

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20
Q

What is used to assess the severity of acute pancreatitis?

A

Glasgow criteria

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21
Q

Using the glasgow criteria, what is considered to be severe pancreatitis?

A

A score of 3 or more

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22
Q

What is the white cell count for the glasgow criteria?

A

>15 x 109/L

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23
Q

What is the blood glucose for the glasgow criteria?

A

>10mmol/L

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24
Q

What is the blood urea for the glasgow criteria?

A

>16mmol/L

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25
Q

What is the AST for the glasgow criteria?

A

>200iu/L

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26
Q

What is the LDH for the glasgow criteria?

A

>600iu/L

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27
Q

What is the serum albumin for the glasgow criteria?

A

<32g/L

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28
Q

What is the serum calcium for the glasgow criteria?

A

<2mmol/L

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29
Q

What is the arterial PO2 for the glasgow criteria?

A

<7.5kPa

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30
Q

What is assessed with the glasgow criteria?

A

White cell count

Blood glucose

Blood urea

AST

LDH

Serum albumin

Serum calcium

Arterial PO2

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31
Q

What is LDH?

A

Lactate dehydrogenase

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32
Q

What does CRP stand for?

A

C-reactive protein

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33
Q

What is another indicator for severe pancreatitis that is not included in the Glasgow criteria?

A

CRP>150mg/L

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34
Q

What is the general management for acute pancreatitis?

A

Analgesia

IV fluids

Blood transfusion (Hb<10g/dL)

Monitor urine output (catheter)

Naso-gastric tube

Oxygen

May need insulin

Rarely required calcium supplements

Nutrition (enteral or parenteal) in severe cases

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35
Q

What is the specific management for acute pancreatitis if pancreatitic necrosis is occuring?

A

CT guided aspiration

Antibiotics and surgery

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36
Q

What is the specific management for acute pancreatitis if gallstones are present?

A

EUS/MRCP/ERCP

Cholecystectomy

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37
Q

What are possible complications of acute pancreatitis?

A

Abscess

Pseudocyst

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38
Q

What is the management of an abscess due to acute pancreatitis?

A

Give antibiotics and drainge

39
Q

What is an abscess?

A

Collection of pus

40
Q

What is a pseudocyst?

A

Fluid collection without an epithelial lining

41
Q

What is a pseudocyst diagnosed by?

A

Ultrasound or CT scan

42
Q

What are possible complications of a pseudocyst?

A

Jaundice

Infection

Haemorrhage

Rupture

43
Q

What is the treatment for pseudocyst?

A

If <6cm resolves spontaneously

If >=6cm, persistent pain or complications then endoscopic drainage or surgery

44
Q

What is the clinical presentation of a pseudocyst?

A

Persistent hyperamylasaemia and/or pain

45
Q

What percentage of cases is mild acute pancreatitis compared to severe?

A

Mild (75-80% of cases)

46
Q

What is the mortality of mild acute pancreatitis?

A

<2%

47
Q

What is the mortality of severe acute pancreatitis?

A

15%

48
Q

What is chronic pancreatitis?

A

Pancreas has become permanently damaged due to inflammation

49
Q

What is the prevalence of chronic pancreatitis?

A

Ranges from 0.01% in Japan to 5.4% in South India

50
Q

What is the incidence of acute pancreatitis?

A

3.5/100000 population/year

51
Q

How does the incidence of chronic pancreatitis compared between males and females?

A

Males > females

52
Q

What age group is chronic pancreatitis most common in?

A

35-50 years

53
Q

What is the aetiology of chronic pancreatitis?

A

Alcohol (80%)

Cystic fibrosis

Congenital anatomical abnormalities

Hereditary pancreatitis

Hypercalcaemia

Possibly diet, not yet proven

54
Q

What are examples of congenital anatomical abnormalities that can cause chronic pancreatitis?

A

Annular pancreas

Pancreas divisum (failed fusion of dorsal and ventral buds)

55
Q

Is hereditary pancreatitis dominant or rescessive?

A

Autosomal dominant

56
Q

What genes are associated with pancreatitis?

A

PRSS1

SPINK1

CFTR

57
Q

What is the pathogenesi of chronic pancreatitis?

A

Duct obstruction due to inflammation

58
Q

What is the pathology of chronic pancreatitis?

A

Glandular atrophy and replacement by fibrosis tissue

Ducts become dilated, tortous and strictured

Inspissated secretions may calcify

Exposed nerves due to loss of perineural cells

Splenic, superior mesenteric and portal veins may thrombose which leads to portal hypertension

59
Q

What does atrophy mean?

A

Wasting away of a body tissue

60
Q

What are clinical features of chronic pancreatitis?

A

Early diseases is asymptomatic

Abdominal pain (85-05%)

Weight loss

Exocrine insufficiency

Endocrine insufficiency

Miscellaneous (jaundice, portal hypertension, GI haemorrhage, pseudocysts)

61
Q

What are abdominal pains due to chronic pancreatitis exacerbated by?

A

Food and alcohol

62
Q

How does the severity of abdominal pain due to chronic pancreatitis change with time?

A

Severity decreases over time

63
Q

What are consequences of weight loss due to chronic pancreatitis?

A

Pain, anorexia, malabsorption

64
Q

What are consequences of exocrine insufficiency due to chronic pancreatitis?

A

Fat malabsorption (steatorrhea)

Low fat soluble vitamins

Low calcium/magnesium levels

Protein malabsorption causing weight loss and low vitamin B12

65
Q

What is a consequence of endocrine insufficiency due to chronic pancreatitis?

A

Diabetes in 30% of cases

66
Q

What is steatorrhoea?

A

Excretion of abnormal amounts of fat with faeces due to fat malabsorption

67
Q

What investigations are done by chronic pancreatitis?

A

Plain abdominal x-ray (30% have calcification of pancreas)

Ultrasound (shows pancreatic size, cysts, ducts diameter, tumours)

EUS

CT scan

Blood tests

Pancreatic function tests

68
Q

What is being checked in ultrasounds for chronic pancreatitis?

A

Pancreatic size

Cysts

Ducts diameter

Tumours

69
Q

What can be seen in blood tests for chronic pancreatitis?

A

Serum amylase increased in acute exacerbations

Decreased albumin, calcium, magnesium and vitamin B12

70
Q

What doe management of chronic pancreatitis involve?

A

Pain control

Managing exocrine and endocrine functions

71
Q

What is done for pain control in chronic pancreatitis?

A

Avoid alcohol

Pancreatic enzyme supplements

Opiate analgesia

Coeliac plexus block

Referral to pain clinic/psychologist

Endoscopic treatment of pancreatic duct stones and strictures

Surgery in selected cases

72
Q

What is done to manage exocrine and endocrine functions of the pancreas in chronic pancreatitis?

A

Low fat diet (30-40g/day)

Pancreatic enzyme supplements

Insulin for diabetes mellitus

73
Q

Why does death usually occur due to chronic pancreatitis?

A

Acute on chronic attack

Cardiovascular complications of diabetes

Associated cirrhosis

Drug dependence

Suicide

74
Q

What is the prognosis of chronic pancreatitis with and without continued alcohol use?

A

Continued alcohol intake causes 50% 10 year survival rate

No alcohol has 80% 10 year survival rate

75
Q

What is the incidence of carcinoma of the pancreas?

A

11/100000 population/year (increasing)

76
Q

How does the incidence for carcinoma of the pancreas change between male and females?

A

Males > females

77
Q

What age group does carcinoma of the pancreas ussualy occur?

A

80% are in 60-80 year age group

78
Q

What are the pathological types of carcinoma of the pancreas?

A

Duct cell mucinous adenocarcinoma (75%)

Carcinosarcoma

Cystadenocarcinoma

Acinar cell

79
Q

What are carcinosarcomas?

A

Malignant tumours that contain a mix of carcinoma (epithelial cancer) and sarcoma (cancer of mesenchymal/connective tissue)

80
Q

What are cystadenocarcinoma?

A

Malignant form of cystadenoma and is derived from glandular epithelium in which cystic accumulations of secreted fluid are formed

81
Q

What is a cystadenoma?

A

Benign tumour that develops from ovarian tissue

82
Q

Out of head, body, tail and multiple sites where do most adenocarcinomas of the pancreas occur?

A

Head (60%)

Multiple sites (22%)

Body (13%)

Tail (5%)

83
Q

What are clinical features of carinoma of the pancreas?

A

Upper abdominal pain (75%)

Painless obstructive jaundice (25%)

Weight loss (90%)

Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting

Tender subcutaneous fat nodules due to metastatic fat necrosis

Ascites, portal hypertension

84
Q

What are physical signs for carcinoma of the pancreas?

A

Hepatomegaly

Jaundice

Abdominal mass

Abdominal tenderness

Ascites, splenomegaly

Supraclavicular lymphadenopathy

Palpable gallbladder

85
Q

What investigations are done for carcinoma of the pancreas?

A
86
Q

What is the management for carcinoma of the pancreas?

A

Pancreatoduodenectomy (if patient is fit, <3cm diameter and no metastasis)

Palliation of jaundice (stent, palliative surgery - choleduodenostomy)

Pain control (opiates, coeliac plexus block, radiotherapy)

Chemotherapy only in contolled trials

87
Q

When can a pancreatoduodenectomy be done for carcinoma of the pancreas?

A

Patient is fit

<3cm diameter

No metastasis

88
Q

What is the operative mortality of a pancreatoduodenectomy?

A

5%

89
Q

What can be done for pain control in carcinoma of the pancreas?

A

Opiates

Coeliac plexus block

Radiotherapy

90
Q

What can be done for palliation of jaundice in carcinoma of the pancreas?

A

Stent

Palliative surgery (cholechoduodenostomy)

91
Q

Why is the prognosis for carcinoma of the pancreas so bad?

A

Majority of patients present with advanced disease (<10% are operable)

92
Q

What percentage of carcinoma of the pancreas cases are operable?

A

<10%

93
Q

What is the prognosis for operable and inoperable cases of carcinoma of the pancreas?

A

Inoperable 5 year survival is 1%

Operable 5 year survival is 15% (30-50% is ampullary tumours)

94
Q

What is the mean survival time for inoperable cases of carcinoma of the pancreas?

A

<6 months

07. Year 2: Alimentary System (41 decks)

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