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Flashcards in Pancreatic disorders Deck (22)
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1

What are the functions of the pancreas?

  • Endocrine production:
    • Insulin
    • Glucagon
  • Exocrine production:
    • Pancreatic protease: trypsin; chymotrypsin
    • Amylase
    • Lipase

2

Name three causes of acute pancreatitis

  • Gallstone (60%)
  • Ethanol (30%)
  • Trauma (1.5%)
  • Steroids
  • Mumps; malignancy
  • Autoimmune
  • Scorpion (Tityus trinitatis) sting
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP (5%); emboli
  • Drugs: eg. azathioprine, oestrogen, thiazides, isoniazid

10-30%: Pregnancy, neoplasia, idiopathic

3

Which drugs are particularly associated with acute pancreatitis?

  • NSAIDs
  • Steroids
  • Azathioprine
  • Thiazides
  • Isoniazid
  • Oestrogen

4

How can acute pancreatitis be classified?

  • Oedematous: simple or associated with phlegmon
  • Severe/necrotising: sterile/infected necrosis; pseudocysts
  • Haemorrhagic: Grey Turner's and Cullen's sign

5

Name four presenting features of acute pancreatitis

  • Sudden severe epigastric abdominal pain
    • May radiate to back; worse with movement
    • Alcohol-related: less sudden; poorly localised
  • Severe NaV; anorexia
  • Peritonism; rebound tenderness; guarding
  • Abdominal distension; small bowel ileus
  • Cullen's (periumbilical); Grey Turner's sign (flank)
  • Tachycardia; hypotension

6

Name three differential diagnoses for acute pancreatitis

  • Perforated peptic ulcer; bowel obstruction; ischaemic bowl
  • Ruptured AAA
  • MI
  • Gallstones: biliary colic; acute cholecystitis; cholangitis
  • Viral hepatitis
  • Gastroenteritis

7

How is acute pancreatitis initially investigated?

  • Serum amylase: >1000U/ml or 3x upper limit of normal
    • Does not correlate with severity of disease
    • Levels begin to fall within 24-48hr
  • Serum lipase: more sensitive and specific for pancreatitis
  • Imaging:
    • USS within 48hr admission: Gallstones in CBD
    • AXR (non-specific)
    • CT: assess extent and complications
  • ABG; FBC; U+E; LFTs; glucose: assess severity

8

Name three non-pancreatitis causes of raised serum amylase

  • Intestinal ischaemia
  • Leaking AAA
  • Perforated peptic ulcer
  • Acute cholecystitis
  • Acute appendicitis
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Renal failure
  • DKA
  • Head injury

9

How is severe acute pancreatitis determined?

Glasgow-Imrie criteria

3+ criteria within 48hr of admission ➔ ITU/HDU transfer

  • PaO2 <8kPa
  • Age >55
  • Neutrophils/WCC >15,000 x109/L
  • Corrected Ca2+ <2mmol/L
  • Raised blood urea >16mmol/L
  • Enzymes: AST >200U/L, LDH >600U/L
  • Albumin <32g/L
  • Sugar (CBG) >10mmol/L (secondary diabetes)

10

Outline the management of acute pancreatitis

  • Fluid resuscitation
  • Do not make NBM unless clear reason eg. vomiting
    • Enteral nutrition if moderate-severe pancreatitis
    • Consider parenteral nutrition
  • Urgent ERCP + cholecystectomy: proven bile duct stones
  • Consider debridement or aspiration if refractory necrosis
  • Manage complications eg. insulin for type 3c diabetes

11

Name two early complications of acute pancreatitis

  • Shock; Pre-renal AKI
  • ARDS
  • Sepsis; DIC
  • Hypocalcaemia: soaponification of fats
  • Hyperglycaemia

12

Name three late complications of acute pancreatitis

  • Pancreatic necrosis
  • Pseudocysts; abscess
  • Haemorrhage; Thrombosis
  • Fistula
  • Oedematous pancreas; obstructive jaundice
  • Pancreatic encephalopathy due to hypoperfusion

13

Give four presenting features of chronic pancreatitis

  • Recurrent/persistent severe epigastric pain radiating into back
    • Relieved by sitting forward; hot water bottles
    • Worse with food and alcohol
  • NaV; anorexia
  • Exocrine insufficiency:
    • Malabsorption; weight loss
    • Diarrhoea
    • Steatorrhoea
    • Protein deficiency
  • Endocrine insufficiency:
    • Diabetes mellitus
    • Impaired glucose regulation

14

Describe the histology of chronic pancreatitis

  • Glandular atrophy
  • Duct ectasia
  • Microcalcification
  • Intraductal stone formation

15

What sign may be seen as a result of conservative management of chronic pancreatitis?

Erythema ab igne (hot water bottle rash)

Chronic exposure to infrared radiation (heat) causing localised reticulated erythema and hyperpigmentation

16

List three causes of chronic pancreatitis

  • Alcohol
  • Idiopathic chronic hepatitis
  • Smoking: inhibits exocrine pancreatic secretion
  • Recurrent acute pancreatitis: eg. alcoholic pancreatitis
  • Obstructive causes:
    • Pancreatic head tumours or cysts
    • Pancreatic duct strictures: post-op, ERCP, parasites
    • Congenital: eg. pancreas divisum, annular pancreas
    • Cystic fibrosis
  • Autoimmune: eg. Sjogren's syndrome; IBD; PBC

17

Request three investigations for suspected chronic pancreatitis

  • FBC; LFTs; U+Es
  • CBG; HbA1c
  • AXR: Pancreatic calcifications
  • Abdominal USS; Pancreatic CT
  • ERCP
  • DXA scan

18

What investigation can be used to assess pancreatic function in chronic pancreatitis?

Faecal elastase

Synthesised and excreted by pancreas

19

Outline the initial treatment for chronic pancreatitis

  • Lifestyle:
    • Alcohol and smoking cessation
    • Antioxidant rich diet; dietary advice
  • Adequate analgesia
  • Pancreatic enzyme supplements
  • Insulin if diabetes mellitus develops

20

What are the surgical indications for chronic pancreatitis?

  • Treat underlying reversible causes
  • Severe intractable pain or multiple relapses
  • Complications:
    • Pseudocysts
    • Obstruction
    • Fistula
    • Infections
    • Portal HTN

21

Name three complications of chronic pancreatitis

  • Maldigestion and malabsorption
    • Osteoporosis; pathological fractures
  • Diabetes mellitus
  • Chronic pain; opioid dependency
  • Pancreatic calcification
  • Pseudocysts

22

What surgical management is initially available for chronic pancreatitis?

Remove causes or drain obstructed pancreas:

  • Pancreaticoduodenectomy (Whipple procedure)
  • Partial pancreatectomy of head or tail
  • Pancreaticojejunostomy (Puestow procedure)