Disease of the Pancreas (CP1 Standard)

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  • Created by: NDumps97
  • Created on: 03-04-19 15:51
Briefly explain the pathophysiology of acute pancreatitis.
This is self-perpetuating autodigestion of the pancreas. Digestive enzymes are inappropriately activated at pancreatic + peripancreatic tissue causing inflammatory reaction.
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I GET SMASHED = mnemonic for the causes of pancreatitis. What are they?
Idiotpathic, Gallstones, Ethanol (alcohol), Trauma, Steroids, Mumps, Autoimmune, Scorpion venom, Hyper-lipidaemia/calcaemia/thermia, ERCP, and Drugs (thiazides, NSAIDs etc). Also pregnancy / neoplasia if no cause found.
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What is the most common cause of pancreatitis and explain why it causes this condition?
Gallstones - they damage the ampulla of Vater (hepatopancreatic duct) which allows gastric contents up the duct which activates digestive enzymes
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If gallstones were suspected to be causing pancreatitis what would you do? What risks does this procedure pose?
ERCP (Endoscopic Retrograde Cholangio-Pancreatography). The endoscope goes into the duct. A tool on the end can be used to remove the stone. However this process can make pancreatitis worse or introduce infection to a previously sterile site.
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In pancreatitis litres of fluid collect where? (three sites)
Loads of extracellular fluid collects in the gut, peritoneum and retro-peritoneum.
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How many cases (rough %) of pancreatitis are mild and how many develop severe, life-threatening complications?
~80% of cases = mild. ~20% of cases = severe complications
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How many of the complicated pancreatitis cases end up in ICU and survive?
All cases of severe pancreatitis are likely to end up spending some time in ITU. ~50% of these patients will survive. (High mortality)
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What are the signs & symptoms of acute pancreatitis?
Gradual or sudden severe epigastric pain, central abdominal pain which may radiate to the back. Prominent vominting. Signs: tachycardic, jaundiced, ileus, rigid abdomen.
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Raised serum _______ (>1000U/ml) suggests acute severe pancreatitis. Will it always be raised?
Raised serum amylase (>3x more than normal) is senstive and specific for this when measured <24 hrs from onset. However the levels may be normal even in severe cases as levels start to fall from 24-48 hours from onset.
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What other conditions could cause raised serum amylase?
Cholecystitis, mesenteric infarctions, GI perforations,
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Increased serum _____ is more sensitive for pancreatitis than serum amylase? (Especially in alcohol-related pancreatitis)
Increased serum lipase (increases earlier and begins to fall again later than serum amylase)
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What would ABG be used to monitor in the patient with suspected pancreatitis? Why is this important in pacnreatitis?
ABG monitors oxidation status and acid-base status. This is important because early respiratory failure can occur in severe cases.
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Why would an erect CXR be used in suspected pancreatitis?
To rule out other causes of the symptoms, such as GI perforations
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What is the standard imaging modality to assess severity and look for complications? What are some of the things you may see on this?
CT - it can show enlarged pancreas with stranding (fat stranding - increased attenutation of fat on the image), abcesses, necrosis, pseudocyts
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When should an AXR/ erect CXR / blood investigations (FBC, U&Es, LFTs) be done for a patient with suspected pancreatitis? When should the CT/MRCP be done and repeated?
Complete AXR/ erect CXR and bloods on admission. Then book in CT (or MRCP). The CT should be repeated after 48-72 hrs.
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Why would you repeat the CT after 48-72 hrs?
This assess the severity of necrosis - i.e. looking at the progression of the disease after the original onset. Has it changed/got worse over a couple of days etc
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The severity of necrosis can be classified into the basis of how severely the organ is damaged. What does periductal necrosis mean?
The pancreas is divided into lobules like the liver. Periductal necrosis means acinar cells adjacent to the ducts are necrotic.
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What is the most common cause of periductal necrosis in pancreatitis?
Due to gallstones
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What does panlobular necrosis mean in pancreatitis? What are the general causes of this?
Pan (all) lobular necrosis = the whole of the acinar lobules are necrotic. This is normally because of drugs/toxins/viruses etc
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What causes perilobular necrosis and what is this caused by?
This is necrosis of the peripheris of the lobules of the pancreas. This is generally due to poor perfusion of the blood (shock etc).
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What are Cullen's and Grey Turner's sign? (Describe the same thing in different places) - both seen in pancreatitis sometimes
Cullen's = periumbilical brusing. Grey Turner's = bruising of the flank. Due to retroperitoneal haemorrhage and autodigestion of blood vessels.
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The Modified Glasgow Criteria helps decide if the pancreatitis is severe. What things are on the criteria? (PANCREAS = mneuominc)
PaO2 (<8kPa); Age (>55); Neutrophils (>15x10^9/L); Calcium (<2mmol/L); Renal (Urea >16mmol/L); Enzymes (LDH high and AST high); albumin (<32g/L); sugar (glucose >10mmol/L)
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How many positive factors on the modified Glasgow Criteria suggests severe pancreatitis? What should then be done with the patient if severe?
3+ features within 48 hours = severe. Transfer to ITU
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What are some of the early complications of acute pancreatitis?
Shock (hypovolaemic or septic); ARDS; Renal failure; DIC; hyperglycaemia; hypocalcaemia
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What is ARDS and why does it occur in acute pancreatitis?
Acute respiratory distress syndrome - occurs due to microthrombi in the pulmonary vessels
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Name 4 metabolic conditions which occur due to pancreatitis - 3 of these levels are all measured on the Glasgow Criteria - would they be high or low?
Hyperglycaemia (high glucose on Glasgow); Hypocalcaemia (low calcium levels); reduced serum albumin (low albumin on Glasgow); also Malabsorption
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What type of pancreatic cancer is most common?
Pancreatic (ductal) adenocarcinoma (it is a glandular organ)
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Name 3 risk factors this pancreatic neoplasm is associated with.
Smoking, alcohol, chronic pancreatitis, high waist circumfence and diabetes.
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What genetic mutation do ~95% of people with pancreatic cancer have?
Mutation in the K-ras (an important proto-oncogene in many cancers) gene
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Which part of the pancreas are the majority of pancreatic malignancies at? (60% of them)
In the head of the pancreas
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Name 1 main symptom which would distinguish whether the carcinoma was in the head of the pancreas compared to the body / tail or the pancreas.
Head of the pancreas = painless obstructive jaundice. Body/tail of pancreas = 75% have epigastic pain which is relieved when sitting forward.
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What are some other symptoms which many present with carcinomas in either the head or the body/tail of the pancreas?
Anorexia, weight loss, diabetes or acute pancreatitis. Heaptosplenomegaly and ascites may also occur in carcinomas of the head of the pancreas.
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What is Courvoisier's Law/sign and what might it show clinically?
Courvoisier's sign states that the presence of an enlarged gallbladder with painless jaundice - the cause is unlikely to be gallstones. This is because gallstones causes fibrosis of the gallbladder so it won't enlarge.
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What does a positive Courvoisier's sign lead you to think about?
If the patient has a palpable, enlarged gallbladder and painless jaundice - it makes a strong case this is because of malignancy.
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Trousseau's syndome is thrombosis of superficial or deep veins of the ___ (thrombophlebitis ______) which is related to pancreatic carcinoma
Trousseau's syndome is thrombosis of superficial or deep veins of the leg (thrombophlebitis migrans) which is related to pancreatic carcinoma
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What investigations would you do if you suspect pancreatic carcinoma?
Bloods: FBC, U&Es, LFTs (to investigate the obstructive jaundice); USS or CT (shows panreactic mass, liver metastases, and dilated biliary duct); endoscopic biopsy
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How would you distinguish between jaundice caused by acute pancreatitis and carcinoma?
Amylase is unlikely to be raised in pancreatic carcinoma
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True or False: pancreatic carcinomas are unlikely to have metastasised by the time of diagnosis?
False. Pancreatic carcinomas metastasise early + present late
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Other cards in this set

Card 2

Front

I GET SMASHED = mnemonic for the causes of pancreatitis. What are they?

Back

Idiotpathic, Gallstones, Ethanol (alcohol), Trauma, Steroids, Mumps, Autoimmune, Scorpion venom, Hyper-lipidaemia/calcaemia/thermia, ERCP, and Drugs (thiazides, NSAIDs etc). Also pregnancy / neoplasia if no cause found.

Card 3

Front

What is the most common cause of pancreatitis and explain why it causes this condition?

Back

Preview of the front of card 3

Card 4

Front

If gallstones were suspected to be causing pancreatitis what would you do? What risks does this procedure pose?

Back

Preview of the front of card 4

Card 5

Front

In pancreatitis litres of fluid collect where? (three sites)

Back

Preview of the front of card 5
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