Gastroenterology

Pancreatic disease

Acute Pancreatitis

About

  • Acute inflammation of the pancreas with significant morbidity and mortality.

Aetiology

  • Inflammation of the pancreas can lead to the release of activated proteolytic enzymes with localised tissue damage.  
  • Local tissue injury and a marked inflammatory response  which can lead to a systemic inflammatory response.  

Causes 

  • Gallstones or Alcohol and Post ERCP complication.
  • Less common causes include hypertriglyceridaemia - look at fundi for lipaemia retinalis
  • Hyperparathyroidism - check calcium
  • Pancreatic cancer, Trauma, Infections - HIV, CMV, EBV
  • Drugs - steroids, azathioprine, sulphonamide

Clinical Findings

  • Epigastric pain through to back eased with sitting up and forwards.
  • May be peritonitis with guarding. Symptoms of gallstones, alcoholism. 
  • A more severe haemorrhagic pancreatitis causes shock, septsis, bruising in flanks suggest retroperitoneal bleeding - Grey Turner's sign and Periumbilical bruising - Cullen's sign (haemorrhagic pancreatitis)

Prognosis - Ranson's criteria: At admission or diagnosis

  • Age > 55
  • WCC > 16,000/mm^3
  • Glucose > 11 mmol/L (200 mg/dl)
  • LDH > 350 iu/L
  • AST > 600 iu/L

First 48 hours

  • Hct fall > 10%
  • Low Calcium < 2 mmol/L
  • Low Pa O2 < 8 Kpa
  • BE > -4 mmol/L
  • Urea increase > 1.8 mmol/L
  • Fluid needs > 6 L

Prognosis

  • 0-2 criteria < 5% mortality
  • 3-4 criteria 20% mortality
  • 5-6 criteria 40% mortality
  • 7-8 criteria 100% mortality

Complications

  • Sepsis
  • ARDS
  • Hypovolaemic shock
  • Renal failure
  • Hyperglycaemia
  • Hypocalcaemia

Investigations

  • FBC U&E ABG Calcium, Lipids - increased Trigs (can cause falsely low amylase)
  • Amylase - A raised Amylase is not unique to Pancreatitis but may also be seen in abdominal pain due to perforation of a viscus, small bowel obstruction, Leaking abdominal aortic aneurysm, Ectopic pregnancy
  • Lipase - has a higher sensitivity and specificity than amylase
  • Erect CXR/AXR - exclude perforation/ileus
  • USS Abdomen - mass, gallstones, pseudocyst
  • CT abdomen or more commonly now MRI

Management

  • Initial management should focus on ABC's with fluid replacement - accurate management of fluid balance is necessary in all but the mildest cases with CVP monitoring if needed, urinary catheter and clinical assessments of hydration, oxygenation etc.
  • All patients who are vomiting require an NG tube
  • Analgesia - pethidine preferred (concerns that Morphine increases tone at the sphincter of Oddi)
  • Enteral feeding should not be avoided early on and is an important mode of acute treatment. It is cheaper , safer and there are less septic complications when compared with parenteral feeding. Nasogastric or nasojejunal feeding are equally useful.
  • Broad spectrum antibiotics are given where sepsis is suspected
  • ERCP considered where there is a cholangitis or jaundice and a common duct stone which requires removal
  • Surgery may be required where there is a severe necrotizing pancreatitis or if there is an abscess or pseudocyst

Pancreatic Cancer

About

  • Common typically lethal cancer

Risks

  • Smoking
  • Alcohol
  • Coffee intake

Clinical Findings

  • Painless jaundice - Cancer of the head of pancreas presents earlier with obstructive jaundice
  • Weight loss, Ascites
  • Distended gallbladder not typically seen in chronic cholecystitis due to gallstones (Courvoisier's law)
  • Venous thrombosis - DVT , PE sometimes in atypical sites
  • Secondary Diabetes

Investigations

  • FBC U&E LFT'S
  • USS abdomen - biliary obstruction, mass at head of pancreas
  • ERCP allows biopsy and stenting
  • CT and biopsy in some cases

Management

  • Prognosis has changed little over 20 years and out come for those who are inoperable is poor
  • Surgical resection in a few with limited disease
  • Palliative chemotherapy can prolong survival in advanced disease
  • Palliation - ERCP and stenting
  • Prognosis is very poor with typical survival of 12 months or less