Pancreatic Conditions

Pancreatic cancer

This refers to a metastatic proliferation of pancreatic cells.

It is usually an adenocarcinoma which arises from the head of the pancreas.

It is seen in older patients and usually presents late with established metastases. 

Risk factors

Smoking, Alcohol

Diabetes

Chronic pancreatitis

Hereditary non-polyposis colorectal carcinoma

Multiple endocrine neoplasia

Symptoms

Painless obstructive jaundice, as the tumour compresses the common bile duct

Epigastric pain which may radiate to the back, weight loss, decreased appetite

Palpable gallbladder on examination (Courvoisier’s law states that patients with painless jaundice and a palpable gallbladder often have a malignant CBD obstruction)

Complications

Steatorrhea, obstructed pancreatic duct blocks secretion of digestive enzymes

Secondary Diabetes, due to damage of the cells in islets of Langerhans

Migratory thrombophlebitis (Trousseau sign) – this refers to recurring blood clots in small vessels, presenting as swelling, erythema and tenderness in extremities

Key tests

CT with contrast is the imaging modality of choice

If diagnostic doubt, endoscopic ultrasound with biopsy can be used

Bloods show raised CA 19-9, a non-specific marker that aids prognosis

Management

Surgical options include Whipple’s procedure, the removal of head and neck of pancreas and duodenum

If surgery is not possible, options include palliative chemotherapy, radiotherapy and ERCP for stenting

Acute Pancreatitis

This is a term which describes acute inflammation of the pancreas.

This leads to autodigestion of the pancreas by pancreatic enzymes. The inflammation can lead to systemic effects resulting in a host of complications.

Causes

These can be learnt by the acronym “I GET SMASHED”

Symptoms

Acute epigastric pain that radiates to the back, better when sitting forward

Nausea and vomiting, leading to dehydration and malaise

Can lead to hypovolaemic shock and acute respiratory distress syndrome (ARDS)

Key tests

Blood tests show raised amylase (diagnostic cut-off is 3x upper limit of normal)

Lipase is used in some centres as it is a more specific marker for pancreatitis

CT scan with contrast is the imaging modality of choice

LFTs and abdominal ultrasound scanning are useful if suspicion of gallstones

Grading

The severity of pancreatitis is graded using systems like Glasgow score.

We can simplify this using the acronym PANCREAS. If a patient has >3 then they are very sick

Management

Managed conservatively. IV fluids, analgesia, anti-emetics (may require NG feeding)

If due to gallstones, ERCP for removal and delayed cholecystectomy

If infection or there is a high risk of necrotising pancreatitis, start antibiotics 

Chronic Pancreatitis

This is when chronic inflammation results in fibrosis of the pancreatic parenchyma, leading to pain and impairment of both the exocrine and endocrine functions.

In adults it is mostly due to alcohol excess or chronic conditions like cystic fibrosis.

Causes

Mostly due to alcohol (adults) and cystic fibrosis (kids)

Symptoms

Epigastric pain that radiates to the back and is usually worse after a meal

Malabsorption and steatorrhea secondary to pancreatic exocrine insufficiency

Secondary diabetes mellitus secondary to pancreatic endocrine insufficiency

Key tests

CT scan is the imaging of choice and shows pancreatic calcification

Faecal elastase shows decreased exocrine function

Pancreatic enzymes (amylase) and not reliable indicators for chronic pancreatitis

Management

Advise patients to stop drinking

Treat complications (e.g., diabetes) and give pancreatic enzyme supplements