Disorders of the by hjkuiw354

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                                                                                                                                                                      inside
                                                                                                                                                                      Acute pancreatitis

                                                                                                                                                                      Chronic
                                                                                                                                                                      pancreatitis

                                                                                                                                                                      Pancreatic cancer

                                                                                                                                                                      Case studies



                                                                                                                                                                      The authors
                                                                                                                                                                      DR JONATHAN BROMLEY,
                                                                                                                                                                      advanced trainee in
                                                                                                                                                                      gastroenterology, The Canberra
                                                                                                                                                                      Hospital, ACT.

                                                                                                                                                                      ASSOCIATE PROFESSOR
                                                                                                                                                                      PAUL PAVLI,
                                                                                                                                                                      senior specialist, The Canberra
                                                                                                                                                                      Hospital; and Associate Professor,
                                                                                                                                                                      Australian National University
                                                                                                                                                                      Medical School, ACT.




       Disorders of the
       pancreas
 Introduction
THE main diseases of the pancreas        presentation, prognostic markers         life and provides major treatment       management.
that present with gastrointestinal       and aetiology of this relatively         challenges, such as meeting the anal-     Pancreatic cancer is a condition
manifestations are acute and             uncommon but potentially life-           gesic requirements of the patient,      that generally presents late in its clin-
chronic pancreatitis and pancreatic      threatening condition. Management        particularly in the long-term.          ical course and carries a poor prog-
cancer. Cystic fibrosis, as it affects   generally involves admission to hos-        An often underestimated aspect       nosis. Common presentations
pancreatic function, is also covered     pital for intravenous fluids, analge-    of management is the correction of      include painless jaundice, weight loss
briefly in this article.                 sia and the management of compli-        nutritional deficiencies resulting      or anorexia associated with new-
  Acute pancreatitis is an important     cations.                                 from pancreatic enzyme insuffi-         onset abdominal pain, or the devel-
cause of abdominal pain. GPs need           Chronic pancreatitis has signifi-     ciency. Abstinence from alcohol         opment of diabetes in an elderly
to have a good understanding of the      cant effects on a patient’s quality of   is also an important part of            patient without risk factors.




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                                                                                    www.australiandoctor.com.au                                                 6 October 2006 | Australian Doctor |       29
 Acute pancreatitis
MOST patients with acute                                                                                                                        patients suffer from pancre-           Reference ranges for pan-
pancreatitis do not present                                                                                                                     atitis, which calls its signifi-    creatic enzymes vary between
to their GP, but the diagno-                                                                                                                    cance into question.                laboratories so they should be
sis should be considered in                                                                                                                                                         specified, especially when
all patients presenting with                                                                                                                    Infection                           transferring patients between
upper abdominal pain.                                                                                                                           A range of infections can be        hospitals.
   Acute pancreatitis usually                                                                                                                   associated with episodes of
causes severe epigastric pain                                                                                                                   acute pancreatitis but the          When to refer
that requires hospitalisation                                                                                                                   exact incidence is unclear.         All patients with suspected or
for pain relief or for man-                                                                              Pseudocysts                            Whether treatment of the            proven acute pancreatitis are
agement of complications. In                                                                                                                    infection has significant bear-     best referred to hospital for
a recent survey of the gas-                                                            Pancreas                                                 ing on the natural history of       assessment, pain relief and
troenterology ward of The
Canberra Hospital, patients
                                                            Gallbladder                                                                         the disease process is also
                                                                                                                                                unknown. Causation has been
                                                                                                                                                                                    management of fluid replace-
                                                                                                                                                                                    ment and complications.
with pancreatic conditions                                                                                                                      demonstrated by culture of          Although most patients have
accounted for about 10% of                                                                                                                      the infective organism from         severe pain, some may have
                      1
the total bed days.                                                                                                                             the pancreas. Proven infective      milder pain and appear rea-
   The major difficulties in                                                                                                                    agents include:                     sonably well clinically, yet
management relate to                                                                                                                            ■ Viruses (CMV, hepatitis B,        have prognostic markers of
making the diagnosis in                                                                                                                           varicella zoster, HIV —           severe pancreatitis; they may
patients who have only                                                                                                                            although this may be due to       need to be managed in a high-
mildly elevated amylase                                                                                                                           drug treatment such as            dependency unit (see below).
and/or lipase levels, and in                                                                                                                      didanosine [Videx]).                 After the diagnosis has been
correctly identifying those                                                                                                                     ■ Bacteria       (salmonella,       made, determining the severity
with severe pancreatitis.                                                                                                                         legionella).                      of the episode is the most
   The pathogenesis of this                                                                                                                     ■ Fungi (aspergillus).              important issue. Overall about
disease is unclear but, what-       Acute pancreatitis showing pseudocysts, sludge or stones in the gall bladder and ascites.                                                       20% of cases are classified as
ever the triggers, the end result                                                                                                               Cancer                              severe; these have a mortality
is an acute inflammatory                                                                                     risk have not been defined.        Cancer of the pancreas is a         rate of about 20-30% — a
response due to inappropri-                                                                                     Acute pancreatitis related to   rare cause (<2-3% of acute          rate that has changed little
ately enhanced secretion of                                                                                  use of prescription drugs is an    pancreatitis) but it should be      over the past 30 years despite
pancreatic enzymes.                                                                                          unusual but well-recognised        considered.                         intensive care advances.
                                                                                                             entity. Drugs that have been                                              By contrast, the mortality
Aetiology                                                                                                    clearly associated with pan-       No cause found                      rate for mild pancreatitis is
Gallstones and excessive alco-                                                                               creatitis include:                 In about 15-20% of cases no         low. About 75% have mild
hol consumption account for                                                                                  ■ Diuretics (thiazides and         obvious cause is found.             disease and the mortality in
most cases of acute pancreati-                                                                                 frusemide [Frusemide, Fruse-     Although biliary sludge is          this group is <3%.
tis in Australia.                                                                                              hexal, Frusid, Lasix]).          often seen on ultrasound in            In the early phases of a
                                                                                                             ■ Antimicrobials (metronida-       this group, no clear link has       severe attack, mortality is gen-
Gallstones                                                                                                     zole [Flagyl, Metrogyl,          been firmly established.            erally from multiple organ fail-
Gallstones are responsible for                                                                                 Metronidazole, Metronide]                                            ure, and patients require inten-
30-50% of cases, and women                                                                                     and tetracycline).               Making the diagnosis                sive supportive care during
are affected more often than                                                                                 ■ Immunosuppressive agents         The enzymes elevated in             this period. Most deaths that
men. Smaller stones, which                                                                                     (azathioprine [Azahexal,         patients with acute pancreati-      occur later (after the first
can travel into the common                                                                                     Azamun, Azapin, Azathio-         tis are serum amylase (normal       week) are due to infective
bile duct, are more likely to                                                                                  prine, Imuran, Thioprine]).      range [NR] 30-110U/L) and           complications, especially
cause pancreatitis than larger                                                                               ■ Anticonvulsants (sodium          lipase (NR <80U/L).                 infected pancreatic necrosis.
ones. Increased levels of serum                                                                                valproate [Epilim, Valpro]).        Making a diagnosis of               Patients with severe pancre-
aminotransferases or bilirubin,                                                                                 All medications in patients     acute pancreatitis is straight-     atitis are best managed in a
or both, early in the course of                                                                              with suspected or proven pan-      forward when there is a typi-       high-dependency or intensive
the illness suggests gallstones                                                                              creatitis should be reviewed       cal clinical presentation and       care unit, where they can be
as the cause.                                                                                                for their potential to cause       pancreatic enzyme levels are        monitored closely. Immediate
   Because gallstones are a                                                                                  pancreatitis.                      markedly elevated (eg, >10          management includes:
common precipitating factor,        After the                           Table 1: Complications                                                  times the upper limit of            ■ Assessing the severity of the

one approach to establishing                                                                                 Trauma                             normal). However, lower ele-          attack.
the cause is to arrange an
                                    diagnosis has                           of pancreatitis
                                                                                                             Trauma accounts for 5% of          vations of serum amylase or         ■ Aggressive fluid resuscitation

ultrasound within 24-48             been made,                          Local                                cases of acute pancreatitis and    lipase levels (ie, >3-4 times         and close monitoring of
hours of presentation in all        determining the                     ■   Pseudocyst formation             is usually postoperative or        the upper limit of normal)            haemodynamic status.
patients with diagnosed             severity of the                     ■   Ascites
                                                                                                             post-ERCP. Blunt trauma to         can still occur in patients         ■ Providing adequate pain

acute pancreatitis.                                                                                          the abdomen (eg, seat belt         with acute pancreatitis.              relief.
   If gallstones are present
                                    episode is the                      ■   Pancreatic necrosis              injuries) can occasionally            If the amylase and/or lipase     ■ Determining the cause.

and there is additional sup-        most important                      ■   GI haemorrhage                   cause the condition.               levels are only slightly elevated   ■ Providing adequate nutrition

porting evidence such as            issue.                              ■   Pancreatic fistula                                                  in the presence of significant        when prolonged hospitalisa-
duct dilation, abnormal                                                                                      Hypertriglyceridaemia              pain, other conditions should         tion is expected.
                                                                        ■   Abscess
LFTs and fevers, manage-                                                                                     Serum triglyceride levels          be considered. For example,
ment usually includes endo-                                                                                  >11mmol/L can precipitate          elevated serum amylase level        Severity
scopic retrograde cholan-                                               Systemic                             attacks of acute pancreatitis      can occur with pancreatic           Severe acute pancreatitis
giopancreatography (ERCP)                                               ■   Acute respiratory distress       (although the pathogenesis is      cancer, cholecystitis, appen-       occurs when there is organ
and sphincterotomy (see                                                     syndrome                         unclear) and accounts for          dicitis, bowel perforation,         failure and/or local complica-
Author’s case studies — Epi-                                            ■   Acute renal failure              about 2% of cases. Pancreati-      ectopic pregnancy, drugs and        tions (table 1). There are sev-
gastric pain and weight loss                                                                                 tis may be the presenting          salivary gland diseases.            eral ways of gauging the sever-
                                                                        ■   Sepsis
in a patient with normal                                                                                     symptom of hypertriglyceri-           Conditions associated with       ity of an attack and the
pancreatic enzyme levels,                                               ■   Cardiac failure                  daemia or the condition may        an elevated lipase level include    prognosis for the patient.
page 34).                                                               ■   Acidaemia (pH <7.25)             have already been diagnosed.       cholecystitis, duodenal ulcera-     Measurements of either the
   In the few centres where                                             ■   Disseminated                                                        tion, pancreatic tumours and        haematocrit and/or the serum
it is available, endoscopic                                                 intravascular coagulation        Hypercalcaemia                     as a side effect of some drugs.     C-reactive protein (CRP) have
ultrasound can be used to                                                                                    Although uncommon, hyper-          Sometimes no obvious cause          useful prognostic significance,
help determine if there are                                                                                  calcaemia of any cause can         of an elevated amylase or           independent of other findings.
stones in the common bile                                             Alcohol and prescription drugs         trigger acute pancreatitis.        lipase level can be found.             Haemoconcentration indi-
duct (which are rarely seen                                           Excessive alcohol consump-                                                   It is important to correlate     cates significant fluid loss
on transabdominal ultra-                                              tion accounts for up to 40%            Pancreas divisum                   biochemical results with the        into the ‘third space’ and
sound) and to help decide                                             of cases of acute pancreatitis         This is an anatomical variant      clinical findings and, if the       reflects severe acute pancre-
which patients should                                                 and also causes the bulk of            caused by embryological fail-      diagnosis is in doubt, to           atitis. An admission haemat-
undergo ERCP. When gall-                                              cases of chronic pancreatitis.         ure of the fusion of the dorsal    exclude other life-threatening      ocrit >45% or a failure to
stones are found, cholecys-                                           It is more common in men               and ventral pancreas, result-      conditions that may mimic           reduce the haematocrit in 24
tectomy is indicated (usu-                                            because alcohol abuse is               ing in two separate pancreatic     acute pancreatitis, such as         hours are risk factors for
ally by laparoscopy),                                                 more common in males. The              ductal systems. It is seen in      mesenteric ischaemia, visceral      both pancreatic necrosis and
preferably during the same                                            blood levels of alcohol asso-          7% of people at post-mortem        perforation and leaking             distant organ failure.
admission.                                                            ciated with an increase in             but only 5% of affected            abdominal aortic aneurysm.                         cont’d next page


                                                                                              www.australiandoctor.com.au                                                     6 October 2006 | Australian Doctor |   31
 How to treat – disorders of the pancreas

 from previous page                                                                                                                            than twice the normal level.       Acute pancreatitis —
    An admission haematocrit                                                                                                                   Pain can recur and enzyme
                                                                                                                                                                                  management summary
 >45% has a sensitivity of                                                                                                                     levels rise when oral intake is
 34% and a specificity of 91%                                                                                                                  re-established, and the patient    Diagnosis confirmed — pain
 for identifying patients with                                                                                                                 should be warned of this pos-      and elevated lipase or
 severe pancreatitis, but when                                                                                                                 sibility.                          amylase levels (at least >3
 the same reading is present                                                                                                                      Nutritional support for         times the upper limit of
 after 24 hours the sensitivity                                                                                                                more complex patients such         normal).
 and specificity are 81% and                                                                                                                   as those with pancreatic
 88-91%, respectively.                                                                                                                         pseudocyts or necrosis, and in     First 24 hours
    Conversely a haematocrit                                                                                                                   whom prolonged fasting is          ■ Assess severity.
 <40% on admission has a                                                                                                                       necessary, can be difficult and    ■ Estimate BMI, record vital
 100% negative predictive                                                                                                                      is controversial. Choices            observations.
 value for pancreatic necrosis,                                                                                                                include naso-jejunal tube          ■ Blood tests: FBC for
 and is a reassuring result.                                                                                                                   insertion for enteral feeding,       haematocrit, WCC and
    CRP is an acute-phase reac-                                                                                                                or parenteral nutrition.             platelet count, CRP, BSL,
 tant that, in severe episodes,                                                                                                                   With a naso-jejunal tube the      calcium, electrolytes,
 is markedly elevated on the                                                                                                                   food is released distal to the       creatinine and urea,
 second day. The normal range                                                                                                                  pancreas to avoid stimulating        lactate dehydrogenase,
 in our laboratory is 0-10mg/L.                                                                                                                pancreatic enzyme produc-            aspartate aminotrans-
 It is as reliable as the Ranson                                                                                                               tion. Placement of the tube
                                     Contrast-enhanced CT is the gold standard for evaluating the presence and extent of pancreatic                                                 ferase, estimate base
 criteria (see below) for pre-                                                                                                                 can be difficult and may
                                     necrosis.                                                                                                                                      deficit in PaO2
 dicting severe acute pancreati-                                                                                                               involve multiple trips to the
                                                                                                                                                                                  ■ Give aggressive fluid
 tis. It has high sensitivity (70-                                                                          ment may be necessary, espe-       radiology department. The
                                                                                                                                                                                    resuscitation and keep nil
 86%) and specificity (71%)                                                                                 cially if there is ongoing vom-    tube is best sited under image
                                                                                                                                                                                    by mouth.
 for predicting pancreatic                                                                                  iting.                             intensification or fluoroscopic
                                                                                                                                                                                  ■ Provide appropriate pain
 necrosis, but only after the                                                                                  Most patients require uri-      guidance by an experienced
                                                                                                                                                                                    relief.
 third day.                                                                                                 nary catheterisation and main-     radiologist.
                                                                                                                                                                                  ■ Determine cause —
    A CRP level >210mg/L on                                                                                 tenance of an hourly fluid bal-       An alternative is surgical
 days 2-4, or >120mg/L at the                                                                               ance chart. In more complex        insertion of a jejunostomy           arrange abdominal
 end of the first week, discrim-                                                                            cases, such as patients with       tube, which also provides            ultrasound to look for
 inates well between mild and                                                                               coexisting cardiac failure, a      mucosal protection. If the           evidence of gallstones
 severe pancreatitis.                                                                                       central venous line and more       patient requires repeat endo-        and consider ERCP if
    The degree of elevation of                                                                              intensive monitoring in a high-    scopic aspirations of pancre-        present; check history of
 amylase and lipase assays does                                                                             dependency or intensive care       atic pseudocysts, tubes often        alcohol intake.
 not correlate with disease                                                                                 unit may be needed.                become displaced or have to        ■ Check medications if

 severity or recovery. In most                                                                                 Antibiotics are not given       be removed, and blockage             appropriate. Consider
 cases serum amylase level nor-                                                                             routinely because there is no      requiring a tube change is not       other causes (rare).
 malises before serum lipase                                                                                evidence that their use in mild    uncommon.
 during recovery, but enzyme                                                                                cases affects outcome or              Parenteral nutrition does       First 3-7 days
 levels remain elevated if there                                                                            reduces the incidence of septic    not provide mucosal protec-        ■ Continue fluid

 is ongoing pancreatic inflam-                                                                              complications. There is some       tion and there is significant        resuscitation and pain
 mation or a complicating pan-                                                                              evidence for the use of pro-       risk of line-related sepsis.         relief.
 creatic pseudocyst.                                                                                        phylactic antibiotics (such as     However, the supply of nutri-      ■ Monitor closely for

    Several scoring systems                                                                                 IV ceftriaxone [Ceftriaxone,       tion is more constant, as tube       evidence of organ failure,
 have been devised to assess                                                                                Rocephin] or meropenem             blockages are not an issue.          especially if there is
 severity and prognosis in                                                                                  [Merrem IV]) in patients with         A recent meta-analysis            evidence of severe
 patients with acute pancreati-                                                                             severe pancreatitis associated     showed superiority of enteral        pancreatitis on initial
 tis. These include:                                                                                        with necrosis, to prevent septic   feeding with respect to              assessment.
 ■ Atlanta criteria — based on
                                     Patients can                      between days 3 and 7 for any         complications.                     decreased infection and surgi-     ■ Arrange CT scan of
   the presence of local (eg,                                          patient with severe disease.                                            cal intervention rates, reduced      abdomen if pancreatitis is
   abscess, pseudocyst) and sys-     have high fluid                      If pancreatic necrosis            Pain management                    hospital stay and reduced cost,      severe or if pancreatic
   temic (eg, sepsis, acute renal    requirements                      (defined as the absence of con-      Acute pancreatitis is associ-      compared with parenteral
                                                                                                                                                         2                          cancer is suspected (rare).
   failure) complications. Mor-      because of loss                   trast enhancement) is found          ated with severe pain usually      feeding. It should be consid-      ■ Consider antibiotics if
   tality in the severe group                                          on CT, the patient is best           requiring opioid analgesia.        ered in patients who are likely      pancreatic necrosis is
   approaches 45%.                   of fluid into the                 managed in a high-depen-             Patient-controlled analgesia       to need frequent tube chang-         present on CT scan.
 ■ Ranson’s criteria — based         abdominal cavity                  dency setting with a combined        supervised by an acute pain        ing or when placement is tech-     ■ Consider enteral or
   on haematological (eg, white                                        medical        and     surgical      team may be appropriate if         nically difficult.
   cell count, haematocrit), bio-
                                     (third space) and                 approach.                            repeated doses of parenteral
                                                                                                                                                                                    parenteral nutrition if

   chemical (eg, blood sugar         from vomiting.                       Morbidity and mortality           opioid are needed. There is no     Recurrent acute
                                                                                                                                                                                    course is prolonged.

   level, blood urea nitrogen)                                         increases with increasing            evidence that morphine wors-       pancreatitis
                                                                                                                                                                                  First 1-2 weeks
   and patient (eg, age) para-                                         extent of glandular necrosis.        ens pancreatitis or that pethi-    Up to one-third of patients
                                                                                                                                                                                  ■ Continue management as
   meters on admission and in                                          If there is clinical deteriora-      dine should be used in prefer-     experience a repeat attack.
                                                                                                                                                                                    above.
   the first 24 hours. Patients                                        tion, percutaneous aspiration        ence to morphine.                  Recurrences are more com-
                                                                                                                                                                                  ■ If there is evidence of
   with more than five positive                                        of the necrotic tissue should          Analgesic requirements           mon in alcohol-associated dis-
                                                                                                                                                                                    sepsis, consider
   parameters have a mortality                                         be considered either under           differ enormously depending        ease and in gallstone disease
   rate of 50%.                                                        ultrasound or CT guidance.           on many factors such as age,       if cholecystectomy has been          percutaneous aspiration
 ■ Apache II scoring system —                                             If there is evidence of infec-    sex, body mass and previous        delayed. Recurrences can be          of necrotic pancreatic
   calculated using parameters                                         tion, treatment with antibi-         exposure to opioids.               distinguished from chronic           tissue and start
   such as heart rate and serum                                        otics and debridement of the                                            pancreatitis by the absence of       appropriate antibiotics if
   sodium at admission and                                             infected necrotic tissue (by         Nutrition                          exocrine or endocrine dys-           an organism is identified.
                                                                                                                                                                                  ■ Arrange surgical,
   after 24 hours and allows                                           radiological, surgical or endo-      During the acute phase,            function in the former.
   incorporation of age and                                            scopic means depending on            patients are kept nil by mouth                                          radiological or endoscopic
   chronic health points into                                          expertise) is appropriate.           to rest the GI tract and to        Discharge planning                   review for drainage if
   the scoring system. Higher                                                                               minimise secretion of pancre-      It is important to identify the      infected necrosis is
   scores correlate well with                                          Management                           atic enzymes and further           underlying aetiology of the          present.
   disease activity and the need                                       Fluid resuscitation                  inflammation: passing a naso-      pancreatitis before discharge.     ■ When pancreatic enzyme

   for ICU admission. It has                                           Patients can have high fluid         gastric tube is no longer          If gallstones are present and        levels fall to below twice
   high sensitivity and speci-                                         requirements because of loss         common practice.                   thought to be the likely cause,      the upper limit of normal
   ficity for diagnosis of acute                                       of fluid into the abdominal             The optimal timing for re-      the patient should have a firm       and/or the patient is
   severe pancreatitis (75% and                                        cavity (third space) and from        introducing oral fluids and        surgical plan on discharge if        pain-free: re-introduce
   92%, respectively).                                                 vomiting.                            foods is not known. Some           the cholecystectomy cannot be        fluids and food (but pain
                                                                          Patients need aggressive          experts advocate being guided      performed for some reason            may recur).
 Investigations                                                        fluid resuscitation. They often      by the patient: they will not      during the admission.              ■ If pancreatic enzyme

 Contrast-enhanced CT is the                                           require 5-10L or more in the         want to eat when unwell and           It is also important to iden-     levels remain persistently
 gold standard for evaluating                                          first 24 hours, and fluid bal-       the return of appetite nor-        tify alcohol as a cause because      elevated: repeat
 the presence and extent of                                            ance must be monitored               mally mirrors an improve-          of the potential for future          abdominal ultrasound to
 pancreatic necrosis, peri-pan-                                        closely. Normal saline is often      ment in pancreatitis.              attacks and the development          exclude a pancreatic
 creatic inflammation and                                              used but, if the patient is             Others monitor pancreatic       of chronic pancreatitis. Any         pseudocyst.
 other local complications                                             hypotensive, replacement with        enzymes and reintroduce            potentially offending drugs
 (pleural effusions and ascites).                                      a colloid should be considered       fluids, then food, only when       should be identified and with-     ■   Manage underlying cause
 CT should be performed                                                initially. Potassium replace-        the lipase level drops to less     drawn.

32   | Australian Doctor | 6 October 2006                                                    www.australiandoctor.com.au
 Chronic pancreatitis
CHRONIC pancreatitis dif-                                                                                                                    a value >7g/day is suggestive     Fat intake is typically
fers from acute pancreatitis by                                                                                                              of fat malabsorption. Fat         restricted to <30g/day, so the
the demonstration of a reduc-                                                                                                                staining of a faecal specimen     intake of fat-soluble vitamins
tion in exocrine and or                                                                                                                      is often used as a screening      may be inadequate.
endocrine function of the pan-                                                                                                               test in hospital.                    Pancreatic enzyme replace-
creas. It is more common in                                                                                                                ■ Fasting blood sugar levels or     ment can be given in tablet
men and usually occurs after                                                                                                                 a glucose tolerance test may      formulation with meals.
one or several episodes of                                                                                                                   be abnormal when there is         Timing of ingestion is vital:
acute pancreatitis, although                                                                                                                 endocrine involvement.            capsules are best taken with
sometimes a patient presents                                                                                                                                                   meals rather than before or
with no history of any previ-                                                                                                              Imaging studies                     after.
ous attacks.                                                                                                                               In 30% of patients calcifica-          Persistence or recurrence of
                                                                                                                                           tion of the pancreas can be         steatorrhoea is a sign of one
Clinical presentation                                                                                                                      seen on a plain abdominal           or more of the following:
The two main manifestations                                                                                                                X-ray. Calcium deposition is        ■ Inadequate dose replace-

of chronic pancreatitis are                                                                                                                more common when alcohol              ment.
pain and pancreatic exocrine                                                                                                               is the underlying cause.            ■ Poor patient compliance (the

and endocrine insufficiency.                                                                                                                  Ultrasound is useful for           tablets may be unpalatable).
   Pain is typically epigastric,                                                                                                           detecting dilated biliary ducts     ■ Incorrect timing of ingestion.

often radiates to the back, is     More than 90% of chronic pancreatitis is caused by excessive alcohol consumption.                       and collections around the             Medium-chain fatty acids
commonly accompanied by                                                                                                                    pancreas.                           are sometimes of benefit in
vomiting and may be exacer-                                                                             rarely cause chronic disease.         ERCP has been considered         patients who are losing weight
bated by food or alcohol.                                                                                                                  the gold standard test for          despite enzyme replacement
Painful episodes gradually                                                                              Complications                      diagnosis and, when positive,       and a low-fat diet because,
improve as inflammation of                                                                              Symptomatic obstruction of         demonstrates characteristic         unlike long-chain fatty acids,
the pancreas is replaced by                                                                             the bile duct or duodenum          beading of the main pancre-         they do not require bile salts
fibrosis, but this process can                                                                          occurs in 5-10% of patients.       atic duct or clubbing of the        for digestion.
take years.                                                                                             Symptoms include abdominal         side branches. The distribu-           If symptoms persist, the
   Although pain is the most                                                                            pain, abnormal LFTs and            tion and extent of beading          possibility of another cause for
common presentation, not all                                                                            postprandial pain.                 correlates with the degree of       malabsorption (such as coeliac
patients with chronic pancre-                                                                             Pseudocysts (single or mul-      pancreatic dysfunction.             disease) should be considered.
atitis present with pain. About                                                                         tiple) develop in 10% of              In the future, magnetic res-
20% present with exocrine or                                                                            patients secondary to pancre-      onance cholangiopancreatog-         Endocrine replacement
endocrine pancreatic insuffi-                                                                           atic duct obstruction. Most        raphy (MRCP) is likely to           therapy
ciency. One study found that                                                                            pseudocysts are asymptomatic       replace ERCP.                       Oral hypoglycaemics are
45% of alcoholics had evi-                                                                              but, depending on their size                                           seldom useful and insulin
dence of chronic pancreatitis                                                                           and location, they can cause       Functional assessment               replacement is normally
in the absence of any symp-                                                                             problems such as abdominal         A variety of functional assays      required. Treatment follows
       3
toms.                                                                                                   pain, duodenal or biliary          is available for diagnosing         the same principles as that for
   The hallmark of exocrine                                                                             obstruction and spontaneous        pancreatic insufficiency but        patients with diabetes unre-
insufficiency is steatorrhoea                                                                           abscess formation.                 these are not necessary in          lated to chronic pancreatitis.
caused by defective secretion                                                                             Small,      asymptomatic         everyday clinical practice.
of lipase and bicarbonate,                                                                              pseudocysts tend either to                                             Surgical and other options
causing fat malabsorption. A                                                                            improve or enlarge. They can       Management                          Surgery may have a beneficial
90% loss of exocrine function                                                                           be safely monitored for up to      Pain control                        effect on pain when there is a
is needed before steatorrhoea                                                                           12 months and to a size of         Pain is the most debilitating       single isolated ductal stricture
develops.                                                                                               12cm. Indications for              component of chronic pancre-        demonstrated by ERCP. More
   If the patient reduces fat                                                                                  drainage include pain       atitis, and providing adequate      often the disease is diffuse
intake either intentionally or                                                                                     or visceral obstruc-    analgesic control is often diffi-   (especially when alcohol
as a result of anorexia and                                                                                         tion.                  cult. Obvious measures              related) and surgical interven-
general ill-health, the pre-                                                                                            Ascites and        include avoiding alcohol and        tion is not possible.
sentation may be masked.                                                                                             pleural effusions     reducing dietary fat.                  When there is ductal
Weight loss is exacerbated                                                                                           may develop and          Opioid analgesia is often        obstruction and dilation due
by protein catabolism                                                                                              can be managed          required and, because of the        to stones or a stricture, ductal
because deficient pancreatic                                                                                     non-surgically using      chronicity and severity of the      decompression may provide
proteases also cause protein                                                                                     diuretics and percuta-    pain, large amounts may be          effective pain relief. Extracor-
malabsorption.                                                                                                   neous drainage. Alter-    needed, leading to problems         poreal shock wave lithotripsy
   Although glucose intoler-                                                                                    natively, stenting of a    with dependence. For this           may also be used if there are
ance is a common feature of                                                                                    disrupted duct can be       reason, referral to a chronic       stones in the pancreatic duct;
patients with chronic pancre-                                                                                attempted endoscopically      pain service is advisable and       complete clearance of stones
atitis, frank diabetes usually                                                                           and has variable success.         the input of psychological          has been described in up to
occurs late and is usually                                                                                                                 services can be very helpful.       50% of cases and improve-
insulin dependent. Unlike                                                                               Investigations                        Coeliac axis nerve blocks        ment in up to 70%.
patients with type 1 diabetes,     Fat intake is                    Genetic                             Blood tests                        using alcohol or steroids and
alpha cells (which secrete                                          Several genetic variants have       Chronic pancreatitis is a          local anaesthetic are com-          Prognosis
glucagon to counter the effects
                                   typically                        been associated with develop-       patchy focal disease, so           monly tried, but long-lasting       If they abstain from alcohol,
of insulin) are affected as well   restricted to                    ment of chronic pancreatitis.       increases in pancreatic enzyme     benefits are infrequent. The        80% of patients with alco-
as beta cells, making patients     <30g/day, so                     The most common is an               levels are usually minimal.        injection can be performed          hol-related chronic pancre-
more predisposed to hypogly-       the intake of                    abnormality in the cystic           Possible changes to pancreatic     under X-ray guidance or             atitis are alive 10 years after
caemic attacks.                                                     fibrosis transmembrane con-         function include:                  endoscopic ultrasound and           diagnosis. Death usually
   Diabetic ketoacidosis and       fat-soluble                      ductance regulator (CFTR)           ■ Relative      deficiency of      repeated as often as needed:        occurs from the complica-
end-organ damage (nep-             vitamins may                     gene, which can cause chronic         enzymes in the pancreas and      hypotension is fairly common        tions of diabetes or attacks
hropathy or retinopathy) are       be inadequate.                   pancreatitis as part of cystic        blood, caused by fibrosis.       after blockade.                     of acute-on-chronic pancre-
uncommon, so if these occur                                         fibrosis or in the absence of       ■ Liver function (demonstra-          Relief is often temporary,       atitis, cirrhosis or suicide.
the possibility of concomi-                                         demonstrable pulmonary                ble as changes in levels of      lasting weeks to months.
tant diabetes mellitus should                                       involvement. Several other            serum albumin and clot-          Surgical excision of the            When to refer?
be explored. The main risk                                          rare genetic variants may also        ting factors) may be             coeliac plexus is an option         When the diagnosis of chronic
factor for development of                                           cause chronic pancreatitis.           deranged if there is under-      for patients requiring re-          pancreatitis has been made,
diabetes is the presence and                                                                              lying cirrhosis of the liver     peated blocks.                      referral may be necessary if
extent of calcification of the                                      Ductal obstruction                    from alcohol abuse.                 If pain increases, repeat        there is poor pain control (a
pancreas, which is most                                             Obstruction of the pancreas         ■ Decreased vitamin B12 and        ultrasound scans should be          chronic pain service can be
extensive in alcohol-related                                        from any cause, such as               serum calcium levels because     considered, given the possi-        very helpful for managing
pancreatitis.                                                       benign or malignant biliary           of malabsorption. To             bility of strictures and resul-     ongoing pain and lifestyle
                                                                    strictures or stones, can result      demonstrate fat malabsorp-       tant obstruction.                   modification) or if abdominal
Causes                                                              in chronic pancreatitis.              tion and/or steatorrhoea the                                         pain worsens rapidly (the pos-
Alcohol                                                                                                   most accurate test involves      Exocrine replacement therapy        sibility of a ductal obstruction
More than 90% of chronic                                            Gallstones                            three-day faecal fat collec-     A low-fat diet is part of           or other pathology needs con-
pancreatitis is caused by exces-                                    Although a common cause of            tion on a diet with con-         management and is often             sideration, and urgent review
sive alcohol consumption.                                           acute pancreatitis, gallstones        trolled fat intake (100g/day):   best guided by a dietitian.         is warranted).

                                                                                         www.australiandoctor.com.au                                                     6 October 2006 | Australian Doctor |   33
 How to treat – disorders of the pancreas


     Pancreatic cancer
 PANCREATIC cancer occurs most                                                                                               creatic cancer is inferior to that of     accretion of biological material) pro-
 often in the 60-80-year age group,                                                                                          CT. The sensitivity and specificity of    vides excellent palliation in most
 and men are more commonly                                                                                                   CT in diagnosing pancreatic cancer        patients.
 affected than women. In Australia                                                                                           exceeds 80% and 90%, respectively.           Fewer than 20% of patients have
 the incidence is 8.8 per 100,000 of                                                                                         In addition, CT may give additional       potentially resectable disease. Some
 population. The outlook is poor,                                                                                            information regarding liver metas-        of this group will be unfit for
 with a five-year survival rate of only                                                                                      tases and lymph node involvement.         surgery and some will be found to
 3%. The incidence of pancreatic                                                                                                The detection rate of ERCP is sim-     have disease spread at the time of
 cancer is increasing in Western soci-                                                                                       ilar to that of CT but the former is      staging laparoscopy or surgery.
 ety for unexplained reasons.                                                                                                preferable when jaundice is a pre-           Pancreatoduodenectomy carries a
                                                                                                                             senting feature because it allows         mortality rate of about 5% in the
 Risk factors                                                                                                                tissue sampling and stenting of           hands of an experienced surgeon.
 Risk factors include:                                                                                                       obstructed bile or pancreatic ducts.      The five-year survival rate after this
 ■ Smoking — heavy smokers have a                                                                                               Endoscopic ultrasound is an            procedure is <20%, compared with
   2-3-fold increased risk of pancre-                                                                                        emerging technique with high diag-        an overall five-year survival of 3%.
   atic cancer compared with non-                                                                                            nostic accuracy (but is very operator        If duodenal obstruction develops,
   smokers.                                                                                                                  dependent) and allows fine-needle         bypass surgery (eg, gastroenteros-
 ■ Chronic pancreatitis — the 25-year                                                                                        sampling. It can also give informa-       tomy) may be necessary.
   cumulative risk of pancreatic cancer                                              head is affected, and many patients     tion about resectability.
   in a person with chronic pancreati-                                                also have steatorrhoea.                   Although the tumour marker             Chemotherapy
   tis is about 4%.                                                                      Pain is a feature common to all     CA19-9 is often used as a diagnostic      The median survival time for patients
 ■ Several genetic syndromes are                                                      sites although it often predomi-       tool its role has not been validated.     whose cancer is surgically unre-
   linked with an increased risk of                                                  nates if the cancer is in the body or   However, it has use both as a prog-       sectable is six months. Systemic
   pancreatic cancer: hereditary non-                                              the tail — these tumours are often        nostic marker and as a guide to           chemotherapy provides little survival
   polyposis colon cancer, familial                                               quite large before they are detected.      treatment response.                       advantage but the combination of 5-
   adenomatous polyposis and famil-                                                  New-onset diabetes is seen in 15-                                                 flurouracil (5-FU) and gemcitabine
   ial breast cancer (BRCA2 gene).           Heavy smokers have                   20% of cases, so a pancreatic              Management                                has been shown to provide sympto-
 ■ A positive family history — up to                                              tumour should be considered when           Most patients have incurable dis-         matic benefit. Other chemothera-
   10% of patients with pancreatic           a 2-3-fold increased                 risk factors for development of dia-       ease at the time of diagnosis, and a      peutic combinations can also be used
   cancer have a positive family his-        risk of pancreatic                   betes (excess weight, positive family      multidisciplinary team involving sur-     as second-line treatment.
   tory.                                                                          history) are absent.                       geons, therapeutic endoscopists,
    Neither alcohol nor gallstones
                                             cancer compared                         Other symptoms such as weight           radiologists, oncologists, and pain       Palliative care
 increase the risk of pancreatic cancer,     with non-smokers.                    loss may provide a clue to diagnosis.      and/or palliative care specialists gen-   Perhaps more than in any other GI
 except when associated with chronic                                              However, a delay in diagnosis is           erally provides best management.          malignancy, palliative care plays a
 pancreatitis.                                                                    common, given the non-specific                Patients with biliary duct obstruc-    vital role in patients with pancreatic
                                                                                  nature of many of the symptoms and         tion and symptoms such as jaundice        cancer. Pain is a major problem, and
 Clinical features                                                                the limitations of imaging modalities.     or pruritus benefit from drainage         administering long-acting opioid-
 Cancer can develop in the head                                                                                              and stenting, either endoscopically       based pain relief is important. Vom-
 (70%), body (20%) and tail (10%)                                                 Investigations                             or percutaneously. Endoscopic             iting can become a problem, espe-
 of the pancreas, and the site can                                                While ultrasound should be the first       stenting, with regular scheduled          cially late in the disease if cerebral
 influence likely clinical features. Jaun-                                        imaging modality for a patient with        changes (in anticipation of stents        metastasis or intestinal obstruction
 dice is common (80%) when the                                                    jaundice, its use in diagnosing pan-       blocked by external compression or        develops.



     Authors’ case studies
 ERCP yields the diagnosis                                                                              admission revealed multiple        included perindopril 4mg           ■   Coagulation profile —
 in a patient with acute                                                                                stones in the gallbladder and      daily, aspirin 150mg daily,            normal.
 pancreatitis with several                                                                              a dilated common bile duct         metoprolol 25mg bd and
 possible causes                                                                                        (1cm wide). An ERCP was            citalopram 20mg daily. He          Comment
 AH, 47, presents to the local                                                                          arranged and a large stone         had smoked a packet of cig-        This man had unexplained
 emergency department with                                                                              was seen in the common bile        arettes a day for 40 years         abdominal pain and signifi-
 12 hours of progressively                                                                              duct.                              and drank three standard           cant weight loss. His LFTs
 worsening epigastric pain                                                                                 A generous sphincterotomy       glasses of wine a day. There       suggested a cholestatic pic-
 and vomiting. She scores her                                                                           was performed. A balloon           was no significant family his-     ture and he had mild nor-
 pain severity as 8/10.                                                                                 was introduced into the            tory.                              mochromic anaemia.
   She has a past history of                                                                            common bile duct, inflated            Examination showed:                Given the site of pain and
 essential hypertension, which                                                                          and gently withdrawn, pulling      ■ BMI 18.                          abnormal LFTs, an abdomi-
 is well controlled on                                                                                  the stone and associated           ■ Dual heart sounds.               nal ultrasound scan was the
 amlodipine (Norvasc) and                                                                               debris into the duodenum.          ■ Clear lung fields.               investigation of choice. This
 hydrochlorothiazide (Dithi-                                                                               Over the next 48 hours          ■ No lymphadenopathy.              showed an empty gallbladder
 azide). She also has a long-                                                                           her pain settled and her pan-      ■ Fullness in the epigastrium      with no wall thickening. The
 standing       history      of                                                                         creatic enzyme levels                and mild tenderness on           intra- and extra-hepatic ducts
 migraines, treated with                                                                                returned to normal. Fluids           abdominal examination            were mildly dilated, the
 sumatriptan        (Imigran,                                                                           and food were then reintro-          (rectal examination was          common bile duct was poorly
 Suvalan). Past history                 the epigastrium and right    ■ Amylase 800U/L (NR 30-           duced. A surgical consulta-          normal).                         visualised and the pancreas
 includes appendicectomy at             upper quadrant.                110U/L).                         tion was arranged and the             Laboratory results were:        was obscured by bowel gas.
 age 20.                              ■ Bowel sounds present, and    ■ Lipase 2000U/L (NR 30-           patient underwent a laparo-        ■ Haemoglobin 102g/L.                 Because of the high degree
   AH is married with two               rectal examination normal.     300U/L).                         scopic cholecystectomy             ■ White cell count 9.1 ×           of suspicion of an obstruc-
                                                                                                                                                9
 children. She has smoked a           ■ No peripheral oedema.           Acute pancreatitis was          before discharge.                    10 /L.                           tive lesion, a CT scan of the
                                                                                                                                                                   9
 packet of cigarettes a day for          Laboratory results were:    diagnosed, based on the clin-                                         ■ Neutrophils 8.7 × 10 /L.         abdomen with oral and IV
                                                                                                                                                                9
 20 years and drinks 2-3              ■ Haemoglobin 140g/L.          ical presentation and the pan-     Epigastric pain and                ■ Platelets 235 × 10 /L.           contrast was arranged and
 standard glasses of wine             ■ Haematocrit 44%.             creatic enzyme findings. The       weight loss in a patient           ■ Mean corpuscular volume          showed dilation of the intra-
 daily and sometimes more at          ■ White cell count 11.5 ×      cause could be gallstones          with normal pancreatic               93fL.                            and extra-hepatic biliary tree
                                           9
 weekends.                              10 /L.                       (given the family history,         enzyme levels                      ■ Sodium 146mmol/L.                and a “bulky pancreas”.
   Her mother had a history           ■ Platelets 180 × 109/L.       LFTs showing an alanine            RB, 68 and a retired builder,      ■ Potassium 3.9mmol/L.                However, RB’s pancreatic
 of gallstones treated by             ■ Sodium 140mmol/L.            aminotransferase more than         presented with epigastric          ■ Urea 11mmol/L.                   enzyme levels were normal,
 cholecystectomy. Her father          ■ Potassium 3.1mmol/L.         three times normal and her         pain radiating to his back         ■ Creatinine 119µmol/L.            essentially excluding acute
 died of colorectal cancer at         ■ Urea 8.9mmol/L.              body habitus), alcohol (she        that tended to be worse after      ■ Bilirubin 42µmol/L.              pancreatitis as the cause for
 71.                                  ■ Creatinine 120µmol/L.        has a significant alcohol          eating and relieved by sitting     ■ Alanine aminotransferase         the bulky pancreas, and an
   Examination showed:                ■ Bilirubin 12µmol/L.          intake) or medications (she        forward. He had lost 12kg            80U/L                            obstructing lesion of the
 ■ BMI 31.                            ■ Alanine aminotransferase     takes a thiazide diuretic          in three months.                   ■ Alkaline     phosphatase         pancreas was more likely.
 ■ Temperature 37.2˚C.                  200U/L.                      known to cause pancreatitis).        RB had a past history of           190U/L.                             An ERCP revealed steno-
 ■ Pulse 102bpm.                      ■ Alkaline     phosphatase        AH was placed on nil by         ischaemic heart disease            ■ Gamma-glutamyltranspep-          sis of both the pancreatic
 ■ BP 105/65mmHg.                       300U/L.                      mouth, and patient-con-            treated by CABG in 2001.             tidase 260U/L.                   and common bile ducts: the
 ■ Normal heart sounds.               ■ Gamma-glutamyltranspep-      trolled analgesia was pre-         He also had well-controlled        ■ Albumin 30g/L.                   ‘double duct’ sign, which is
 ■ Clear lung fields.                   tidase 200U/L.               scribed. An abdominal ultra-       hypertension and depression.       ■ Amylase and lipase —             highly suggestive of pancre-
 ■ Abdominal tenderness in            ■ Albumin 33g/L.               sound scan on the day of           Current         medications          normal.                          atic cancer.

34   | Australian Doctor | 6 October 2006                                               www.australiandoctor.com.au
 How to treat – disorders of the pancreas


     GP’s contribution
                                                                Case study                                                                                                                                                                                         creatitis are notoriously dif-
                                                                JACK, 25, had an episode                                                                                                                                                                           ficult to manage because of
                                                                of acute pancreatitis at age                                                                                                                                                                       opioid dependence and a
                                                                19 after a prolonged period                                                                                                                                                                        severe shortage of pain clin-
                                                                of heavy drinking. He                                                                                                                                                                              ics. Is it likely that a patient             References
                                                                required 48 hours of hospi-                                                                                                                                                                        with this disorder can be                    1. Malki SA, et al. Inflam-
                                                                tal admission at the time                                                                                                                                                                          weaned off opioids over the                  matory bowel disease, acute
                                                                and has remained well ever                                                                                                                                                                         longer term?                                 pancreatitis and cirrhosis: a
     DR MATILDA METLEDGE                                        since. He was told to                                                                                                                                                                                 Over time the inflamma-                   prospective comparison.
                Sydney, NSW                                     abstain from alcohol and                                                                                                                                                                           tion may be gradually                        Gastroenterology 2000;
                                                                has, up to this point, largely                                                                                                                                                                     replaced by fibrosis, which                  118 [Suppl 2, part 2 of 2].
                                                                followed that advice, with a                                                                                                                                                                       may result in reduced anal-                  2. Marik PE, Zagola GP.
                                                                few minor exceptions.                                                                                                                                                                              gesic requirements. How-                     Meta-analysis of parenteral
                                                                                                                                                                                                                                                                   ever, it is not often possible               nutrition versus enteral
                                                                Questions for the author                                                                                                                                                                           to wean patients off opioids,                nutrition in patients with
                                                                What is the likelihood that,                                                                                                                                                                       and realistic treatment goals                acute pancreatitis. BMJ
                                                                if Jack returns to drinking                                                                                                                                                                        should be set.                               2004; 328:1407.
                                                                in moderation, a second                                                                                                                                                                                                                         3. Clark, E. Pancreatitis
                                                                attack would occur?                                                                                                                                                                                There seems to have been                     in acute and chronic
                                                                   Jack has demonstrated a                                       a first attack and resump-                                       the common bile duct. Is                                         very little progress in the                  alcoholism. American
                                                                susceptibility to developing                                     tion of alcohol consump-                                         this no longer correct?                                          treatment of pancreatic                      Journal of Digestive
                                                                alcohol-induced pancreatitis                                     tion?                                                               There is some experimen-                                      cancer over the years — it                   Diseases 1942; 9:428.
                                                                and is at high risk of further                                      The potential severity                                        tal evidence that morphine                                       still has a median survival
                                                                attacks even if he drinks in                                     from a further attack of                                         is associated with the devel-                                    measured only in months.                     Online resources:
                                                                moderation. Reducing his                                         pancreatitis should be                                           opment of spasm of the                                           Why is this and are there                    information for patients
                                                                intake of alcohol will clearly                                   relayed to the patient. It is                                    sphincter of Oddi, but there                                     any new treatments on                        ■ National Digestive Dis-
                                                                have a beneficial effect on                                      not possible to say what                                         is no clinical evidence that                                     the horizon that look                          eases Information Clear-
                                                                his risk for future attacks of                                   level of alcohol consump-                                        it worsens pancreatitis.                                         promising?                                     inghouse (NDDIC):
                                                                pancreatitis but will not                                        tion would be low enough                                            Pethidine is no longer                                           Most cases of pancreatic                    http://digestive.niddk.nih.
                                                                completely alleviate it.                                         to avoid further attacks.                                        used as a first-line opioid                                      cancer aren’t identified until                 gov/ddiseases/pubs/
                                                                Despite reducing or abstain-                                                                                                      agent in emergency depart-                                       the disease is in an advanced                  pancreatitis/index.htm
                                                                ing from alcohol he will still                                   General questions for the                                        ments for this indication. It                                    stage, by which point surgi-                 ■ Pancreatitis explained.

                                                                have a risk of developing                                        author                                                           has a higher potential for                                       cal resection is not possible.                 Better Health Channel,
                                                                chronic pancreatitis.                                            Traditionally it was taught                                      abuse than morphine and                                          There have been improve-                       Victoria: www.better-
                                                                                                                                 that pethidine was the drug                                      the latter is now the pre-                                       ments in palliative chemo-                     health.vic.gov.au/bhcv2/
                                                                If it is safe for him to do                                      of choice in acute pancreati-                                    ferred analgesic agent.                                          therapy but the survival rate                  bhcarticles.nsf/pages/
                                                                so, what would generally be                                      tis secondary to gallstones,                                                                                                      in this condition remains                      Pancreatitis_explained
                                                                the advisable time between                                       as it did not cause spasm of                                     Patients with chronic pan-                                       very poor.


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     1. Which THREE statements about acute                                                        3. If Paloma has drug-induced acute                                                             6. Stephen, 43, presents with pain,                                                         ❏ c) Beading of the main pancreatic duct on
     pancreatitis are correct?                                                                    pancreatitis which TWO drugs are most                                                           steatorrhoea and weight loss. Which TWO                                                       ERCP
     ❏ a) Patients with acute pancreatitis always                                                 likely to be implicated?                                                                        symptoms or findings would support a                                                        ❏ d) Dilated biliary ducts on ultrasound
        have significantly elevated amylase and/or                                                ❏ a) Antihistamines                                                                             diagnosis of chronic pancreatitis?
        lipase levels (>10 times the upper limit of                                               ❏ b) Paracetamol                                                                                ❏ a) Epigastric pain that radiates to the back                                              9. Stephen’s tests confirm chronic
        normal)                                                                                   ❏ c) Tetracyclines                                                                              ❏ b) Diabetic nephropathy                                                                   pancreatitis. How would you be most likely
     ❏ b) Most cases of acute pancreatitis in                                                     ❏ d) Thiazide diuretics                                                                         ❏ c) Previous episodes of acute pancreatitis                                                to manage him (choose TWO)?
        Australia are caused by gallstones or alcohol                                                                                                                                             ❏ d) Bilateral supraclavicular lymph-                                                       ❏ a) Begin regular pethidine injections for
        abuse                                                                                     4. Paloma’s tests are consistent with acute                                                        adenopathy                                                                                  pain
     ❏ c) Infection with CMV, hepatitis B and                                                     pancreatitis secondary to gallstones. Her                                                                                                                                                   ❏ b) Advise strict alcohol avoidance
        varicella-zoster can cause acute pancreatitis                                             pain worsens and she is admitted to                                                             7. Which TWO test results would be                                                          ❏ c) Restrict his fat intake to no more than
     ❏ d) Trauma-induced acute pancreatitis occurs                                                hospital. Which TWO test results would                                                          consistent with a diagnosis of chronic                                                         60g/day
        most often after ERCP or surgery                                                          suggest mild uncomplicated pancreatitis?                                                        pancreatitis?                                                                               ❏ d) Start pancreatic enzyme replacement
                                                                                                  ❏ a) A haematocrit <40%                                                                         ❏ a) Abnormal glucose tolerance test                                                           with meals
     2. You are called to see Paloma, 45, on a                                                    ❏ b) Mildly elevated amylase and lipase levels                                                  ❏ b) 4g/day faecal fat on a controlled high-fat
                                                                                                  ❏ c) WCC of 22 × 10 /L
                                                                                                                       9
     home visit because of upper abdominal pain                                                                                                                                                      (100g/day) diet                                                                          10. Which TWO statements about
     and vomiting. She describes similar                                                          ❏ d) A CRP level of <210mg/L on days 2-4                                                        ❏ c) Minimally raised levels of serum lipase                                                pancreatic cancer are correct?
     episodes in the past. History and                                                                                                                                                               and amylase                                                                              ❏ a) The sensitivity and specificity for
     examination suggest gallstones or acute                                                      5. Paloma’s mild pancreatitis settles with                                                      ❏ d) Elevated TSH level                                                                        diagnosis of pancreatic cancer using CT
     pancreatitis. Paloma’s vital signs are normal                                                treatment. Which THREE investigations or                                                                                                                                                       scan are >80% and >90%, respectively
     and she does not want to be admitted to                                                      treatments would be part of optimal                                                             8. Stephen has a history of alcohol abuse                                                   ❏ b) Pancreatic cancer has a five-year
     hospital. Which THREE tests are you most                                                     management, depending on access to                                                              and his blood tests are consistent with                                                        survival rate of 13%
     likely to order?                                                                             equipment and expertise?                                                                        chronic pancreatitis. Which THREE                                                           ❏ c) Alcohol abuse and gallstones are
     ❏ a) Serum amylase and lipase levels                                                         ❏ a) An ERCP                                                                                    imaging findings would support your                                                            independent risk factors for pancreatic
     ❏ b) CT of the abdomen                                                                       ❏ b) Endoscopic ultrasound                                                                      diagnosis?                                                                                     cancer
     ❏ c) Ultrasound scan of the gall bladder                                                     ❏ c) Cholecystectomy at least six months                                                        ❏ a) Calcification of the pancreas on plain                                                 ❏ d) Fewer than 20% of patients with
     ❏ d) Serum bilirubin and serum                                                                  after the last episode of acute pancreatitis                                                    abdominal X-ray                                                                             pancreatic cancer have potentially
        aminotransferase levels                                                                   ❏ d) Sphincterotomy                                                                             ❏ b) Mass in the head of the pancreas on CT                                                    resectable disease

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     NEXT WEEK How do you assess the reliability or applicability of clinical trial results to your patients? The next How To Treat explains how to distinguish a well-designed well-conducted trial from one that
     isn’t, and how to gauge the relevance of trial results to your practice. The authors are Dr Jenny Doust, senior research fellow in clinical epidemiology, school of medicine and school of population health,
     University of Queensland, and Dr Patricia McGettigan, senior lecturer, school of medicine and public health, University of Newcastle, NSW.


36     | Australian Doctor | 6 October 2006                                                                                                                           www.australiandoctor.com.au

								
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