Podcast
Questions and Answers
Which statement about chronic pancreatitis (CP) is accurate?
Which statement about chronic pancreatitis (CP) is accurate?
What is the incidence rate range for chronic pancreatitis in the population?
What is the incidence rate range for chronic pancreatitis in the population?
Which complication is associated with chronic pancreatitis?
Which complication is associated with chronic pancreatitis?
What is the role of EUS in the diagnosis of chronic pancreatitis?
What is the role of EUS in the diagnosis of chronic pancreatitis?
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Identify the mechanism through which pancreatic enzyme supplements function in chronic pancreatitis management.
Identify the mechanism through which pancreatic enzyme supplements function in chronic pancreatitis management.
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Which of the following best describes the nature of pain associated with chronic pancreatitis?
Which of the following best describes the nature of pain associated with chronic pancreatitis?
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What is true about pancreatic cancer's incidence and characteristics?
What is true about pancreatic cancer's incidence and characteristics?
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Which tumor type accounts for the majority of pancreatic cancer cases?
Which tumor type accounts for the majority of pancreatic cancer cases?
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What is a key risk factor for cholangiocarcinoma?
What is a key risk factor for cholangiocarcinoma?
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What is a significant aspect of cholangiocarcinoma diagnosis?
What is a significant aspect of cholangiocarcinoma diagnosis?
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What is the most common presenting symptom of ampullary carcinoma?
What is the most common presenting symptom of ampullary carcinoma?
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Which imaging technique is the most useful for identifying ampullary carcinoma and performing a biopsy?
Which imaging technique is the most useful for identifying ampullary carcinoma and performing a biopsy?
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In the treatment of intrahepatic CCA, which surgical procedure is typically performed?
In the treatment of intrahepatic CCA, which surgical procedure is typically performed?
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What factor primarily determines the prognosis of resected ampullary cancer in the absence of metastases?
What factor primarily determines the prognosis of resected ampullary cancer in the absence of metastases?
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Which biochemical marker is widely used for detecting cholangiocarcinoma (CCA) in patients with primary sclerosing cholangitis (PSC)?
Which biochemical marker is widely used for detecting cholangiocarcinoma (CCA) in patients with primary sclerosing cholangitis (PSC)?
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What complication might large ampullary carcinomas cause due to their location?
What complication might large ampullary carcinomas cause due to their location?
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What is the role of alkaline phosphatase in diagnosing ampullary carcinoma?
What is the role of alkaline phosphatase in diagnosing ampullary carcinoma?
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Which age range represents the average age at diagnosis for ampullary carcinoma?
Which age range represents the average age at diagnosis for ampullary carcinoma?
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What is the primary goal of palliative treatment for patients with ampullary carcinoma?
What is the primary goal of palliative treatment for patients with ampullary carcinoma?
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Why is EUS typically not required for the diagnosis of ampullary carcinoma?
Why is EUS typically not required for the diagnosis of ampullary carcinoma?
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Study Notes
Chronic Pancreatitis
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Definition: A condition where the pancreas is chronically inflamed, leading to irreversible exocrine and endocrine dysfunction. More recently, it's defined as a pathologic fibroinflammatory syndrome in individuals with genetic, environmental or other risk factors leading to persistent pathologic responses to injury or stress.
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Pancreas Anatomy: A soft, elongated, flattened gland, 12-20 cm long, situated in the epigastric and left hypochondriac regions of the abdominal cavity.
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Pancreatic Functions:
- Endocrine: Islet of Langerhans with alpha cells (glucagon, 20%), beta cells (insulin, 75%), and delta cells (somatostatin).
- Exocrine: Pancreatic juice with enzymes (amylase, lipase, trypsin, chymotrypsin, carboxypeptidase) for digestion.
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Digestion:
- Digestion of protein: Trypsinogen and chymotrypsinogen are inactive enzyme precursors activated by enterokinase to trypsin and chymotrypsin which convert polypeptides to tripeptides and dipeptides.
- Digestion of carbohydrates: Amylase converts polysaccharides to disaccharides.
- Digestion of fats: Lipase converts fats to fatty acids.
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Epidemiology:
- Incidence: Ranges from 3-9 cases per 100,000 population per year in retrospective studies. A prospective study on alcoholic CP showed an incidence of 8.2 cases per 100,000 and an overall prevalence of 35.5 cases per 100,000.
- Male to Female Ratio: 3.5:1 (based on a Japanese survey).
- Survival: 10-year survival is roughly 70% and 20-year survival about 45%.
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Socio-economic Effects:
- Career: One-third of chronic pancreatitis patients cannot pursue their professional careers.
- Employment: The rate of people losing employment is high (40%) and is related to prolonged illness or continued alcohol consumption.
- Disability: Disability rates are significant (40%).
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Etiology (TIGAR-O): Toxic and metabolic (alcohol, smoking, hypercalcemia, renal failure), idiopathic, genetic (CFTR, SPINK-1), autoimmune, recurrent and severe acute pancreatitis, obstructive (e.g. gallstones). Associated issues include oxidative stress, and toxic metabolic and necrosis-fibrosis, SAPE (severe acute pancreatitis with early complications) hypothesis, and large duct issues.
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Alcohol as a risk factor: A period of >80g of alcohol per day for 6–12 years increases the risk of developing chronic pancreatitis. The type of alcohol consumed does not influence the risk. There is a delay of ~18 years between starting heavy alcohol consumption and the development of pancreatitis.
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Clinical Manifestations:
- Pain: Recurrent, severe, uncontrollable upper abdominal pain, radiating to the back, often worsening after meals.
- Exocrine insufficiency: Diarrhea/steatorrhea (loss of exocrine function)
- Endocrine insufficiency: Diabetes mellitus (loss of endocrine function).
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Additional details on abdominal pain: no specific pattern, epigastric pain, radiating to the back, associated with nausea/vomiting, pain worsens postprandially, nocturnal, relieved by sitting forward or knee-chest position
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Exocrine insufficiency details: steatorrhea does not occur until pancreatic lipase secretion is reduced to less than 10%, a feature of far-advanced CP, maldigestion of fats, proteins, and carbohydrates, and bulky, foul-smelling stools are common.
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Endocrine insufficiency details: half of patients with CP who develop DM will require insulin, DM complications are common in patients with CP who have diabetes similar duration to type 1 DM patients, development of DM is most likely related to disease duration.
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Diagnosis:
- Functional tests (measure specific pancreatic functions)
- Imaging (e.g., CT, MRI, ERCP)
- Laboratory studies (e.g., serum amylase, lipase, CBC, electrolytes, LFTs)
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Imaging role of ERCP - was historically gold standard for diagnosis of CP. Indications include patients for whom CT or MRCP is contraindicated/failed to corroborate the diagnosis. Also a therapeutic modality addressing strictures, stones, pseudocysts and biliary stenosis.
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Imaging EUS- technique used to diagnose early stage CP. Rosemon criteria define diagnostic criteria.
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Diagnostic algorithms: there are algorithms to follow for diagnosing CP.
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Complications • Pseudocysts: Fluid and debris may collect, possibly rupturing and causing infection/bleeding. Jaundice may be common if the pseudocyst is in specific location in the pancreas. • Pancreatic abscess: Collection of pus in the pancreas. • Diabetes: Damage to insulin-producing cells. • Pancreatic ascites: Leakage of pancreatic juice from pseudocyst. • Pancreatic fistula: Occurs due to operative or percutaneous drainage of pseudocysts. • Malnutrition: Due to impaired absorption. • Splenic vein thrombosis: Result of peripancreatic inflammation.
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Treatment:
- Medical (pain management, enzyme supplementation, etc.)
- Endoscopic approaches (e.g., stenting, sphincterotomy)
- Surgical treatments (e.g., resection, drainage)
Pancreatic Cancer
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Introduction: Carcinoma of the exocrine pancreas, over 90% of pancreatic tumors, and a significant oncologic challenge. It is a biologically aggressive cancer from the onset. Only about 20% of cases are operable for cure. Survival is ~10–15% at 12 months after diagnosis.
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Epidemiology: Varying global incidence, highest in Northeast Thailand.
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Risk Factors:
- Cigarette smoking.
- Obesity
- Chronic pancreatitis.
- Hereditary pancreatitis.
- Inherited cancer syndromes (hereditary breast/ovarian, familial atypical multiple mole melanoma, Peutz-Jeghers, Lynch syndrome, ataxia-telangiectasia, Li-Fraumeni).
- Family history of pancreatic cancer (especially multiple family members, first-degree relatives/younger relatives <50 years old).
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Clinical Presentation:
- Commonly a "silent disease" in early stages with no symptoms. When symptomatic:
- Weight loss.
- Anorexia.
- Nausea and vomiting.
- Abdominal pain.
- Obstructive jaundice characterized by “painless jaundice”, (head lesions).
- New onset or worsening pre-existing diabetes.
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Diagnostic Investigations:
- Blood tests.
- ESR (often elevated).
- LFTs (may or may not be abnormal).
- Tumor markers like CA19-9 (sensitivity/specificity varies, not typically diagnostic alone). CEA.
- Imaging tests.
- CT scan (primary modality).
- MRI (useful for inconclusive CT, detecting small liver metastases).
- EUS: often preferred if surgical resection may be an option.
- ERCP, PTC (useful in cases with or for evaluation of biliary obstruction.
- Blood tests.
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Classifications: TNM staging
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Pathology: 95% arise in exocrine cells. Most common is pancreatic ductal adenocarcinoma (PDAC), accounting for ~80% of pancreatic cancers. Other variants exist (adenocarcinoma, undifferentiated with giant cell, acinar cell, pancreatic neuroendocrine tumors, cystic neoplasms, including IPMN and mucinous cystic neoplasms)
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Treatment:
- Surgical resection (resection is only possible for approximately 20% of patients due to factors such as metastases, advanced invasion, advanced cachexia). Surgery often involves:
- Whipple procedure (standard approach).
- Ampullectomy (reasonable approach for poor candidates)
- Nonsurgical treatments (endoscopic, laser ablation, photodynamic therapy) are palliative, not curative.
- Adjuvant chemotherapy: infusional 5-FU, gemcitabine and cisplatin are common options.
- Surgical resection (resection is only possible for approximately 20% of patients due to factors such as metastases, advanced invasion, advanced cachexia). Surgery often involves:
Cholangiocarcinoma
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Introduction: Cancer of the bile ducts arises from the epithelial cells of the biliary tree in intrahepatic, perihilar, or distal sections. A special type involving the hepatic duct bifurcation is called Klatskin.
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Epidemiology: Highly variable based on location. Northeast Thailand has the highest rates of cases.
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Risk factors: Several factors linked to CCA development:
- Chronic pancreatitis.
- PSC (primary sclerosing cholangitis).
- Liver fluke infestations (e.g., Opisthorchis viverrini, Clonorchis sinensis).
- Choledochal cysts.
- Biliary cysts.
- Biliary papillomatosis.
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Clinical Presentation:
- Painless jaundice (most prominent symptom, occurs when the tumor obstructs the bile ducts)
- Pruritus (itching).
- Abdominal pain
- Weight loss
- Fever (less common but may be present).
- Cholangitis (inflammation of the bile ducts).
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Diagnosis:
- Laboratory tests: Elevated TBIL (total bilirubin), DBIL (direct bilirubin), ALK phosphatase are common. Also, AST, ALT, CA19-9, and CEA.
- Imaging:
- CT scan (identifies level of obstruction, tumors)
- MRI/MRCP (further investigation if CT is inconclusive)
- ERCP/PTC (useful for diagnostic/therapeutic procedures to assess or treat biliary obstruction)
- Imaging reports should detail tumor characteristics, tumor-to-vessel contact for each peripancreatic vessel, locoregional involvement and presence of distant metastases
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Treatment: Surgical approach varies based on tumor location:
- Intrahepatic CCA: hepatic segmentectomy or lobectomy
- Distal extrahepatic CCA: pancreatoduodenectomy
- Hilar CCA: biliary duct resection and/or hepatic lobectomy
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Other treatments:
- Palliation (treatments addressing pain, jaundice): ERCP, percutaneous stenting
Ampullary Carcinoma
- Definition: Typically arises in the ampulla of Vater, where the common bile duct and the pancreatic duct join.
- Epidemiology: Typically affects people 60-70 years of age. Sporadic/may be part of a genetic syndrome.
- Clinical Presentation:
- Obstructive jaundice
- Diarrhea (fat malabsorption)
- Mild weight loss and fatigue.
- Occult GI bleeding.
- Possible gastric outlet obstruction (severe nausea/vomiting)
- Diagnosis and Staging:
- Liver biochemical tests (can't definitively establish diagnosis, may reflect the presence of cholestasis).
- Aminotransferases may be elevated. -CA19-9 and CEA
- Imaging:
- Abdominal US (first test for obstructive jaundice).
- CT/MRI (to visualize the tumor).
- ERCP (important for visualization, biopsy if need be).
- EUS (not routinely needed for diagnosis) –
- Prognosis and Treatment:
- Surgical treatment remains the only potentially curative approach. Standard approach often involves pancreaticoduodenectomy (Whipple procedure). Option of ampullectomy may be considered for poor candidates.
- Often palliative therapies address or manage complications. Includes adjuvant chemotherapy (infusional FU, gemcitabine, cisplatin) for resection candidates.
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Description
Explore the condition of chronic pancreatitis, including its definition, anatomical structure, and both endocrine and exocrine functions. This quiz will cover crucial aspects of pancreatic digestion and the impact of chronic inflammation. Test your knowledge on this significant health topic.
