Biliary and Pancreatic Disease

Question 1

Risk factors for cholesterol stones?

Answer 1

Caucasian
Female
Obesity
Age over 40
contraceptive pill
TPN
diabetes

Question 2

The majority of gallstones are symptomatic or asymptomatic?

Answer 2

asymptomatic

Question 3

How do gallstones cause acute cholecystitis? Symptoms?

Answer 3

Block the cystic duct meaning bile cannot escape. Patient will have severe epigastric pain.

Question 4

Biliary colic?

Answer 4

Temporary blockage of cystic duct by the gallstones and will get epigastric pain that usually gets worse after eating fatty foods and may also be associated with nausea and vomiting

Question 5

How do gall stones cause obstructive jaundice?

Answer 5

Stone reaches the common bile duct

Question 6

Complications of gallstones?

Answer 6

Acute or chronic cholecystitis 
Obstructive jaundice
Acute pancreatitis 
Cholangitis and biliary sepsis
Rarely gall stone ileum and carcinoma of the gallbladder

Question 7

Treatment of patient with gallstones?

Answer 7

If asymptomatic nothing
If biliary colic can be treated with painkillers, obese patients advised to lose weight and if there are recurrent episodes of pain people are considered for a cholecystectomy. If patient is unfit for surgery they may be given ursodeoxycholic acid which helps stop the formation of stones.
In acute cholecystitis patients are given IV fluids and antibiotics and cholecystectomy

Question 8

Symptoms of acute pancreatitis?

Answer 8

Patient will have acute onset of severe upper abdominal pain that usually begins in the epigastrium and is accompanied by nausea and vomiting

Question 9

Specific signs that support severe necrotising pancreatitis?

Answer 9

Periumbilical bruising- Cullen’s sign

Flank bruising- Grey turners sign

Question 10

What is usually elevated in acute pancreatitis?

Answer 10

Serum amylase

Question 11

Complications of acute pancreatitis?

Answer 11

systemic inflammatory response syndrome
Multiorgan dysfunction
Pancreatic fluid collections, necrosis or abscess
Pleural effusion, pneumonia and ARDS
Metabolic complications (hypo, hyperglycaemia)
Jaundice
GI bleeding 
Acute kidney injury
Portal venous thrombosis

Question 12

Management of acute pancreatitis?

Answer 12

Initially need to rehydrate the patient
may need to remove gall stones
Pain relief
NG feeding 
Anticoagulation with LMWH to prevent DVT as there is risk of portal vein thrombosis

Question 13

Who gets chronic pancreatitis?

Answer 13

Mainly alcoholics- there is also an autoimmune type though

Question 14

Presentation of chronic pancreatitis?

Answer 14

Pain in the epigastrium often radiating to the back. Anorexia and weight loss. May be diabetes and jaundice as fibroses head obstructs the common bile duct. There may be stearrhoea due to malabsorption. On examination patient may have masses, ascites or jaundice.

Question 15

Most common complication of chronic pancreatitis?

Answer 15

Pancreatic pseudocyst. This is a fluid collection surrounded by granulation tissue and rupture or cyst infection may occur.

Question 16

How can most pancreatic pseudocysts be treated?

Answer 16

Most can be successfully drained endoscopically others need open surgery

Question 17

Management and treatment of chronic pancreatitis?

Answer 17

In alcohol related abstinence should be encouraged. In auto-immune steroids are effective. Short term flare ups of pain treated with NSAIDs and an opiate eg. tramadol. Chronic pain treated with tricyclic antidepressants e.g. amitriptyline and membrane stabilising agents e.g. pregabalin. In those with recurrent, severe or debilitating pain surgical intervention can help. Creon is given as enzyme replacement to help with malabsorption issues.

Question 18

Risk factors for pancreatic cancer?

Answer 18

Smoking, chronic pancreatitis (particularly that caused by genetic mutation), alcohol and diabetes

Question 19

Presentation of pancreatic cancer?

Answer 19

Most commonly presents with weight loss, anorexia and abdominal pain. Many patients have actually been experiencing low grade symptoms for months. The pain often radiates through to the back and can be relieved by leaning forwards. Jaundice occurs if the tumour obstructs the common bile duct and patients may also have an itch with no rash. May also have pale stools and dark urine. Examination may be insignificant.

Question 20

Investigations for pancreatic cancer?

Answer 20

US is done first allowing you to see the bile ducts and the head of the pancreas. Negative result does not exclude cancer though. CT and endoscopic US can be done to confirm as well as blood tests to look for tumour markers.

Question 21

Describe the whipple procedure

Answer 21

Done for pancreatic tumours of the head and neck- remove head of pancreas, duodenum, gall bladder and the common bile duct.

Question 22

Describe total pancreatectomy

Answer 22

remove everything- pancreas, gall bladder, common bile duct, as well as parts of the stomach and small intestine and sometimes parts or all of the spleen.

Question 23

Describe distal pancreatectomy

Answer 23

tail and some of the body removed and some of the spleen