HPB

Question 1

Panc Secretions

Answer 1

Proenzymes stimulated by CCK to secrete into duct

Enterokinase brush border activates trypsinogen to trypsin

Activates
- chymotrypsin
- carboxypeptidase
- elastase

Amylase - starch
Lipase - fats
Nucleases - nucleic acid digestions

HCO3 - to neutralise gastric acid
- stimulated by secretin

Question 2

Panc Trauma

Answer 2

AAST
- 1 - minor no duct injury
- 2 - major no duct injury
- 3 - distal duct injury
- 4 - proximal duct injury
- 5 - massive disruption

Question 3

MCN

Serous cystadenoma

Solid pseudopapillary neoplasms

Answer 3

MCN
- Variable malignant potential
- Mostly female, age 50-60
- Solitary thick walled cyst can have rim calcifications
- Resect for risk - under 15% if small

Serous cystadenoma
- Rarely malignant
- Mostly female, age 60-70
- 30% of cystic neoplasms
- multiple small septated cysts, well circumscribed, starburst calcifications
- observe low risk

Solid pseudopapillary neoplasms
- daughter, usually women under 35
- rare
- more body and tail of pancreas
- well defined, solid and cystic areas, calcifications
- malignant 5%, recommended for resection - en bloc with any involved structures

Question 4

IPMN

Answer 4

Pancreatic cystic lesion with variable malignant potential
- mucin producing columnar cells
- papillary proliferation and cyst formation

Main duct (and mixed) - 70% malig
Branch duct - 20% malig

Poorly demarcated lobulated polycystic mass as dilatation of ducts - either main or branch

High amylase - duct communication
High CEA - mucinous lesion

Malignant change
- adenoma to carcinoma sequence, with KRAS and MAPK pathway changes

Question 5

Portal venous gas

Answer 5

PV gas vs pneumobilia
- PV gas more peripheral - centrifugal
- pneumobilia more central

Causes
- GI infarction
- GI Mucosal cause - peptic ulcer UC divertic
- Gas forming organisms - clostridium
- Lung disorders - copd asthma
- Iatrogenic - gatroscopy, colonoscopy, copd
- Immune - chemo, steroids, AIDs

Question 6

IPMN Fukuoka

Answer 6

Branch Duct IPMN

High risk features - 3 - operation
- Obstructive jaundice due to IPMN
- Enhancing solid component of the cyst
- Associated main pancreatic duct dilatation of >10mm

EUS indicated for 5 worrisome features:
- Associated pancreatitis
- Over 3cm
- Walls - thickened or enhancing, non enhancing mural nodules
- Main panc duct size 5-9mm
- Abrupt change in caliber of panc duct with distal panc atrophy.

EUS - high risk - mural nodules, positive cytology, main duct thickened walls

Surveillance
* <1cm - CT/MR - 3 yearly
* 1-2cm - CT/MRI - 2 yearly
* 2-3cm - EUS /MRI - 6m
* >3cm - EUS / MRI - 3m

Question 7

PNET

Answer 7

Rare neuroendocrine tumours
- 60% non functional
- 40% functional - insulin, gastrin, glucagon, VIP, somtostatin.

Most sporadic
- MEN1 - 80%
- VHL - 20%
- NF1 - 10%

Functional defined by clinical syndrome