Pancreas

Question 1

what is the mnemonic to remember causes for acute pancreatitis

Answer 1

‘GETSMASHED’

G - Gallstones
E - excess alcohol
T - trauma

S - steroids
M - mumps
A - autoimmune disease
S - scorpion venom
H - hypercalcaemia
E - Endoscopic retrograde cholangiopancreatography (ERCP)
D - drugs (NSAIDs, azathioprine, diuretics)

Question 2

what is the pathophysiology of pancreatitis

Answer 2

pancreatic inflammatory response where enzymes are released from the pancreas which then start autodigesting itself

end-stage pancreatitis results in partial or complete necrosis of the pancreas

Question 3

clinical features of acute pancreatitis

Answer 3

sudden severe epigastric pain that radiates through to the back with associated nausea and vomiting

some less common signs include bruising around the umbilicus and flanks which indicate retroperitoneal haemorrhage

Question 4

what are the specific blood tests for acute pancreatitis

Answer 4

serum amylase

LFTs - often have raised ALT levels

serum lipase

Question 5

management of acute pancreatitis

Answer 5

no curative management - treat underlying cause

IV fluids, NG tube, catheter for supportive measures + opioid analgesia

prophylactic abx in cases of necrosis

Question 6

why is hypocalcaemia a complication of pancreatitis

Answer 6

fat necrosis from released lipases results in the release of free fatty acids which react with serum calcium to form chalky deposits in fatty tissue

lowers levels of free serum calcium in the blood

Question 7

what are the main causes of chronic pancreatitis

Answer 7

chronic alcohol abuse (60%)

idiopathic (30%)

Question 8

clinical features of chronic pancreatitis

Answer 8

chronic pain in the epigastrium and back, often associated with nausea and vomiting

patients can also present with malabsorption, weight loss, diarrhoea and steatorrhoea - this is due to the pancreas losing the ability to produce digestive enzymes

patients can also present with diabetes as the pancreas loses its endocrine function and no longer produces insulin

Question 9

why does chronic pancreatitis often present with malabsorption and significant weight loss

Answer 9

pancreas loses its exocrine function and no longer produces digestive enzymes that enter the GI tract - as a result food isn’t broken down and absorbed

this results in malabsorption and weight loss

Question 10

how do the stools appear in chronic pancreatitis

Answer 10

pale and fatty stools

due to the fact that pancreas doesn’t produce lipase anymore - fat not broken down in GI tract

all passes out in faeces giving it a pale colour

Question 11

how do serum amylase and serum lipase appear in chronic pancreatitis patients

Answer 11

often not raised in established disease compared to acute pancreatitis

Question 12

what investigations would you want to do in a patient with suspected chronic pancreatitis

Answer 12

FBC + CRP

urine dip

serum amylase and lipase (often not raised in established disease)

blood glucose - secondary to endocrine dysfunction

faecal elastase level - often low in cases of chronic pancreatitis

Question 13

management of chronic pancreatitis

Answer 13

only managed definitively by treating the underlying cause - e.g. alcohol cessation or statin therapy for hyperlipidaemia

analgesia becomes mainstay of management

those with exocrine and endocrine suits require enzyme replacement and nutritional support

Question 14

what is the most common histological subtype of pancreatic cancer

Answer 14

ductal carcinoma arising from the exocrine portion of the organ

Question 15

endocrine tumours of the pancreas derive from what cells

Answer 15

islet cells

Question 16

where is the most common location of pancreatic tumours

Answer 16

the head of the pancreas

Question 17

risk factors for pancreatic cancer

Answer 17

smoking

chronic pancreatitis

dietary factors; high red meat intake, low fruit and veg intake

family history

diabetes mellitus

Question 18

clinical features of pancreatic cancer

Answer 18

painless obstructive jaundice - compression of common bile duct

weight loss

abdo pain

Question 19

what tumour marker is important in pancreatic cancer

Answer 19

CA19-9

Question 20

imaging in pancreatic cancer

Answer 20

USS first line

CT imaging is gold standard for diagnosis

CT-chest-abdo-pelvis then further needed for staging

Question 21

management of pancreatic cancer

Answer 21

only curative management is radical resection however at presentation <20% of patients have a resectable tumour

overall 5 year survival rate <5%

Question 22

what are functional pancreatic endocrine tumours and give examples

Answer 22

tumours that actively secrete hormones with their symptoms being directly related to this

G cells tumour - secrete excess gastrin causing severe peptic ulcers

alpha cell tumour - secrete excess glucagon resulting in increased blood glucose and diabetes

beta cell tumour - secrete excess insulin resulting in decreased blood glucose and hypogylcaemia

Question 23

what are the broad classifications of pancreatic cysts

Answer 23

mucinous vs non-mucinous

mucinous being higher risk

Question 24

how do most pancreatic cysts present

Answer 24

incidentally on imaging

Question 25

clinical features of pancreatic cysts

Answer 25

mostly asymptomatic

high risk features include; obstructive jaundice, recurrent pancreatitis, new onset diabetes

Question 26

investigations into pancreatic cysts

Answer 26

CT pancreas or MRCP to gain further info

Question 27

What is the most sensitive blood test for diagnosis of acute pancreatitis?

Answer 27

serum lipase

The serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.