Pancreas

Question 1

Describe the ductal system of the pancreas?

Answer 1

Acini cells are connected by intercalated ducts, which unite to form interlobular ducts, which then drain into the main pancreatic duct

Question 2

What is acute pancreatitis?

Answer 2

Acute reversible inflammatory process of the pancreas which can lead to multi-organ failure

Question 3

What is the pathogenesis of acute pancreatitis?

Answer 3

Inappropriate activation of trypsinogen into trypsin -> leads to autodigestion of the pancreas with consequent inflammation

Other contributing enzymes:
- Lipase leads to fat necrosis
- Amylase digests the starch
- Elastase breaks down elastin -> breaks down vessels -> haemorrhagic pancreatitis

Question 4

What does Grey Turner’s sign indicate?

Answer 4

Retroperitoneal haemorrhage

Question 5

How to investigate suspected acute pancreatitis?

Answer 5

A to E if unstable

Bedside (remember ECG if epigastric pain
Bloods (remember ABG for assessing severity)
Imaging (remember erect CXR to rule out perforated ulcer)

CT may be required if there is still diagnostic uncertainty

Question 6

What are the scoring systems for acute pancreatitis?

Answer 6

Modified Glasgow Scale: a score greater than 3 within 24 hours = severe pancreatitis

APACHE-II Score: general disease severity index, typically used in ICU patients

Ranson’s Criteria: mortality risk based on the initial and 48 hour score

Question 7

What makes up the Modified Glasgow Score?

Answer 7

P - PaO2 < 60mmHg/8kPa
A - Age > 55
N - Neutrophils i.e. WCC > 15
C - Calcium < 2
R - Renal i.e. Urea > 16
E - Enzymes i.e. ALT > 200 or LDH > 600
A - Albumin < 32
S - Sugar i.e. glucose > 10

Question 8

What is the criteria for making a diagnosis of acute pancreatitis?

Answer 8

2 of the following 3:
- Elevated lipase or amylase - more than 3 x upper limit of normal
- Clinical features - classic epigastric pain
- Imaging evidence - CT/MRI/USS

Question 9

What is the natural history of amylase?

Answer 9

Amylase peaks in the first 24-48 hours after the onset of pancreatitis

Therefore, it may not be significantly raised if there is late presentation

Question 10

How to treat acute pancreatitis?

Answer 10

Symptomatic management:
- IV fluid replacement with fluid monitoring (catheter)
- Analgesia
- Anti-emetics

Scoring and scoring monitoring

USS to assess for gallstones as the underlying cause

Treat the underlying cause and monitor for complications

ICU involvement in severe cases

Question 11

When are antibiotics used in acute pancreatitis?

Answer 11

Antibiotics are not routinely used

They may be required if there is a superimposed infection or there is necrosis of >30%

Question 12

What are the complications of acute pancreatitis?

Answer 12

Local: necrosis, phlegmon, pseudocyst, abscess, haemorrhage, splenic venous thrombosis

Gastrointestinal: paralytic ileus, gastric outlet obstruction, GI haemorrhage

Hepatobiliary: CBD strictures or obstruction, portal venous thrombosis

Systemic:
- Metabolic - hypocalcaemia, malnutrition, hyperglycaemia
- Respiratory - ARDS
- Cardiology - arrhythmias
- Other - renal failure, DIC, shock