Pancreas

Question 1

Anatomical structure of the pancreas (5)

Answer 1

Head: Lies within C-Shaped curve formed by the duodenum (attaches via connective tissue)
Uncinate process: Lies posterior to the superior mesenteric artery.
Neck: Overlies the superior mesenteric arteries which forms a groove in the neck.
Body: Lies behind the stomach and left to the superior mesenteric artery
Tail: Intraperitoneal. Lies next to hilum of spleen, within the splenorenal ligament with the splenic vessels

Question 2

Duct system of pancreas

Answer 2

Million berry like clusters (acini), connected by short intercalated ducts (centroacinar cells).

Drain into:
Intralobular connecting ducts
Pancreatic duct
Joins Common bile duct (Hepatopancreatic ampulla of Vater)
Duodenum

Question 3

Vasculature of the pancreas

Answer 3

Pancreatic branches of splenic artery

The head also gets supply from superior (gastroduodenal artery from coeliac trunk) and inferior pancreaticoduodenal arteries (Superior mesenteric artery)

Head venous drainage: superior mesenteric branch of hepatic portal vein

Pancreatic veins drain the rest to the splenic vein

Question 4

Lymph drainage

Answer 4

Empty into pancreaticosplenal nodes and pyloric nodes which drain into the superior mesenteric and coeliac lymph nodes.

Question 5

Causes of pancreatitis (I get smashed)

Answer 5

Idiopathic
Gall Stones
Ethanol 
Trauma
Steroids
Mumps, Malignancy
Auto-immune
Scorpion sting
Hypertryglyceridaemia, Hypercalcaemia
Endoscopic retrograde cholangiopancreatography (ERCP)
Drugs- Sodium Valproate, Metformin, Azathioprine

Question 6

Signs and symptoms of pancreatitis

Answer 6

Nausea
Vomiting
Anorexia
Mid epigastric pain radiating to back 
Tachycardia

Less common:
Grey turner's sign
Cullen's sign
Fox's sign
Chvostek's sign

Question 7

Grey turner’s sign

Answer 7

Bilateral flank blue discoloration indicating haemorrhagic pancreatitis

Question 8

Cullen’s sign

Answer 8

Peri-umbilical blue discoloration indicating haemorrhagic pancreatitis

Question 9

Fox’s sign

Answer 9

Ecchymosis (bruised skin showing blood underneath skin) over the inguinal ligament area

Question 10

Chvostek’s sign

Answer 10

Facial muscle spasm when face is tapped on parotid gland region.

Question 11

Investigations to order for pancreatitis

Answer 11

Serum lipase + amylase: 3 times above the normal
FBC: leukocytosis (due to dehydration, raised haematocrit)
CXR. Abdominal ultrasound
(see bmj for more)

Question 12

Treatment for pancreatitis

Answer 12

IV Hydration (Ringer's lactate solution)
Nutrient support (patient nbm)
Analgesia
Antiemetic
Calcium replacement (Calcium gluconate)
Magnesium sulfate (if mg low)

With gall stones (surg, candidate): Cholecystectomy
Non surgical or rapid deterioration after 48hrs treatment: ERCP with sphincterotomy

With alcohol disease: Benzodiazepine (Lorazepam)
Vitamin and mineral replacement

Question 13

ERCP

Answer 13

Endoscopic retrograde cholangiopancreatography
Used to diagnose disease of gall bladder, liver, pancreas
Once problem discovered can be treated by:
sphincterotomy: small incision in opening of bile duct to drain gall stones
Stent Placement or removal of gall stone