Pancreas

Question 1

What is acute pancreatitis?

Answer 1

Inflammation of the pancreas leading to autodigestion

Question 2

What are the causes of acute pancreatitis, and which are most common?

Answer 2

Idiopathic
Gallstones (common)
Ethanol (common)
Trauma (common)
Steroids
Mumps
Autoimmune (common)
Scorpion bite
Hyper-calcaemia/thyroidism/lipidaemia (common)
ERCP
Drugs (azathioprine, antibiotics, oestrogen)

Question 3

What is mild, moderate and severe acute pancreatitis classed as?

Answer 3

Mild - absence of complications, uneventful recovery
Moderate - local complications, resolved in 48 hours
Severe - persistent organ dysfunction, complications like necrosis, abscess, pseudocysts etc

Question 4

What is the pathogenesis of acute pancreatitis?

Answer 4

Premature activation of zymogen granules releases proteases that auto digest the pancreas

Question 5

What are the 4 stages of acute pancreatitis?

Answer 5

1. Oedema and fluid shifts leads to hypovolaemic shock, auto-digestion of fats and hypocalcaemia
2. Autodigestion of blood vessels causes retroperitoneal haemorrhage
3. Infarction due to compromised blood supply causes pancreatic necrosis
4. Necrotic tissue becomes infected, causing abscess formation

Question 6

What are some complications of acute pancreatitis?

Answer 6

Multiorgan dysfunction
Hypovolaemic shock
Necrosis
Pseudocysts
Abscess
Paralytic ileus
GI bleeding
Pleural effusion
Hypocalcaemia and hypo/hyperglycaemia

Question 7

What signs are characteristic of acute pancreatitis?

Answer 7

Cullen’s sign - peri-umbilical area that looks purple and kinda like bruising
Grey Turner’s sign - same as above but on the flanks

Question 8

What are the symptoms of acute pancreatitis?

Answer 8

Acute severe epigastric pain, may radiate to back
Pain alleviated in foetal position or when leaning forward
Pain may be associated with meals/excessive alcohol
Epigastric abdominal tenderness
Abdominal distension
Nausea and vomiting
Jaundice
Fever, tachycardia
Anorexia

Question 9

What investigations are done for acute pancreatitis?

Answer 9

Amylase
Lipase
CRP
Imaging (erect CXR, abdo USS, CT)

Question 10

What are amylase, lipase and CRP levels in acute pancreatitis?

Answer 10

Amylase - raised x3 initially but normalises after 3-4 hours
Lipase - elevated for longer than amylase
CRP raised

Question 11

What does imaging show in acute pancreatitis?

Answer 11

CXR - air under diaphragm
Abdo USS - biliary causes, cysts, presence of free fluid
CT - detects pseudocysts

Question 12

What scoring systems are used in acute pancreatitis?

Answer 12

Glasgow prognostic score
Ranson’s criteria
APACHE scoring system

Question 13

What does the Glasgow prognostic score use?

Answer 13

PaO2
Age >55
Neutrophils
Calcium
Renal function (urea)
Enzymes
Albumin
Sugar -  glucose

Question 14

What is the management for acute pancreatitis?

Answer 14

IV fluid resuscitation
O2 therapy
Pain relief
Enteral nutrition
Antibiotics
If gallstones - ERCP/cholecystectomy
Lifestyle - reduce alcohol
Treat complications

Question 15

What is chronic pancreatitis?

Answer 15

Chronic inflammation of the pancreas that is progressive and irreversible

Question 16

What are the causes of chronic pancreatitis?

Answer 16

Mostly alcohol
Idiopathic
Pancreatic duct obstruction (stricture, tumour, stone, pseudocyst)
Autoimmune
Tropical  countries
Alpha1-antitrypsin
Cystic fibrosis

Question 17

What are the symptoms of chronic pancreatitis?

Answer 17

Epigastric pain radiating to the back
Nausea and vomiting
Jaundice
Itching
Ascites
Masses
History of alcohol, smoking
Medications - antibiotics, steroids, ACEI

Question 18

What are the investigations done for chronic pancreatitis?

Answer 18

LFTs
CXR and AXR
CT pancreas
MRI
USS to exclude other conditions

Question 19

What is the management for chronic pancreatitis?

Answer 19

Manage acute phase
Lifestyle, pain management, screen for other diseases
Creon (replacement pancreatic enzymes if pancreatic insufficiency)
Surgery

Question 20

What surgical procedures are done for chronic pancreatitis?

Answer 20

Pancreatico-jejunostomy or Frey’s procedure

Question 21

What are pancreatic pseudocysts?

Answer 21

Collection of fluid that forms in the pancreas

Question 22

Why are pancreatic pseudocysts called that, and not cysts?

Answer 22

The sac is not lined with epithelial cells so it cannot be called a cyst

Question 23

What are the causes of pancreatic pseudocysts?

Answer 23

Trauma
Idiopathic
Pancreatico-duodenal communication following surgery
Biliary obstruction
Gastric outlet obstruction
Complication of acute pancreatitis

Question 24

What is the treatment for pancreatic pseudocysts?

Answer 24

Surgical drainage or resection

Question 25

What is the most common type of pancreatic tumour?

Answer 25

Adenocarcinoma

Question 26

Where do most pancreatic tumours form?

Answer 26

Exocrine compartment, in the head or the neck of the pancreas

Question 27

What are the risk factors for pancreatic tumours?

Answer 27

Increasing age
Male
Smoking
Alcohol
Diabetes
Chronic pancreatitis

Question 28

What are the symptoms of pancreatic tumours?

Answer 28

Painless jaundice (main)
Dark urine, pale stools
Weight loss
Back pain
Fatigue, nausea, vomiting
Malabsorption
Courvoisier's sign (palpable, non-tender gallbladder + painless jaundice which indicates biliary obstruction)

Question 29

What are the investigations for pancreatic tumours?

Answer 29

Blood tests
USS
Triple phase CT (gold standard)
MRI
MRCP

Question 30

What is the management for pancreatic tumours?

Answer 30

Chemotherapy
Radiotherapy
Palliative surgery may be possible but resection can only be done in 20%

Question 31

What are the surgical managements for pancreatic tumours?

Answer 31

If non-operable: ERCP and stent and decompression of the bile duct
If operable: Stent, laparoscopic staging, pancreatectomy, Whipple’s procedure, bypass