Pancreas

Question 0

Acute pancreatitis

Answer 0

Background normal pancreas, returns to normal structure/function, isolated or recurrent attacks
Untreated can lead to chronic disease
Increasing incidence, 25%- sever AP with multiorgan failure
Of whom about 20% may die

Question 1

The pancreas

Answer 1

Endocrine - islets of Langerhans secrete insulin, glucagon - blood

Exocrine - pancreatic acinar cells produce enzymes (lipase..) pass via main pancreatic duct into duodenum, digest stuff in SI

Question 2

Pathogensis acute pancreatitis

Answer 2

Whatever initiating cause, final pathway is common…
Marked elevation in intracellular calcium, activation intra cellular proteases, release of pancreatic enzymes
Acinar cell injury and necrosis follows, then inflammatory response which can become systemic

Question 3

Clinical features acute pancreatitis

Answer 3

Epigastric pain, radiating to back, nausea/vomiting
Epigastric / general abdo tenderness, guarding, rigidity
May also be coma, mulitorgan failure
Ecchymoses around umbilicus (Cullen’s sign)
Or flanks (Grey Turner’s sign) -> severe necrotising pancreatitis

Question 4

Blood tests in acute pancreatitis

Answer 4

Raised serum amylase/lipase (very high - 3x normal)
Present late - raised urinary amylase/lipase, serum normal
Glasgow criteria for severity - prognostic value

Question 5

Causes acute pancreatitis

Answer 5

Gallstones
Alcohol
Infections - mumps
Pancreatic tumours
Drugs / Iatrogenic (post ERCP)
Metabolic - hypercalcaemia, hypertrigylceridaemia

Question 6

Causes chronic pancreatitis

Answer 6

Alcohol
Tropical disease
Autoimmune
Hereditary eg CF

Question 7

Glasgow criteria severity pancreatitis (3> first 48 hours poor prognosis)

Answer 7

Age >55
High WBC
High BM
High serum urea, aminotransferases
Low serum albumin, calcium, lactate dehydrogenase
Hypoxia

Question 8

Radiology in acute pancreatitis

Answer 8

Erect chest x-ray exclude perforated peptic ulcer
Abdominal US look for gallstones
Contrast CT / MRI usual to confirm diagnosis, extent necrosis

Question 9

Management of acute pancreatitis

Answer 9

Most cases mild, little necrosis, just supportive care needed
Severe - failure of 2+ organ systems, DIC, high dependency, fluid, correction metabolic abnormalities

Question 10

Avoid morphine in acute pancreatitis because …

Answer 10

Increases sphincter of oddi pressure, may aggravate

Question 11

Chronic pancreatitis

Answer 11

Inappropriate activation of enzymes - precipitation of protein plugs in duct lumen - calcification
Subsequent duct blockage - ductal hypertension, further damage
With cytokine activation - inflammation, irreversible changes
Commonest cause - alcohol

Question 12

Clinical features chronic pancreatitis

Answer 12

Epigastric pain, intermittent/constant, radiating to back
May be anorexia, severe weight loss
Diabetes and steatorrhoea may develop due to insulin and lipase insufficiency
Jaundice may be presenting symptom if fibrosis obstructs CBD
Consider carcinoma

Question 13

Imaging in chronic pancreatitis

Answer 13

Plain AXR may show pancreatic calcification
US/CT show calcification, ductal dilatation, irregular consistency/outline, fluid collections
ERCP used for therapy NOT investigation

Question 14

Treatment chronic pancreatitis

Answer 14

Advise stop drinking alcohol
Pain - opiates - addiction risk
Severe - surgical resection
Pancreatic strictures / stone may treat with ERCP

Question 15

Epidemiology carcinoma of pancreas

Answer 15

5th most common cause cancer death worldwide
Men affected more than women
Increases with age
Most are adenocarcinomas, ductal origin

Question 16

Aetiology

Answer 16

Hereditary
Smoking, obesity
Chronic pancreatitis

Question 17

Clinical features cancer affecting head of pancreas / ampulla of vater

Answer 17

Painless jaundice due to obstruction CBD
Weight loss
Jaundice, palpable gall bladder

Question 18

Courvoisier’s law

Answer 18

If painless jaundice the gallbladder is palpable, cause is not gallstones

Question 19

Clinical features cancer of body / tail pancreas

Answer 19

Abdominal pain, weight loss, anorexia

Diabetes can occur

Question 20

Investigations carcinoma of pancreas

Answer 20

Diagnosed by US - mass lesion, dilated bile ducts
Contrast enhanced spiral CT to stage cancer
ERCP restricted to palliative treatment
Tumour marker CA19-9 sensitive for diagnosis

Question 21

Management pancreatic carcinoma

Answer 21

Surgical resection only hope cure. Uncommon as invades major blood vessels
Chemotherapy and radiotherapy. Palliative treatment

Question 22

Cancer of bile ducts (cholangiocarcinoma)

Answer 22

Disease of elderly, poor prognosis
More frequent if primary sclerosing cholangitis, CBD abnormality, liver fluke infection
Presentation - jaundice secondary to bile duct obstruction
Imaging shows bile duct stricture, hilar mass, multiple metastases