Pancreas and biliary pathology

Question 1

What are the classical symptoms of gallstones?

Answer 1

• Right upper quadrant pain that may radiate to the shoulder or the back (between the shoulder blades)
• Crampy pain, attacks increasing in frequency
• Nausea/vomiting

Question 2

What are the options for treatment of gallstones?

Answer 2

• Conservative: painkillers, avoiding fatty foods

* Operative: removal of the gallbladder and cystic duct

Question 3

What are gallstones?

Answer 3

•Can be pure or mixed cholesterol and bile pigment

Question 4

What keeps cholesterol in solution in the bile?

Answer 4

Micelles that contain bile acids and phospholipids

Question 5

What causes the colour of the bile?

Answer 5

Bilirubin (a breakdown product of haemoglobin)

Question 6

When does bile become lithogenic (stone forming)

Answer 6

Lithogenic for cholesterol if there is an excessive secretion of cholesterol or decreased secretion of bile salts

Question 7

What is the treatment of gallstones that have traveled down into the common bile duct?

Answer 7

• ERCP

* Lap chole and bile duct

Question 8

What investigations should be carried out for suspected bile duct gallstones?

Answer 8

• MRCP
• Endoscopic ultrasound
• Operative cholangiogram

Question 9

What are the symptoms of acute pancreatitis?

Answer 9

• Severe upper abdominal pain
• Fever
• Leucocytosis
• Raised serum amylase

Question 10

How can gallstones cause a pancreatitis?

Answer 10

Gallstone at the ampulla causes bile reflux up into the pancreatic duct causing a pressure build up and damage to the cells

Question 11

What are the complications of acute pancreatitis?

Answer 11

• Fat necrosis
• Acute haemorrhagic pancreatitis
• Pancreatic abscess
• infected pancreatic necrosis

Question 12

What is the treatment of a pancreatic abscess?

Answer 12

• Drainage

* necrosectomy and antibiotics

Question 13

What are the differentials for a pancreatic cyst?

Answer 13

• Intraductal papillary mucinous neoplasm
• Mucinous cystic neoplasm
• Serous cystadenoma

Question 14

What are the risk factors of pancreatic cancer?

Answer 14

• Germline mutations

* Smoking

Question 15

What are the signs and symptoms of pancreatic cancer?

Answer 15

• Painless obstructive jaundice
• New onset diabetes
• Abdominal pain due to pancreatic insufficiency or nerve invasion
• Tumours in head may obstruct the pancreatic duct and bile duct (double duct sign on radiology)

Question 16

What is Whipple’s resection?

Answer 16

• Removal of the head of pancreas, first part of the duodenum, the gallbladder and the bile duct
• Only for tumours of the head of the pancreas

Question 17

What is the neoadjuvant therapy for pancreatic cancer?

Answer 17

• Folfirinox chemotherapy

* Associated with limited improvement in metastatic disease

Question 18

Give an example of a pancreatic neuroendocrine tumour

Answer 18

Insulinoma (90% are benign, presents with hypoglycaemia)

Question 19

What are the classification fo cholangiocarcinoma?

Answer 19

Intrahepatic/extrahepatic depending on the origin

Question 20

What does intrahepatic cholangiocarcinoma need to be distinguished from?

Answer 20

Metastatic adenocarcinoma and hepatocellular carcinoma

Question 21

What is the cholangiocarcinoma treated by?

Answer 21

Whipple’s resection