pancreas disease

Question 1

what is the patho of acute pancreatitis?

Answer 1

occurs as consequence of premature activation of zymogen granules releasing proteases which digest the pancr

Question 2

what are the causes of acute pancreatitis?

Answer 2

common (90%): gallstones, alcohol, idiopathic, post-ERCP

rare: post-surgical, trauma, drugs, metabolic, pancreas, renal failure

Question 3

what are the clinical features of acute pancreatitis?

Answer 3

severe, constant upper abdominal pain radiating to back in 65% cases builds up over 15-60 minutes

nausea and vomiting common

epigastric tenderness

in contrast to perforated peptic ulcer, guarding and rebound tenderness absent as inflammation is retroperitoneal

bowel sounds absent as paralytic ileus develops

patient becomes hypoxic and develops hypovolaemic shock with oligouria

discoloration of flanks (grey turner sign) or periumbilical region (cullen sign) feature of severe pancreatitis with haemorrhage

Question 4

what is the differential diagnosis of acute pancreatitis?

Answer 4

perforated viscus, acute cholecystitis and MI

Question 5

what are the systemic complications of acute pancreatitis?

Answer 5

systemic inflammatory response syndrome

hypoxia

hyperglycaemia

hypocalcemia

reduced serum albumin concentration

Question 6

what are the pancreatic complications of acute pancreatitis?

Answer 6

necrosis

abscess: circumcised collection of pus close to pancreas and containing little or no pancreatic necrotic tissue

pseudocuyst

pancreatic ascites or pleural effusion

Question 7

what are the GI complications of acute pancreatitis?

Answer 7

upper GI bleeding

variceal haemorrhage

erosion into colon

duodenal obstruction

obstructive jaundice

Question 8

what is an acute pancreatic pseudocyst?

Answer 8

localised peripancreatic collection of pancreatic juice and debris developing in lesser sac following inflammatory rupture of pancreatic duct

initially contained within poorly defined fragile wall which matures over 6 week period to form fibrous capsule

small ones common and resolve as pancreatitis recovers

greater than 6cm rarely disappear spontaneously and cause abdominal pain, may compress or erode surrounding structures including blood vessels to form pseudoaneurysms

Question 9

what is the diagnosis of acute pancreatitis?

Answer 9

raised serum amylase or lipase concentrations and ultrasound or CT of pancreatic swelling

Question 10

what is the initial management of acute pancreatitis?

Answer 10

analgesia

correction of hypovolaemia using normal saline or colloids

hypoxic patients need oxygen

hyperglycaemia corrected with insulin

prophylactic thromboembolism with los dose heparin advisable

Question 11

what is chronic pancreatitis?

Answer 11

chronic inflammatory disease characterised by fibrosis and destruction of exocrine pancreatic tissue

Question 12

what occurs in advanced cases of chronic pancreatitis?

Answer 12

DIABETES as islets of langerhans involved

Question 13

what are the toxic-metabolic causes of chronic pancreatitis?

Answer 13

alcohol

tobacco

hypercalcaemia

chronic renal failure

Question 14

what are the genetic causes of chronic pancreatitis?

Answer 14

HEREDITARY pancreatitis, SPINK-1 mutation, cystic fibrosis

Question 15

what are the obstructive causes of chronic pancreatitis?

Answer 15

ductal adenocarcinoma

pancreas divisum

sphincter of oddi stenosis

Question 16

what is the pathophysiology of chronic pancreatitis?

Answer 16

80% is alcohol misuse

southern india, severe chronic calcific pancreatitis occurs in non alcoholics possibly due to malnutrition and cassava consumption

alohol and other risk factors trigger acute pancreatitis through multiple mechanisms

first episode of acute pancreatitis initiates inflammatory response involving T helper cells

ongoing exposure to alcohol drives further inflammation modified by regulatory T cells with subsequent fibrosis via activation of pancreatic stellate cells

cycle of inflammation and fibrosis ensues with development of chronic pancreatitis

Question 17

what are the clinical features of chronic pancreatitis?

Answer 17

middle-aged alcoholic men

all present with abdominal pain

50% occurs as episodes of acute pancreatitis although each attack results in degree of permanent pancreatic damage

relentless, slowly progressive chronic pain without acute exacerbations occurs in 35%

remainder no pain but present with diarrhoea

weight loss from anorexia, avoidance of food due to post-prandial pain, malabsorption, diabetes

Question 18

what is the pain in abdomen caused by in chronic pancreatitis?
how is pain releived?

Answer 18

INCREASED PRESSURE within pancreatic ducts and direct involvement of pancreatic and peripancreatic nerves by inflammatory process

pain relieved by leaning forwards or drinking alcohol

opiate analgesics

Question 19

when does steatorrhoea occur?

Answer 19

when more than 90% of exocrine tissue destroyed

protein malabsorption only in most advanced cases