Pancreas pathology

Question 1

State a pneumonic for causes of acute pancreatitis [1]

Answer 1

I– Idiopathic
G – Gallstones
E – Ethanol (alcohol consumption)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting (the one everyone remembers)
H – Hyperlipidaemia
E – ERCP
D – Drugs (furosemide, thiazide diuretics and azathioprine)

Question 2

Name three drugs than can cause pancreatitis [3]

Answer 2

Furosemide, thiazide diuretics and azathioprine

Question 3

The three key causes of pancreatitis to remember are [3]

Answer 3

The three key causes of pancreatitis to remember are:

Gallstones
Alcohol
Post-ERCP

Question 4

Describe the presentation of acute pan.

Answer 4

Severe epigastric pain - that radiates to the back:
- BUT: the pain can be present anywhere in the abdomen and acute pancreatitis should be a differential diagnosis in any case of acute abdominal pain.

Associated vomiting & vomiting:
- Very commonly associated with the pain and due to gastric distension and gastroparesis.

Abdominal tenderness

Jaundice
- In cases due to gallstone obstruction of the ducts there can be marked obstructive jaundice.

Question 5

Why might treatment of an exacerbation of COPD trigger acute pancreatitis? [1]

Answer 5

Steroids can precipitate acute pancreatitis

Question 6

When taking a history about acute pancreatitis - why should you ask about recent infections? [1]

Answer 6

There may be history of recent infection with mumps.

Question 7

Describe the signs you might see from bleeding in acute pancreatitis [2]

Answer 7

Grey-Turner’s sign (bruising of the flanks) and Cullen’s sign (peri-umbilical bruising) are rarely present (less than 10% of cases) and are due to bleeding in the fascial planes from release of protease enzymes.

Question 8

Acute pancreatitis may lead to which resp. pathologies ? [2]

Answer 8

There may be crepitations present on examination and this may progress to severe acute respiratory distress syndrome (ARDS)

Up to 20% of patients may develop a reactive inflammatory pleural effusion.

Question 9

Describe the blood tests you’d expect to see in acute pan

Answer 9

Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function.

Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase

C-reactive protein (CRP) levels correlate with the severity of an attack and a CRP > 150 mg/L at 48-hours from onset indicate a severe attack.

Question 10

What CRP levels would indicate a severe acute pancreatic attack? [1]

What WCC? [1]

Answer 10

CRP > 150 mg/L at 48-hours from onset indicate a severe attack.

White blood cell count > 16 x109/L used in both severity scores.

Question 11

Which score is used to determine the severity of pancreatitis? [1]

What ^ scores would indicate mild, moderate and severe pancreatitis? [3]

Answer 11

Glasgow Score
The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present:

0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis

Question 12

What are the criteria for acute pancreatitis? [+]

Answer 12

The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):

P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)

Question 13

How would you differentiate between acute hepatitis and acute pan? [1]

Answer 13

Although there are features of upper abdominal pain and possibly shock, the main findings would be acute jaundice and deranged liver enzymes including raised transaminase (ALT/AST) levels.

Question 14

Describe how you would manage acute pancreatitis

Answer 14

Initial resuscitation (ABCDE approach)

Analgesia:
- which may be in the form of a patient-controlled intravenous morphine pump.

IV fluids

Nil by mouth
- Begin nutrition as early as possible, ideally enterally if only a mild attack.

Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)

Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)

Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)

Question 15

How do you treat pancreatic necrosis? [1]

Answer 15

Most necrotic collections are sterile and do not require any treatment although frequent monitoring to look for signs of infection should be performed.
- Surgical or radiological drainage or aspiration is indicated if there is any suspicion of infection and drains placed with intravenous antibiotic therapy commenced as soon as possible.

Question 16

How do you treat pseudocyst formation in acute pancreatitis? [1]

Answer 16

Pseudocyst formation:
* Surgery is not indicated unless there are significant pressure symptoms as they are likely to resolve over time.
* Drainage can be performed endoscopically or surgically and a drain into the stomach lumen is usually used to prevent recurrence.

Question 17

Describe why ascites might develop in acute pancreatitis [1] and how to treat [1]

Answer 17

Widespread enzyme-rich ascites can occur with release of pancreatic enzymes into the peritoneal space.
- Multiple large bore ascitic drains should be placed and left in until no further fluid is produced.

Question 18

What are the key features of chronic pancreatitis? [5]

Answer 18

• Chronic epigastric pain
• Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
• Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
• Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
• Formation of pseudocysts or abscesses

Question 19

What can be given to replace the reduction in the production of pancreatic enzymes from chronic pancreatits? [1]

Answer 19

Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins.

Question 20

Which is the most common type of pancreatic cancer? [1]

Answer 20

Adenocarcinoma, arising from ductal epithelium, constitutes approximately 85% of cases.

Question 21

What are the clinical features of pancreatic cancer?

Answer 21

• Classically painless jaundice
• present in a non-specific way with anorexia, weight loss, epigastric pain
• loss of exocrine function (e.g. steatorrhoea)
• loss of endocrine function (e.g. diabetes mellitus)
• atypical back pain is often seen
• migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Question 22

How do you investigate for pancreatic cancer? [2]

Answer 22

ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected - 1st line

Question 23

The NICE guidelines suggest a GP referral for a direct access CT abdomen (or ultrasound if not available) to assess for pancreatic cancer if a patient has weight loss plus any of: [7]

Answer 23

• Diarrhoea
• Back pain
• Abdominal pain
• Nausea
• Vomiting
• Constipation
• New-onset diabetes

Question 24

What is Courvoisier’s law? [1]

Answer 24

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Question 25

What is Trousseau’s sign of malignancy? [1]

Answer 25

Refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma

Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area. Migratory refers to the thrombophlebitis reoccurring in different locations over time.

Question 26

Describe the surgery used in pancreatic cancers [4]

Answer 26

• less than 20% are suitable for surgery at diagnosis
• a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
• adjuvant chemotherapy is usually given following surgery
• ERCP with stenting is often used for palliation

Question 27

Describe in more detail what a Whipple’s procedure is [1]

Answer 27

A Whipple procedure (pancreaticoduodenectomy):
- is a surgical operation to remove a tumour of the head of the pancreas that has not spread.
- A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:

Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes

Question 28

What type of cancer is this most likely to be? [1]

Answer 28

Figure 3 – A adenocarcinoma located in the pancreatic head, identified on CT scan

Question 29

In which of the following scenarios is the Courvoisier’s sign most likely to be positive?

A 31 year-old male with pancreatic cancer located in the head of the pancreas

A 29 year-old female with a rapidly enlarging pancreatic pseudocyst

A 51 year-old female with a gallbladder cancer

A 32 year-old female with necrotic pancreatitis

Answer 29

A 31 year-old male with pancreatic cancer located in the head of the pancreas

Question 30

In a Whipple’s procedure, which viscera is not removed routinely as part of the operation?

Head of the pancreas

Gallbladder

Left lobe of the liver

Antrum of the stomach

Answer 30

In a Whipple’s procedure, which viscera is not removed routinely as part of the operation?

Head of the pancreas

Gallbladder

Left lobe of the liver

Antrum of the stomach

A Whipple’s procedure involves the removal of the head of the pancreas, the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct, and the gallbladder

Question 31

[] is the preferred diagnostic test for chronic pancreatitis - looking for []

Answer 31

CT pancreas is the preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification

Question 32

Early [imaging] in acute pancreatitis is important to determine the aetiology as this may affect management (e.g. patients with gallstones/biliary obstruction)

Answer 32

Early ultrasound imaging in acute pancreatitis is important to determine the aetiology as this may affect management (e.g. patients with gallstones/biliary obstruction)

Question 33

Which is more common in pancreatic pathology?
- Pseudocyst
- Pancreatic abscess

How do you treat? ^ [1]

Answer 33

Pseudocyst
- Symptomatic cases may be observed for 12 weeks as up to 50% resolve
- Treatment is either with endoscopic or surgical cystogastrostomy or aspiration

Question 34

[] is a useful test of exocrine function in chronic pancreatits

Faecal calprotectin
Faecal elastase
Serum amylase
Serum calcium
Serum lipase

Answer 34

[] is a useful test of exocrine function in chronic pancreatits

Faecal calprotectin
Faecal elastase
Serum amylase
Serum calcium
Serum lipase