Pancreatic conditions

Question 1

Causes/risk factors of acute pancreatitis (5)

Answer 1

Alcohol abuse
Gallstones blocking main pancreatic duct
Trauma
ERCP induced
Certain drugs

Question 2

Pathophysiology of acute pancreatitis

Answer 2

Primary insult (i.e. alcohol or gallstones etc) --> release of activated pancreatic enzymes
--> autodigestion (pancreas digesting itself)

Question 3

Symptoms (4) /signs (4) of acute pancreatitis

Answer 3

Epigastric pain - can radiate to back
vomiting,
nausea,
Anorexia

jaundice
Pyrexia,
tachycardia,
Tender/swelling of abdomen

Question 4

Where can pain radiate to in pancreatitis

Answer 4

Back

Question 5

Investigations of acute pancreatitis

• bloods (5)
• imaging (2)

Answer 5

AMYLASE (Raised 3x) ,
LIPASE (Raised 3x),
CRP
LFTs - raised AST/ALT suggest gallstone cause
FBC
Haematocrit (ratio of RBCs to volume of blood)
ABG - low O2

AXR
ERCP or EUS if jaundiced - look for gallstones

Question 6

What Glasgow criteria score indicates severe pancreatitis

Answer 6

> 3

Question 7

What score system can be used to assess severity of pancreatitis

+ name one criteria (i.e. a finding) of severe pancreatitis

Answer 7

Glasgow criteria score

Blood glucose >10mmol/l

Question 8

Treatment of acute pancreatitis (5)

+ 3 others which may be used in certain cases

Answer 8

Analgesia
IV fluids
Nutritional support when symptoms subside
\+/- anti-emetics
\+/- supplemental oxygen

Antibiotics only given if there’s severe pancreatic necrosis
Cholecystectomy if it was induced by gallstones
Counselling plus alcohol withdrawal prophylaxis if alcohol induced

Question 9

Complications of acute pancreatitis (3)

Answer 9

Acute renal failure
Pancreatic necrosis
Pancreatic abscess

Question 10

Pathophysiology of chronic pancreatitis

Answer 10

Continuous inflammatory disease of the pancreas –> irreversible glandular damage –> leading to loss of function

Pancreatic duct obstruction –> abnormal sphincter of oddi function

Question 11

Chronic pancreatitis usually due to recurrent cases of what

Answer 11

Alcohol related acute pancreatitis

Question 12

Causes of chronic pancreatitis (OATIGER) + which are the main ones

Answer 12

Obstruction of main pancreatic duct - eg. tumour, trauma
Autoimmune
Toxins - ALCOHOL, SMOKING
Idiopathic
GENETIC
Environmental
Recurrent injuries

Capital = main ones

Question 13

Symptoms (3) /signs (3) of chronic pancreatitis

Answer 13

Epigastric pain - radiates to back
Nausea/vomiting

Weight loss/malnutrition
Steatorrhoea
Diabetes

Question 14

Why does chronic pancreatitis cause weight loss/maulnutrition, steatorrhoea and diabetes

Answer 14

Exocrine insufficiency –> fat/ protein malabsorption –> STEATORRHOEA and WEIGHT LOSS respectively

Endocrine insufficiency –> diabetes

Question 15

Investigations of chronic pancreatitis (6)

• bloods
• imaging (5)

Answer 15

Blood glucose
CT abdo
Abdo USS
AXR

EUS
ERCP

Question 16

Treatment of chronic pancreatitis (4)

Answer 16

Alcohol/ smoking abstinence
Pancreatic enzyme supplements
Opiate analgesia
Low fat diet

Question 17

What is the most common pancreatic carcinoma

Answer 17

Primary pancreatic ductal adenocarcinomas (mostly in head of pancreas)

Question 18

Risk factors of pancreatic cancer (4)

Answer 18

Smoking
Alcohol
Chronic pancreatitis
Inherited

Question 19

Pathophysiology of pancreatic ductal adenocarcinomas

Answer 19

Pre-invasive pancreatic intraepithelial neoplastic lesions –> invasive ductal adenocarcinoma

Question 20

Symptoms (2) /signs (2) of pancreatic cancer

Answer 20

Non specific upper abdo pain
Anorexia

PAINLESS OBSTRUCTIVE JAUNDICE
Weight loss

Question 21

Name 4 causes of obstructive jaundice

Answer 21

gall stone in common bile duct
tumour of common bile duct
stricture of common bile duct
carcinoma head of pancreas

Question 22

Investigations of pancreatic cancer

• bloods (1)
• imaging (2)
• tumour marker (1)

Answer 22

LFTs - high bilirubin, AlkP, gamma GT
Abdo USS
Pancreas specific CT

Tumour marker – CA19-9

Question 23

Treatment of pancreatic cancer

• if resectable (stage I-II) (3)
• if locally advanced unresectable (stage III) (3)

Answer 23

If resectable:
-pancreaticoduodenectomy (whipple's)
OR 
PPPD - pylorus preserving pancreaticoduodenectomy
- + adjuvant chemo

If locally advanced:

• ERCP + stent - to relive jaundice
• • chemo or chemoradiotherapy
• analgesia (opiates) + pancreatic enzyme supplements

Question 24

Gold standard investigation of pancreatic carcinoma

Answer 24

Spiral CT

Question 25

Surgical treatment of pancreatic cancer

Answer 25

pancreaticoduodenectomy (whipple’s procedure) - for pancreas head tumour

PPPD - pylorus preserving pancreaticoduodenectomy

Question 26

What therapeutic investigation may follow an abdo USS for pancreatic cancer to relieve jaundice

Answer 26

ERCP + stent - to relieve jaundice

Question 27

What treatment is done if ERCP +stent not possible (too blocked to stent) in obstructive jaundice due to pancreatic tumour

Answer 27

Palliative bypass/drainage

Question 28

Surgical treatment of acute pancreatitis

Answer 28

ERCP + ES (endoscopic sphincterotomy) - cutting the muscle between CBD and pancreatic duct

Question 29

Surgical treatment of chronic pancreatitis (5)

Answer 29

Pylorus preserving pancreatoduodectomy (PPD)
Whipple’s - pancreaticoduodenectomy - if intractable pain + small duct disease
Biliary decompression - if biliary obstruction
Pancreatic ductal decompression - if pancreatic duct obstruction
Coeliac plexus block - if intractable pain + small duct disease

Question 30

Complications of chronic pancreatitis (5)

Answer 30

Pancreatic pseudocyst
Pancreatic exocrine insufficiency 
Diabetes mellitus
Pancreatic calcifications
Pancreatic duct obstruction