Pancreatic disease

Question 1

Diagnosis of acute pancreatitis requires?

Answer 1

> 2 out of 3

• Persistent, severe epigastric pain radiating to the back
• Serum lipase/ amylase >X3 upper limit of normal
• Characteristic finding on CECT/ MRI/ trans-abdominal ultrasound

Question 2

Causes of acute pancreatitis

Answer 2

> I GET SMASHEd

• Idiopathic
• Gallstones
• Ethanol abuse
• Trauma
• Steroids
• Mumps virus
• Autoimmune disease
• Scorpion stings
• Hypertriglyceridemia & hypercalcemia
• ERCP

Question 3

Investigation for acute pancreatitis

Answer 3

> Diagnostic

• Serum amylase >3x upper limit [Normal = 30-100 U/L]
• Serum lipase >3x upper limit [Normal = 10-140 U/L]

> Underlying etiology

• LFT (elevated ALT - gallstone pancreatitis; elevated AST - Ranson and Glasgow)
• Ultrasound abdomen (dilated CBD/ gallstone)
• Ca/ Mg/ PO4 (hypercalcemia)
• Fasting lipid (hyperlipidemia)

> Imaging

• Erect CXR (air under diaphragm)
• Supine AXR (localized ileus)
• MRCP (visualizing cholelithiasis, choledocholithiasis, anomalies of the pancreatic and common bile duct)

Question 4

Management of acute pancreatitis

Answer 4

> Supportive treatment - 90% response

• Keep NBM
• IV fluid resuscitation
• Pain management (Tramadol)
• NG tube insertion, anti-emetics
• Antibiotic management

> Management etiology

• Avoid alcohol, control hyperlipidemia
• ERCP + endoscopic sphincterotomy (for severe biliary pancreatitis)
• Cholecystectomy

Question 5

Complication of acute pancreatitis

Answer 5

> Local

• Acute fluid collection
• Pseudocyst
• Pancreatic abscess
• Chronic pancreatitis
• Exocrine/ endocrine insufficiency

> Systemic

• Peritoneal sepsis
• Pleura effusion
• Shock
• Multiple organ failure
• Hypocalcemia, hyper/ hypoglycemia

Question 6

Clinical features head/ periampullary of pancreas Ca

Answer 6

• Obstructive jaundice
• NV
• LOW
• Recurrent pancreatitis

Question 7

Clinical features pancreatic body/ tail Ca

Answer 7

• Epigastric pain
• Malaise, LOW, LOA
• Nausea
• Exocrine insufficiency
• Trousseau’s sign

Question 8

Investigaiton for pancreatic Ca

Answer 8

> Imaging

• Contrast CT
• Endoscopic US + FNA biopsy
• ERCP

> Lab

• CA 19-9
• Serum bilirubin
• Serum alkaline phosphatase
• AST/ ALT

> Staging

• CT TAP
• Endoscopic US
• Bone scan
• Staging laparoscopy

Question 9

Management for pancreatic Ca

Answer 9

> Head/ Uncinate process
- Whipple’s operation

> Body/ Tail
- Distal subtotal pancreatectomy +- splenectomy

> Entire glands
- Total pancreatectomy

Question 10

Absolute contraindication for resection

Answer 10

• Presence of metastases in liver, peritoneum, omentum, or extra abdominal site
• Encasement (>1/2 circumference) or occlusion of SMA

Question 11

Describe Whipple procedure

Answer 11

> Removal of

• Pancreatic head
• Duodenum
• Proximal 15cm of jejunum
• Common bile duct
• Gallbladder
• Partial gastrectomy

> Reconstruciton

• Pancreatojejunostomy
• Hepaticojejunostomy
• Gastrojejunostomy

Question 12

Post-Op care Whipple procedure

Answer 12

• Most do not required ICU monitoring
• Majority discharge within 7-10 days of operation
• Nutritional support (D1-2: clear liquid; D3-4: regular diet)
• Drain management (close suction drain; removed once tolerating regular diet)

Question 13

Ranson/ Glasgow criteria component

Answer 13

> PANCREAS

• PaO2
• Age>55
• Neutrophils (WBC)
• Calcium
• Renal (BUN)
• Enzyme (AST + LDH)
• Albumin
• Sugar (Glucose)

> Replace Albumin with HepatoBiliary Failure in Ranson

• Hematocrit
• Base deficit
• Fluid sequestration

Question 14

Definition of chronic pancreatitis

Answer 14

• Continuing inflammatory disease of the pancreas characterized by irreversible morphological change typically causing pain and/or permanent loss of function

Question 15

What is pseudocyst

Answer 15

• Walled off fluid collection that are more common in chronic pancreatitis than acute
• Takes at least 4 weeks to develop
• Caused by inflammation and subsequent damage of the pancreatic ducts leading to extravasation and accumulation of pancreatic fluid