Pancreatic disease

Question 1

State two pathological variations of chronic pancreatitis

Answer 1

Large duct pancreatitis and small duct pancreatitis

Question 2

State three specific types of chronic pancreatitis (as opposed to general chronic pancreatitis caused by alcohol etc.)

Answer 2

Auto-immune chronic pancreatitis
Tropical chronic pancreatitis
Hereditary chronic pancreatitis

Question 3

Give the common causes of chronic pancreatitis

Answer 3

Alcohol
Cystic fibrosis
Congenital anatomical abnormalities

Question 4

Describe the pathology of chronic pancreatitis

Answer 4

Glandular atrophy an replacement by fibrous tissue
Ducts become dilated, tortous and strictured
Congealed secreations may calcify
‘Exposed’ nerves due to loss of perineural cells

Question 5

In chronic pancreatitis, which veins are at risk of thrombosis and what complication can this cause?

Answer 5

Splenic, Superior mesenteric and Portal veins

Leads to portal hypertension

Question 6

Describe the disease process of acute pancreatitis

Answer 6

The pancreas releases high levels of exocrine enzymes that cause autodigestion of the organ ond of surrounding tissues. This causes oedema, fat necrosis and bleeding

Question 7

What are the most common causes of acute pancreatitis?

Answer 7

Alcohol abuse
Gallstones
Trauma
Idiopathic

Question 8

Describe the most common presentation of acute pancreatitis

Answer 8

Severe abdominal pain of sudden onset with vomiting

Question 9

How is the severity of acute pancreatitis assessed?

Answer 9

Using the Glasgow criteria: a score of greater than three indicates severe pancreatitis

Question 10

List the criteria for assessing acute pancreatitis

Answer 10

White cell count >15x10^9 /l
Blood glucose >10 mmol/l
Blood urea >16 mmol/l
AST >200 u/l
LDH >600 u/l
Serum albumin <32 g/l
Arterial Po2 <7.5 kPa

Question 11

Describe the general management for acute pancreatitis

Answer 11

Analgesia - pain is severe so this is very important
  - high dose opiates
IV fluids
Blood transfusion in some cases
Monitor urine output
Naso-gastric tube
Oxygen
May need supplemental insulin
Ensure adequate nutrition
Treat underlying cause

Question 12

Describe how specific aspects of acute pancreatitis are managed

Answer 12

Pancreatic necrosis: treat with CT-guided fluid aspiration and then antibiotics and/or surgery
Gallstones: EUS, MRCP, ERCP, maybe cholecystectomy

Question 13

Describe the pathology of pancreatic cancer

Answer 13

95% of cancers are of exocrine tissue
75% are duct cell mucinous adenocarcinoma
Other types:
  - carcinosarcoma
  - cystadenocarcinoma
  - acinar cell carcinoma

Question 14

Give the risk factors for pancreatic cancer

Answer 14

Age (above 60, rare below 40)
Smoking
Diabetes mellitus
Helicobacter pylori infection
Partial gastrectomy
Family history/genetics
Obesity
Male sex

Question 15

Describe the clinical features of pancreatic cancer

Answer 15

Upper abdominal pain
Painless obstructive jaundice
  - itch due to peripheral bilirubin
Anorexia, weight loss
Fatigue, nausea, vomiting
Diarrhoea, steatorrhoea
Tender subcutaneous fat nodules due to metastatic
  fat necrosis
Thrombophlebitis migrans
Ascites, portal hypertension

Question 16

What causes abdominal pain in pancreatic cancer?

Answer 16

Infiltration of cancer cells to coeliac plexus

Question 17

How is pancreatic cancer managed?

Answer 17

Radical surgery: pancreatoduodenectomy
  - only if patient is fit enough, tumour is <3cm diameter
   and there are no metastases
Palliation of jaundice
  - stent, palliative surgery
Pain control
  - opiates
  - coeliac plexus block
  - radiotherapy
(chemotherapy is only in controlled trials)

Question 18

What is the normal level of amylase in the blood?

Answer 18

<90 U/L