Pancreatic disease

Question 1

Describe acute pancreatitis and its clinical features

Answer 1

• Acute inflammation of the pancreas
• Upper abdominal pain
• Elevated serum amylase (> 4 x upper limit of normal)
• May be associated with multi-organ failure in severe cases

Question 2

What is the most common cause of acute pancreatitis (60-75% of cases)?

Answer 2

Alcohol abuse

Question 3

What is the 2nd most common cause of acute pancreatitis (25-40% of cases)?

Answer 3

Gallstones

Question 4

List the aetiologies of acute pancreatitis

Answer 4

Alcohol Abuse (60-75%)

Gallstones (25-40%)

Trauma- blunt/postoperative/post-ERCP

Miscellaneous causes:

• Drugs (steroids, azathioprine, diuretics)
• Viruses (mumps, coxsackie B4, HIV, CMV)
• Pancreatic carcinoma
• Metabolic (↑calcium, ↑triglycerides, ↓temp)
• Auto-immune

Idiopathic ~10%

Question 5

What drugs are known to cause acute pancreatitis?

Answer 5

steroids, azathioprine, diuretics

Question 6

What viruses are known to cause acute pancreatitis?

Answer 6

mumps, coxsackie B4, HIV, CMV

Question 7

What is the 3rd most common cause of acute pancreatitis (10% of cases)?

Answer 7

Idiopathic

Question 8

Describe the pathogenesis of acute pancreatitis

Answer 8

• Primary insult to the pancreas results in the release of activated pancreatic enzymes
• These enzymes cause autodigestion, leading to the production of pro-inflammatory cytokines and reactive oxygen species.
• These all result in the production of symptoms such as oedema, fat necrosis and haemorrhage.

Question 9

What is Cullen’s sign?

Answer 9

• Cullen’s sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus
• This sign takes 24–48 hours to appear and can predict acute pancreatitis, with mortality rising from 8–10% to 40%.

Question 10

What can accompany Cullen’s sign?

Answer 10

It may be accompanied by Grey Turner’s sign (bruising of the flank), which may then be indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding.

Question 11

What sign can indicate acute pancreatitis?

Answer 11

Cullens sign

Question 12

What sign can indicate that acute pancreatitis may have caused pancreatic necrosis or retroperitoneal or intraabdominal bleeding?

Answer 12

Grey Turner’s sign - bruising of flanks

Question 13

What is ERCP?

Answer 13

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs

Question 14

What blood tests are used for investigating potential acute pancreatitis patients?

Answer 14

o	Amylase/lipase – higher in pancreatitis 
o	FBC, U&Es, LFTs, 
o	Ca2+ - hypercalcaemia in cancer
o	Glucose
o	Arterial blood gases
o	Lipids
o	Coagulation screen

Question 15

What criteria is used for assessing the severity of acute pancreatitis?

Answer 15

Glasgow Imrie criteria: positive for severe acute pancreatitis if there are 3 or more signs present in the first 48hrs from admission:

P - PaO2 <8KPa
A - age >55yo
N - neutrophils >15x10^9/L
C - <2mmol/L
R - renal function: urea >16mmol/L
E - enzymes LDH >600iU/L, AST >2000iU/L
A - albumin <32g/L
S - sugar, glucose >10mmol/L

Question 16

What biomarker indicates severe pancreatitis?

Answer 16

CRP >150 mg/l also indicates severe pancreatitis

Question 17

How is acute pancreatitis managed generally?

Answer 17

• Analgesia (pethidine, indomethacin)
• Intravenous fluids
• Blood transfusion (if Hb <10 g/dl)
• Monitor urine output (catheter)
• Naso-gastric tube
• Oxygen
• May need insulin
• Rarely require calcium supplements
• Nutrition (enteral or parenteral) in severe cases

Question 18

How is pancreatic necrosis treated?

Answer 18

CT guided aspiration

Antibiotics ± surgery

Question 19

How are gallstones associated with acute pancreatitis treated?

Answer 19

o → EUS/MRCP/ERCP

o → Cholecystectomy

Question 20

How are abscesses treated?

Answer 20

antibiotics + drainage

Question 21

What are pseudocysts and how are they treated?

Answer 21

o Fluid collection without an epithelial lining
o Persistent hyperamylasaemia and/or pain
o Dx by ultrasound or CT scan
o Complications: jaundice, infection, haemorrhage, rupture
o <6 cm diameter → resolve spontaneously
o Endoscopic drainage or surgery if persistent pain or complications

Question 22

What is the mortality rate of mild acute pancreatitis?

Answer 22

<2%

Question 23

What is the mortality rate of severe acute pancreatitis?

Answer 23

15%

Question 24

Define chronic pancreatitis

Answer 24

• ‘Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function’

Question 25

Who is most commonly affected by chronic pancreatitis?

Answer 25

• Males > Females

* Age 35-50 years

Question 26

What is the most common cause of chronic pancreatitis (80% of cases)?

Answer 26

Alcohol

Question 27

What are some common causes of chronic pancreatitis?

Answer 27

Alcohol (80%)

Cystic Fibrosis (CP in 2%)

Congenital anatomical abnormalities e..g Annular pancreas, Pancreas divisum (failed fusion of dorsal & ventral buds)

Hereditary pancreatitis: rare, auto. dom.

Hypercalcaemia

Diet: ?antioxidants ↓ in tropical pancreatitis

Question 28

List 3 genes associated with chronic pancreatitis

Answer 28

PRSS1 – cationic trypsinogen

SPINK1 – pancreatic secretory trypsin inhibitor

CFTR – cystic fibrosis transmembrane conductance regulator)