Pancreatic Disease

Question 1

What is acute pancreatitis?

Answer 1

Acute inflammation of the pancrease

Question 2

What is the main symptom of AP?

Answer 2

Upper abdominal pain

Question 3

What is the main diagnostic test result for AP?

Answer 3

Elevation of serum amylase (>4x upper limit of normal)

Question 4

What may AP be associated with in severe cases?

Answer 4

Multi-organ failure

Question 5

What are the 2 major aetiologies for AP?

Answer 5

Alcohol abuse (60-75%)
Gallstones (25-40%)

Question 6

What is the acronym for aetiology of acute pancreatitis?

Answer 6

I GET SMASHED
Idiopathic 
Gallstones
Ethanol abuse
Trauma
Steroids
Mumps virus
Autoimmune disease
Scorpion stings
Hypertriglyceridaemia/hypercalcaemia
ERCP
Drugs
(also pancreatic carcinoma)

Question 7

What is the pathogenesis for AP?

Answer 7

Acute inflammation of the pancreas
Primary insult
Release of activated pancreatic enzymes resulting in auto-digestion
Leading to release of pro-inflammatory cytokine and reactive oxygen species causing oedema, fat necrosis and haemorrhage

Question 8

What are some possible clinical features of AP?

Answer 8

Abdominal pain - may radiate to back
Vomiting
Pyrexia

Tachycardia, hypovolaemic shock
Oliguria, acute renal failure
Jaundice
Paralytic ileus 
Retroperitoneal haemorrhage (Grey Turner's and Cullen's signs)
Hypoxia (resp failure in severe cases)
Hypocalcaemia (tetany rare)
Hyperglycaemia (sometimes diabetic coma)
Effusions (ascitic + pleural; high amylase)

Question 9

What blood tests can be done to investigate AP? (lots)

Answer 9

Amylase/lipase
GBC
U+Es
LFTs
Ca2+
Glucose
ABG
Lipids
Coagulation screen

Question 10

What 4 imaging tests can be done to investigate AP?

Answer 10

AXR (ileus)
CXR (pleural effusion)
Abdo USS (pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced)

Question 11

What 2 things indicate severe pancreatitis?

Answer 11

Glasgow score >3 (within 48 hrs of admission)

CRP >150mg/l

Question 12

General management for AP? (lots again)

Answer 12

Analgesia (pethidine, indomethacin)
IV fluids
Blood transfusion
Catheter - monitor urine output
NG tube
Oxygen
May need insulin 
(rarely - calcium supplement, nutrition if severe)
Treat cause !

Question 13

Specific management for AP? (2 specific situations)

Answer 13

Pancreatic necrosis ! - CT guided aspiration -> abx +/- surgery

Gallstones ! - EUS/MRCP/ERCO -> cholecystectomy

Question 14

2 complications for AP? How to manage?

Answer 14

Abscess (abx + drain)
Pseudocyst (Dx by USS and CT; can lead to jaundice, infection, haemorrhage, rupture; endoscopic drainage/surgery if persistent pain/complications)

Question 15

What is chronic pancreatitis?

Answer 15

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

Question 16

What demographic is chronic pancreatitis more common in?

Answer 16

Males/Females

Age 35-50 yrs

Question 17

Give the most common cause of chronic pancreatitis

Answer 17

Alcohol (80%)

Question 18

Name some other aetiologies of chronic pancreatitis

Answer 18

Cystic fibrosis (CP in 2%)
Congenital anatomical abnormalities 
Hereditary (rare, auto. dom.)
Hypercalcaemia
Diet (?antioxidants decreased in tropical pancreatitis)

Question 19

Describe 3 methods of pathogenesis for chronic pancreatitis

Answer 19

• Duct obstruction (calculi, inflammation, protein plugs)
• Abnormal sphincter of Oddi function (spasm: increased intrapancreatic pressure; relaxation: refluc of duodenal contents)
• Genetic polymorphisms (abnormal trypsin activation)

Question 20

Describe the pathologies involved in chronic pancreatitis

Answer 20

Glandular atrophy + replacement by fibrous tissue

Ducts become dilated, tortuous + strictured