Pancreatic Disease

Question 1

Describe the aetiology of acute pancreatitis.

Answer 1

• Alcohol Abuse (60-75%)
• Gallstones (25-40%)
• Trauma
  Miscellaneous;
• Drugs
• Viruses
• Pancreatic carcinoma
• Autoimmune
• Idiopathic

Question 2

Describe the pathogenesis of acute pancreatitis.

Answer 2

Primary insult --> release of activated pancreatic enzymes --> auto digestion
-->
Pro-inflammatory cytokines
Reaction O2 species
--> 
Oedema
Fat necrosis
Haemorrhage

Question 3

Describe the presentation of acute pancreatitis.

Answer 3

• Abdominal pain (may radiate to lower back)
• Vomiting
• Pyrexia
• Tachycardia (hypovolemic shock)
• Oliguria (acute renal failure)
• Jaundice
• Paralytic ileus
• Pleural effusion, ascites

Hypoxia –> resp. failure
Hypocalcaemia –> tetany (rare)
Hyperglycaemia –> diabetic coma

Question 4

Describe the investigation of acute pancreatitis.

Answer 4

• Bloods: serum amylase elevated (up to 4x)
• AXR, CXR
• CT (USS not helpful)

Question 5

Describe the general management of acute pancreatitis.

Answer 5

• Assess severity: Glasgow criteria >3 = severe
• Analgesia
• IV fluids
• Blood transfusions
• Catheter (monitor output)
• Nasogastric tube
• Oxygen
• ?Insulin, calcium, nutrition

Question 6

Describe the complications of acute pancreatitis and how to treat them.

Answer 6

Pancreatic necrosis –> CT-guided aspiration –> antibiotics +/- surgery

Gallstones –> EUS/ERCP/MRCP –> cholecystectomy

Abscess –> drainage and surgery

Pseudocyst –> UCC/CT –> drainage or surgery

Question 7

Describe the prognosis of acute pancreatitis.

Answer 7

• Mild pancreatitis: <2%

- Severe: 15%

Question 8

What is the definition of chronic pancreatitis?

Answer 8

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

Question 9

Is chronic pancreatitis more common in males or females? And in what age group?

Answer 9

M>F.

35-50 years.

Question 10

Describe the aetiology of chronic pancreatitis.

Answer 10

• Alcohol (80%)
• CF
• Congenital anatomical abnormalities e.g. pancreas divisum in 7%
• Hereditary pancreatitis
• ?Diet

Question 11

Name the associated genes of chronic pancreatitis.

Answer 11

• PRSS1: cationic trypsinogen
• SPINK1: pancreatic secretory trypsin inhibitor
• CFTR: CF transmembrane conductance regulator

Question 12

Describe the pathogenesis of chronic pancreatitis.

Answer 12

Duct obstruction;

• Calculi
• Inflammation
• Protein plugs

?Abnormal sphincter of Oddi function;

• Spasm: increase in intrapancreatic pressure
• Relaxation: reflux of duodenal contents

Genetic polymorphisms;
- Abnormal trypsin activation

Question 13

Describe the pathology of chronic pancreatitis.

Answer 13

• Glandular atrophy and fibrosis
• Ducts become dilated, tortuous and strictured
• Secretions may calcify
• Demyelinated nerves due to loss of perineurial cells
• Splenic, sup. mesenteric and portal veins may thrombose –> portal hypertension

Question 14

Describe the presentation of chronic pancreatitis.

Answer 14

Early disease is asymptomatic.

Abdominal pain (85-95%);

• Exacerbated by food and alcohol
• Severity decreases over time

Weight loss;

• Pain
• Anorexia
• Malabsorption

Exocrine insufficiency;

• Fat malabsorption –> steatorrhoea
• Decrease in fat-soluble vitamins (A, D, E, K)
• Decrease in Ca2+, Mg+

Endocrine insufficiency –> diabetes (30%).

Miscellaneous;

• Jaundice
• Portal hypertension
• GI bleed
• Pseudocysts
• ?Pancreatic carcinoma

Question 15

Describe the investigations of chronic pancreatitis.

Answer 15

• AXR –> pancreatic calcification (30%)
• USS: size, diameter, ducts, cysts, tumours
• EUS
• CT

Bloods;

• Elevated serum amylase in acute cases
• Low albumin, Ca2+/Mg+, vitamins
• Pancreatic function tests

Question 16

Describe the management of pain control in chronic pancreatitis.

Answer 16

• Avoid alcohol
• Opiate analgesics
• Coeliac plexus block
• Refer to pain clinic/psychologist
• Endoscopy: pancreatic stones and strictures
• Surgery in selected cases

Question 17

Describe the management of endocrine/exocrine insufficiency in chronic pancreatitis.

Answer 17

• Low fat diet
• Pancreatic enzyme supplements
• May need acid suppression
• Insulin for DM
  (- Vit supplements usually not needed)

Question 18

Describe the prognosis of chronic pancreatitis.

Answer 18

Continued alcohol intake –> 10YS 50%

Abstinence –> 10YS 80%

Question 19

Is pancreatic carcinoma more common in males or females? And in what age group?

Answer 19

• M>F

- 80% 60-80 years

Question 20

Describe the pathology of pancreatic carcinoma.

Answer 20

• Duct cell mutinous adenocarcinoma (75%)

Others;

• Carcinosarcoma
• Cystaadenocarcinoma (better prognosis)
• Acinar cell (aggressive)

Question 21

Describe the symptoms of pancreatic carcinoma.

Answer 21

• Upper abdo pain (75%)
• Painless obstructive jaundice (25%)
• Weight loss (90%)
  Above are alarm symptoms!
• Anorexia, fatigues, diarrhoea/steatorrhoea, nausea, vomiting
• Tender subcut. fat nodules due to metastatic fat necrosis
• Thrombocytopenia migrans
• Ascites, portal hypertension
• Recurrent pancreatitis

Question 22

Describe the signs of pancreatic carcinoma.

Answer 22

• Hepato/splenomegaly
• Jaundice
• Abdo mass, tenderness
• Ascites
• Supraclavicular lymphadenopathy
  Above indicate unresectablee tumour.
• Palpable gallbladder

Question 23

Describe the investigations of pancreatic carcinoma.

Answer 23

USS/CT/EUS

• -> Jaundice with mass
• -> ERCP +/- stent
• -> ?Surgery
• -> Jaundice without mass
• -> EUS/biopsy
• -> CT/EUS/laparoscopy/laparotomy
• -> ?Surgery

Question 24

Describe the management of pancreatic carcinoma.

Answer 24

• <10% are inoperable
• Pacreaduodectomy
• Pain control

Question 25

Describe the prognosis of pancreatic carcinoma.

Answer 25

Inoperable;

• Mean survival <6 months
• 5YS 1%

Operable;
- 5YS 15%