Pancreatic disease

Question 1

What is acute pancreatitis? What are some cardinal features?

Answer 1

Acute inflammation of the exocrine pancreas

Upper abdominal pain
Elevation of serum amylase

Question 2

Causes of acute pancreatitis?

Answer 2

Alcohol abuse (60-75%)
Gallstones (25-40%)
Pancreatic carcinoma 
Drugs (steroids/diuretics/azathioprine)
Viruses (mumps, coxsackie B4, HIV)
Autoimmune 
Idiopathic (10%)

Question 3

Describe the pathogenesis of acute pancreatitis

Answer 3

Primary insult occurs, causes release of activated pancreatic enzymes

Activated enzymes engage in autodigestion of the pancreas - causes oedema, inflammation and haemorrhage

Question 4

Clinical features of acute pancreatitis?

Answer 4

Abdominal pain
Vomiting 
Pyrexia
Bruising 
Tachycardia 
Renal failure

Question 5

Investigations for acute pancreatitis?

Answer 5

ERCP
EUS
Bloods (amylase/lipase/FBC)
AXR/CXR
Contrast CT scan 
MRCP

Question 6

What does ERCP stand for?

Answer 6

Endoscopic retrograde Cholagio-Pancreatography

Question 7

How do you assess severity of acute pancreatitis?

Answer 7

Glasgow criteria (measures levels of several substances in blood) - score of above 3 indicates severe pancreatitis

CRP>150mg/L indicates severe pancreatitis

Question 8

Management of acute pancreatitis?

Answer 8

Analgesia & IV fluids (nutritional support if needed)

If pancreatic necrosis is detected: CT guided aspiration then antibiotic and surgery to treat

If gallstones: EUS/ERCP - cholecystectomy

Question 9

Complications of acute pancreatitis?

Answer 9

Abscess - Antibiotics and drainage

Pseudocyst - fluid collection in pancreas without an epithelial lining. Endoscopic drainage or surgery if doesn’t respond spontaneously

Question 10

What is chronic pancreatitis?

Answer 10

Ongoing inflammatory disease of the pancreas characterized by irreversible glandular destruction that usually causes pain/loss of function

Question 11

Causes of chronic pancreatitis?

Answer 11

Alcohol (80%)
Cystic fibrosis
Congenital abnormalities (annular pancreas/pancreas divisum)
Hypercalcaemia

Question 12

Genes associated with pancreatitis?

Answer 12

PRSS1 - cationic trypsinogen
SPINK1 - fibrosis transmembrane conductor regulator
CFTR - cystic fibrosis transmembrane regulator

Question 13

Sources of possible pathophysiology for chronic pancreatitis?

Answer 13

Duct obstruction (calculi, inflammation, protein plug)

Abnormal sphincter of oddi function (spasm-high intrapancreatic pressure, relaxed - reflux of duodenal contents)

Genetic polymorphisms - eg. abnormal trypsin activation

Question 14

Describe the progression of chronic pancreatitis

Answer 14

Glandular atrophy and fibrosis - ducts become dilated, tortuous and strictured
Secretions may begin to calcify
Exposed nerves may emerge due to loss of perineural cells
Splenic, sup. mes. and portal veins may thrombose - portal hypertension

Question 15

Clinical features of chronic pancreatitis?

Answer 15

Early on is mostly asymptomatic

Abdominal pain (85-95%) - exacerbated by food & alcohol, but diminishes over time 
Weight loss (due to pain & malabsorption)
Exocrine insufficiency (malabsorption)
Endocrine insufficiency (diabetes in 30%)
Other: jaundice, portal hypertension, GI haemorrhage

Question 16

Investigations for chronic pancreatitis?

Answer 16

Abdominal XRay - pancreatic calcification in 30%
Ultrasound (panc. size, cysts, tumours?)
EUS
CT scan (calcification)
Bloods (serum amylase, low albumin?)
Pancreatic function tests (Lundh, pancreolauryl)

Question 17

Management of chronic pancreatitis?

Answer 17

For pain:

• Avoid alcohol - Coeliac plexus block
• Enzyme supplements

For exocrine/endocrine symptoms:

• Low fat diet - Enzyme supplements
• Insulin if diabetes develops

Surgical resection if needed

Question 18

Epidemiology of carcinoma of the pancreas?

Answer 18

Males > Females
80% in 60-80yrs old group
More common in Western countries (most common in Maoris and Hawaiians)

Question 19

Most common type of pancreas carcinoma? Usual anatomical location?

Answer 19

Duct cell mucinous adenocarcinoma (75%)

Usually in pancreas head (60%)
Body (13%), tail (5%)

Question 20

Clinical features of pancreatic carcinoma?

Answer 20

Upper abdominal pain (75%)
Painless obstructive jaundice (25%)
Weight loss (90%)
Fatigue, nausea, vomiting 
Tender subcutaneous fat nodules 
Thrombophlebitis migrans (migrating thrombus)
Ascites/portal hypertension

Question 21

Physical signs of carcinoma of the pancreas?

Answer 21

Hepatomegaly 
Painless Jaundice 
Abdominal mass 
Abdominal tenderness
Ascites/splenomegaly 
Supraclavicular lymphadenopathy 

Above signs usually indicate unresectable tumour

Palpable gallbladder

Question 22

Investigations for carcinoma of Pancreas?

Answer 22

Ultrasound 
CT scan
MRI
EUS 
ERCP
Needle Biopsy

Question 23

Management of carcinoma of pancreas?

Answer 23

<10% operable at time of presentation
Radical surgery - pancreaduodenectomy (Whipple) - can be curative

Palliative:

• Stent for jaundice (or surgery)
• Pain control (opiates/coeliac plexus block)
• Chemotherapy (only in controlled trials)

Question 24

What’s the prognosis for pancreatic carcinoma like?

Answer 24

Very poor

Inoperable cases - mean survival is 6 months, <1% survive 5 years

Operable cases: 15% 5 year survival