Pancreatic Disease - Medical and Endoscopic Management

Question 1

What are some complications of acute pancreatitis that cause associated collections?

Answer 1

Can get interstitial oedematous pancreatitis - Acute fluid or pseudocyst
Necrotising pancreatitis - acute necrotic collection or walled off necrosis
Both can be sterile or infected

Question 2

How do you treat post-pancreatitis fluid collection?

Answer 2

Endoscopic Ultrasound (EUS) guided LAMS HOT AXIOS stent then removed stent once resolved
Non-surgical management

Question 3

What would suggest in pleural fluid aspiration that its caused by acute pancreatitis?

Answer 3

High fluid amylase

Question 4

What is the initial conservative treatment for pancreatico-plueral fistula?

Answer 4

Pleural effusion aspiration
HPB clinic
Stop alcohol and smoking
Octreotide injections
Prevent recurrence

Question 5

What is the definite endoscopic treatment of pancreatico-pleural fistula?

Answer 5

ERCP at pancreatic duct
Pancreatic sphincterotomy stent insertion

Question 6

What is the treatment for pancreatic ascites?

Answer 6

Standard percutaneous ascites drainage
NJ tube feeding
Octreotide injections

Question 7

How is pancreatic ascites treated by endoscopy?

Answer 7

ERCP stent insertion

Question 8

What is the definition of chronic pancreatitis?

Answer 8

Continuing inflammatory disease of the pancreas which has irreversible glandular destruction and causes pain or permanent loss of function

Question 9

What are the main causes for chronic pancreatitis?

Answer 9

Alcohol
CF
Congenital anatomical abnormalities
Hereditary pancreatitis
Hypercalcaemia

Question 10

What investigation are used for chronic pancreatitis?

Answer 10

CT, MRI with MRCP and EUS

Question 11

What teams are needed for treatment of chronic pancreatitis?

Answer 11

Gastroenterologist
HPB surgeon
Psychiatry
Dietician
Health point

Question 12

How is chronic pancreatitis managed?

Answer 12

Endoscopic - balloon dilation, removal of stones, stent in MPD
Surgical - Pancreatic head excavation and pancreatotomy to remove distal stones then anastomose with jejunum

Question 13

What are the different types of pancreatic cysts?

Answer 13

SCN (serous cystic neoplasm), MCN (mucinous), IPMN, Pseudocyst (debris)

Question 14

What are the high risk features which suggest surgery for pancreatic cyst?

Answer 14

Jaundice
Main PD > 10mm
Enhancing nodule > 5 mm within cyst

Question 15

What are the worrisome features of pancreatic cysts?

Answer 15

Pancreatitis
Main PD > 5mm
Mural nodule/ solid
Thick cyst wall
Cyst growth more than 5mm in 2 years

Question 16

What radiology is used for PCLs?

Answer 16

CT and MRI
MRI preferred method for follow up

Question 17

What investigations are used for PCLs?

Answer 17

EUS-FNA improves diagnostic accuracy - if benign or malignant
Cyst fluid analyst CEA
Lipase and cytology
Contrast enhanced EUS is superior

Question 18

What are the biomarkers that are analysed in cystic fluid?

Answer 18

DNA markers
Carcino Embrionic Antigen (CEA)
Amylase

Question 19

What are the clinical features of carcinoma of the pancreas?

Answer 19

Abdominal pain - body and tail
Obstructive jaundice - head
Weight loss, anorexia, nausea
Tender subcutaneous fat nodules
Ascites and portal hypertension

Question 20

What is used to investigate carcinoma of the pancreas?

Answer 20

EUS radial and linear

Question 21

What is used to help improve stricture in carcinoma of pancreas?

Answer 21

Metal stent is stricture
ERCP
RFA then metal stent

Question 22

Explain EUS guided Coeliac plexus block

Answer 22

Block - triamcinolone
Neurolysis - absolute alcohol