Pancreatitis

Question 1

What are the causes of acute pancreatitis?

Answer 1

Gallstones
Alcohol
Infections (mumps, coxsackie B)
Pancreatic tumors
Drugs (azathioprine, oestrogen, corticosteroids)
Iatrogenic (post-surgical, ERCP)
Hyperlipidameias 
Trauma
Scorpion bite
Cardiac surgery

I: idiopathic
G: gallstones, genetic - cystic fibrosis
E: ethanol (alcohol)
T: trauma
S: steroids
M: mumps (and other infections)/malignancy
A: autoimmune
S: scorpion stings/spider bites
H: hyperlipidaemia/hypercalcaemia/hyperparathyroidism (metabolic disorders)
E: ERCP
D: drugs (tetracyclines, furosemide, azathioprine, thiazides and many others)

Question 2

What are the causes of chronic pancreatitis?

Answer 2

Alcohol
tropical (nutritional)
Hereditary (CF, trypsinogen defects)
Trauma
Hypercalcaemia

Question 3

What are the clinical features of acute pancreatitis?

Answer 3

Upper abdominal pain that starts in the epigastrium
Nausea and vomiting
Gallstones, attack may follow alcohol binge
Tachycardia, hypotension, oliguric
Tenderness with guarding, reduced or absent bowel sounds
Cullen’s sign (periumbillical) Grey Turner’s (flank bruising)
Cholangitis, jaundice (gallstone aetiology)

Question 4

How is pancreatitis diagnosed?

Answer 4

Serum amylase level
Urinary amylase
Serum lipase levels

Question 5

What are complications of acute pancreatitis?

Answer 5

Pancreatic- necrosis, pseudocyst, abscess, ascites
Intestinal- paralytic ileus, GI haemorrhage
Hepatobiliary- jaundice, obstruction of CBD, portal vein thrombosis
Systemic metabolic- malnutrition, hypoglycaemia, hypocalcaemia
Haemotological- disseminated intravascular coagulation, portal vein thrombosis
Renal- acute renal failure
Cardiovascular- circulatory failure
Respiratory- hypoxic acute respiratory failure

Question 6

What are the clinical features of chronic pancreatitis?

Answer 6

Epigastric pain radiating through to the back (exacerbated in alcohol excess)
Anorexia and weight loss
Malabsorption or diabetes
Jaundice secondary to common bile duct obstruction

Question 7

What are the symptoms of carcinoma of the head of the pancreas or ampulla of vater?

Answer 7

Present earlier with obstruction to the bile duct as this passes through the head of the pancreas giving jaundice
Localised lesions are often painless
Often no physical signs

Question 8

What are the symptoms of carcinoma localised to the body or tail of the pancreas?

Answer 8

Abdominal pain 
Anorexia and weight loss
Dull pain with radiation to the back, relieved by sitting forwards
Jaundice, scratch marks
Gallbladdermay be palpable (Courvoisier's sign)
Central abdominal mass
Hepatomegaly
Polyarthritis, skin nodules

Question 9

What are gastrinomas?

Answer 9

Duidenal ulcer disease
Hypersecretion of gastric acid secondary to ectopic gastrin secretion within the endocrine pancreas (Zollinger-Ellison)
Elevated gastrin level

Question 10

What are VIPomas?

Answer 10

Endocrine pancreatic tumour producing vasoactive intestinal polypeptide (VIP)
Severe secretory diarrhoea secondary to the stimulation of adenyl cyclase within the enterocyte (Verner-morrison syndrome)
Hypokalaemia and metabolic acidosis
TRIAD- diarrhoea, hypokalaemia, hypochlorhydria

Question 11

What are glucagonomas?

Answer 11

Rare alpha-cell tutors which are responsible for migratory necrolytic dermatitis, weight loss, diabetes, deep vein thrombosis, anaemia, hypoalbuminaemia
Measure pancreatic glucagon in the serum

Question 12

What’s the difference between a pancreatic cyst and a pseudocyst?

Answer 12

Pseudocyst- granulation tissue
Cyst- epithelial tissue
Pancreatic abscess would present with fever, riggers and a tender mass

Question 13

What are the associations for pancreatic cancer?

Answer 13

increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene

Question 14

What are the features of pancreatic cancer?

Answer 14

classically painless jaundice
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Question 15

What is the Glasgow prognostic score for severity of acute pancreatitis? (PANCREAS)

Answer 15

Score over 3 severe 
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L

Question 16

What are the differentials of hyperamylasaemia?

Answer 16

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Question 17

What occurs in necrosis?

Answer 17

Inflammatory process causes blood vessels to leak and then rupture leading to swelling
Premature activation of lipase which destroys peripancreatic fat
Liquefactive haemorrhage necrosis

Question 18

What occurs when a pseudocyst develops?

Answer 18

Fibrous tissue surrounds necrotic tissues and fills with pancreatic juices
Can become infected to form an abscess