The Pancreas

Question 1

What’s the pathophysiology in acute pancreatitis?

Answer 1

Increases in intracellular calcium activate protease and pancreatic enzyme release. Injury and necrosis of acinar cells causes inflammation. Local or systemic response occurs.

Question 2

Investigations in suspected pancreatitis?

Answer 2

Blood/urine amylase and lipase levels (raised) amylase 3x normal levels.
Bloods - fbc, CRP, urea, electrolytes, liver biochem, plasma calcium, and ABG (lactate)

Erect CXR - to exclude perforated peptic ulcer. Us for stones or swelling.
MRI or CT will confirm diagnosis and the extent of the necrosis.

Question 3

Management of acute pancreatitis?

Answer 3

Severe vs mild - can be assessed via glasgow criteria for severity, or ransons or APACHE.

Mild - IV fluid, pain relief, NBM, ?NG.

Severe- consider HDU/ITU, abx, NG tube, ERCP within 48hrs if gallstone and or cholangitis.
Contrast enhanced CT/MRI within 3-7days.

Monitor for complications

Question 4

What are the complications of acute pancreatitis?

Answer 4

Hyperglycaemia, hypocalcemia, renal failure and shock

Pts need up to 5 L fluid per day to maintain a good urine output

Question 5

What are the investigations for chronic pancreatitis?

Answer 5

Imaging - AXR, to show calcified pancreas. US/ CT, MRCP, endo US.

Functional - faecal elastase (is reduced), blood sugars ?DM.

Question 6

Treatment for chronic pancreatitis?

Answer 6

ERCP for structures.

Pseudocyst drainage.

Surgical resection - pancreaticojejunostomy - only in cases with severe disease and intractable pain.

Question 7

What is courvoisers law?

Answer 7

In cases of painless jaundice, if the gall bladder is palpable then the cause is not gallstones. (As inflammation and fibrosis of GB would prevent distension)

Causes include pancreatic cancer, or other obstructive diseases.

Question 8

How is pancreatic cancer diagnosed?

Answer 8

High resolution CT is the investigation of choice.

US and or CT (contrast enhanced and spiral)
Ca19-9 marker is present but not specific.

Question 9

Management of pancreatic cancer?

Answer 9

Often palliative, if not able to resect cancer.

5-flurouricil and gemcitabine improve survival.

Symptomatic relief with stent and pain relief.

Question 10

Prognosis for pancreatic cancer?

Answer 10

Surgically treated - 3 year survival 30-40%
Locally advanced 8-12months
Metastatic 3-6months

Question 11

What is Zollinger-Ellison syndrome?i

Answer 11

Gastrinoma (neuroendocrin tumour) produces gastric
Causes duodenal ulceration, and diarrhoea due to hypersecretion of gastric acid which inhibits digestive enzymes.

Dx- fasting gastrin levels

Question 12

Symptoms of a somatastatinoma?

Answer 12

Diabetes mellitus, gallstones, diarrhoea/steatorrhoea.

Symptom relief : octreotide

Question 13

Symptoms of a glucagonoma

Answer 13

Migratory necrolytic dermitis, diabetes mellitus, weight loss, deep venous thrombosis.

Question 14

In which type of MEN is pancreatic neuroendocrine tumours a feature?

Answer 14

MEN 1 
Mainly gastrinoma (50%),insulinoma (20%)

Question 15

What is the modified Glasgow score for severity of pancreatitis?

Answer 15

3 with 48hrs indicates severe

P- pa02 <8
A- age > 55
N - neutrophillia wbc >15
C - calcium <2
R -renal function urea >16
E - enzymes LDH>600; AST >200
A - albumin <32
S - sugar >10 

Amylase and lipase are NOT included.