Pancreas & Spleen

Question 1

___ joins the ___ and terminates at the Ampulla of Vater, which is surrounded by the ___

___ terminates at the minor papilla

Answer 1

main pancreatic duct joins Duct of Wirsung

surrounded by sphincter of Oddi

Duct of Santorini

Question 2

What hormones do the endocrine cells of the pancreas secrete?

Answer 2

Alpha - glucagon
Beta - insulin
Delta - somatostatin
Gamma - pancreatic polypeptide
Epsilon - ghrelin

Question 3

What cells make up the exocrine pancreas and what do they produce?

Answer 3

Acinar cells
- pancreatic protease (trypsinogen) activated by enterokinase in duodenum
- pancreatic lipase and amylase

Question 4

Blood supply of the pancreas

Answer 4

1) Splenic artery
2) Superior pancreaticoduodenal artery (from celiac)
3) Inferior pancreaticoduodenal artery (from SMA)

Question 5

Diagnosis of acute pancreatitis requires

Answer 5

2 of 3

1) Epigastric pain (acute, persistent, severe, radiates to back)
2) Raised serum lipase/amylase (3x normal)
3) CT/MRI findings

Question 6

Causes of acute pancreatitis

Answer 6

I GET SMASHED

Gallstone, alcohol (60-80%)

idiopathic
gallstones
ethanol
trauma
steroids
mumps
autoimmune
scorpion poison
hypertriglyceridemia, hypercalcaemia
ERCP
drugs
others: neoplasm, congenital

Question 7

Pathophysiology of acute pancreatitis

Answer 7

unregulated activation of trypsin in acinar cells -> auto-digestion -> liquefactive necrosis of pancreatic parenchyma

inflammatory cascade -> SIRS

Question 8

Cx of acute pancreatitis

Answer 8

Respiratory failure
Renal failure
GIT failure

SIRS/infection: fever +- hypotension
tachycardia
obstructive jaundice

Question 9

Signs of haemorrhagic pancreatitis

Answer 9

1. Grey-Turner sign: flank discolouration (ecchymosis)
2. Cullen’s sign: periumbilical ecchymosis
3. Fox’s sign: inguinal ecchymosis

Question 10

Diagnostic lab test for acute pancreatitis

Answer 10

1) Amylase (normal 30-100U/L)
- rises within few hours, normalise in 5 days
- normalises in 5 days

2) Lipase (normal 10-140U/L)
- rises within 4-8 hours, stays elevated 8-14 days
- good for delayed presentation

Question 11

Antibiotics given in acute pancreatitis

Answer 11

None~

Unless tgt with cholangitis -> give IV Rocephin

Question 12

Cx of acute pancreatitis

Answer 12

1) Peripancreatic fluid/necrotic collection -> can become infected -> IV abx + drainage

2) Pseudocyst formation
- persistent pain, mass, high amylase/lipase

3) Walled off pancreatic necrosis
- encapsulated collection of pancreatic/extra-pancreatic necrosis w welldefined inflammatory wall

Question 13

What causes chronic pancreatitis?

Answer 13

Alcohol, smoking
Hypertriglyceridemia
Recurrent severe acute pancreatitis
Autoimmune
Chronic obstruction of pancreatic duct by tumours, scars, stones, cysts

Question 14

Pathogenesis of chronic pancreatitis

Answer 14

Progressive destruction of pancreas by repeated flareups -> diffuse scarring & strictures of pancreatic duct

Question 15

Clinical presentation of chronic pancreatitis

Answer 15

Epigastric pain radiating to back
- worse after eating
- can be hours to days
- a/w nausea/vomiting

Pancreatic insufficiency symptoms
- fat malabsorption -> oily, loose stools (difficult to flush) + Vit ADEK,B12 deficiency
- pancreatic diabetes

Question 16

Diagnosis for chronic pancreatitis

Answer 16

• Calcifications seen on CT

Triad in late advanced disease: calcifications + pancreatic diabetes + steatorrhea

Question 17

Imaging Ix for chronic pancreatitis

Answer 17

• CT
• *MRCP
• ERCP: chain of lakes of main pancreatic duct

Question 18

Gold standard for biochemical test for chronic pancreatitis

Answer 18

Pancreatic secretin stimulation test
- secretin given via IV, pancreatic secretions into duodenum are aspirated and analysed over 2 hrs
- chronic pancreatitis -> little secretions

Question 19

Serum amylase & lipase are used in both acute and chronic pancreatitis. True or false?

Answer 19

False. amylase & lipase usually normal in chronic -> significant fibrosis, decreases these enzymes

Question 20

What is a Whipple’s procedure?

Answer 20

Removal of pancreatic head, distal stomach, duodenum, proximal jejunum, common bile duct, gall bladder

Question 21

Majority of pancreatic tumours are ___ that originate from the ___ pancreas

Answer 21

ductal adenocarcinoma

exocrine pancreas

Question 22

Risk factors for pancreatic cancer

Answer 22

Modifiable: smoking, alcohol, obesity, high fat diet, chlorinated hydrocarbon solvent & asbestos exposure

Un-modifiable: Age, male, family history, DM etc.

DOMINANT RISK FACTORS
- chronic pancreatitis history (family or personal)
- smoking
- family history of pancreatic cancer

Question 23

Most common site for pancreatic cancer

Answer 23

head of pancreas: tends to present earlier as it obstructs bile duct

tail is rare, presents late

Question 24

Symptoms of pancreatic cancer

Answer 24

1) Courvoisier’s law
- painless obstructive jaundice w palpable GB

2) Obstructive jaundice +/- pain
- pain is due to invasion of celiac/mesenteric plexus nerves

3) New onset DM in old patients

Question 25

Signs of advanced pancreatic malignany

Answer 25

1) Virchow’s node: left supraclavicular
2) Sister Mary Joseph nodule: umbilical metastatic lesion via falciform ligament
3) Trousseau’s sign: migratory thrombophlebitis

Question 26

Tumour markers to test for in pancreatic cancer

Answer 26

Carbohydrate Antigen 19-9 (CA19-9)
- marker for recurrence
- marker for prognosis

Lewis blood group antigen

Question 27

____ sign on ____ (what scan) is worrying for pancreatic malignancy (esp HOP)

Answer 27

double duct sign - dilated CBD & pancreatic duct

Seen on triphasic pancreatic protocol CT scan

Question 28

__ of pancreatic cancer pts are not suitable for curative resection

Answer 28

80%

Question 29

Pls make cards for PNET onwards

Answer 29

:)