pancreas

Question 1

why must the duodenum be removed if head of pancreas is removed?

endocrine and exocrine function?

Answer 1

because they share the same blood supply (gastroduodenal artery)

endocrine: alpha cells -> glucagon beta cells -> insulin
exocrine: release digestive enzymes (amylase, lipase, trypsin, chymotrypsin)

Question 2

causes of acute pancreatitis?

Answer 2

I: idiopathic
G: gallstones
E: ethanol
T: trauma
S: scorpion bite
M: mumps (CMV, coxsackie B)
A: autoimmune (hyperparathyroid)
S: steroid
H: hyperlipidemia/ hypercalcemia
E: ERCP
D: drugs (metronidazole, valproate, isoniazid)

Question 3

signs and symptoms of acute pancreatitis?

Answer 3

severe constant epigastric pain radiating to the back (worse after meals and lying supine, better when leaning forward), N/V, decreased bowel sounds (adynamic ileus), fever, hypovolemic shock due to third spacing of fluid and vomiting

rare skin changes: cullen sign (periumbilical ecchymosis), grey turner sign (flank ecchymosis), fox sign (inguinal ligament ecchymosis) indicate severe hemorrhagic pancreatitis

Question 4

diagnosis for acute pancreatitis? sign of pancreatitis on xray?

Answer 4

CBC (high WBC and hmt), electrolytes (focus on calcium), RFT (complication AKI), LFT (cause may be stones), amylase and lipase (highly sensitive) must be more than 3 times level of normal, lipid profile (more than 1000 can be a cause)

ultrasound for all patients (gallstones, sludge
ct abdomen (diagnostic uncertainty, severe pancreatitis, know underlying cause)

sign on xray: sentinel loop (dilated loop of bowel)

Question 5

management of acute pancreatitis?

Answer 5

stabilize the patient in acute setting
IV fluids: crystalloids or lactate ringer
nutrition: oral asap/ enteral with NGT/ or TPN
analgesics (nsaids/opioids), antiemetics, correct electrolytes

treat underlying cause

Question 6

complications of acute pancreatitis?

Answer 6

pseudocyst (unresolving symptoms with palpable epigastric mass, treated with drainage/observation)

necrotizing pancreatitis (unresolving symptoms, dx by CECT, tx conservatively, if infected give ABs and drain abscess if present)

abdomen compartment syndrome (due to aggressive IV resus, cause multiorgan failure, laparotomy for decompression/paracentesis)

shock, ARDS, DIC, hypocalcemia (due to fat saponification)

Question 7

define chronic pancreatitis, give etiology and symptoms

Answer 7

it’s progressive inflammation that leads to damage to structure and exo/endocrine function of pancreas

etiology: heavy alcohol use, pancreatic duct obstruction, idiopathic, autoimmune, severe triglyceridemia/hypercalcemia

symptoms: typical epigastric pain is episodic first then becomes persistent, steatorrhea, weight loss, type 1 diabetes

Question 8

diagnosis and treatment of chronic pancreatitis?

Answer 8

amylase and lipase -normal
fecal elastase test (most common)/ 72hr fecal fat estimation (confirmatory) for steatorrhea
glucose tolerance test

imaging: first line is CT abdomen (atrophic pancreas with calcifications and string of beads appearance of pancreatic duct)
can also do xray (show calcifications) and US

treatment: pancreatic enzyme replacement, insulin, analgesics
if pain persists: endoscopic celiac ganglion block/ papillotomy with stent
if pain persists: surgical lateral pancreaticojejunostomy/ pancreaticoduodenectomy/ total pancreatectomy is last line