Pancreatic Disease/Surgery of Pancreatic Disorders

Question 1

What is acute pancreatitis and how does it present?

Answer 1

Acute inflammation of the pancreas presenting with upper abdominal pain and elevation of serum amylase

Question 2

What is the normal level of elevated serum amylase in acute pancreatitis?

Answer 2

4 times the normal upper limit

Question 3

What are the two main causes of acute pancreatitis?

Answer 3

Alcohol abuse

Gallstones

Question 4

Give the less common causes of acute pancreatitis

Answer 4

Trauma 
Drugs
Viruses 
Pancreatic carcinoma 
Metabolic disorders 
Autoimmune disorders 
Idiopathic

Question 5

Other than abdominal pain, what are the typical presentations of acute pancreatitis?

Answer 5

Nausea and vomiting 
Collapse due to fluid loss 
Pyrexia 
Dehydration 
Abdominal tenderness 
Circulatory failure

Question 6

What is the first line treatment in suspected acute pancreatitis?

Answer 6

ERCP

Question 7

What would an endoscopic ultrasound be useful for showing in acute pancreatitis?

Answer 7

Gallstones/obstruction of the bile or pancreatic ducts, pancreatic oedema or pseudocysts

Question 8

Name 3 other investigations done in suspected acute pancreatitis

Answer 8

Amylase and lipase
Bloods - FBC, ABGs, U+Es, calcium, glucose, lipids, coagulations screen
AXR/CXR
Contrast CT

Question 9

What scoring system is used to determine the severity of acute pancreatitis and what score would indicate severe pancreatitis?

Answer 9

The Glasgow Criteria Score

Severe if score > 3

Question 10

What treatments are used in the general management of acute pancreatitis?

Answer 10

Analgesia 
IV fluids 
Blood transfusion 
Urine output monitoring 
Naso-gastric tube if unable to eat
Nutrition 
Oxygen 
Occasionally insulin

Question 11

If pancreatic necrosis is present in pancreatitis, what treatment is necessary?

Answer 11

CT guided aspiration, antibiotics and/or surgery

Question 12

If the cause of acute pancreatitis is gallstones, what may be used to treat?

Answer 12

EUS, MRCP or ERCP

Cholecystectomy

Question 13

What surgical treatment is indicated in acute pancreatitis presenting with jaundice or cholangitis?

Answer 13

Cholecystectomy

Question 14

When would a necrosectomy be indicated?

Answer 14

In acute pancreatitis with necrosis

Question 15

What treatment is indicated for a pseudocyst in acute pancreatitis?

Answer 15

Diagnosis via ultrasound or CT then endoscopic drainage or surgery if persistent pain or complications

Question 16

At would diameter would a pseudocyst normally resolve without medical/surgical treatment?

Answer 16

< 6cm

Question 17

What is chronic pancreatitis?

Answer 17

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

Question 18

What is the major cause of chronic pancreatitis?

Answer 18

Alcohol abuse

Question 19

What is the pathogenesis of chronic pancreatitis?

Answer 19

Duct obstruction leading to calculi formation, inflammation and protein plugs

Question 20

What happens to the pancreatic ducts in chronic pancreatitis?

Answer 20

Become dilated, tortuous and strictured, calcification may occur

Question 21

What veins may thrombose and cause portal hypertension as a result of chronic pancreatitis?

Answer 21

Splenic, superior mesenteric and portal veins

Question 22

What is the typical presentation of chronic pancreatitis?

Answer 22

Upper abdominal pain and weight loss 
Endocrine and exocrine insufficiencies 
Jaundice 
Portal hypertension 
GI haemorrhage 
Pseudocysts 
Pancreatic carcinoma

Question 23

What features of abdominal pain are indicative of chronic pancreatitis?

Answer 23

Pain aggravated by binge drinking

Pain more frequent and less treatable by abstinence

Question 24

What investigations are done in suspected chronic pancreatitis?

Answer 24

Abdominal x-ray 
Ultrasound 
EUS 
CT 
Bloods 
Pancreatic function tests

Question 25

What are the main treatments of chronic pancreatitis?

Answer 25

Pain control is central to management - opiates, coeliac plexus block, referral to pain clinic or psychologist Abstinence from alcohol and cigarettes Endoscopic treatment of stones and strictures Treatment of endocrine or exocrine insufficiencies

Question 26

Why should patients with chronic pancreatitis abstain from cigarettes?

Answer 26

Cigarettes won't cause chronic pancreatitis but will aggravate it once it is established

Question 27

Under what circumstances would surgical treatment of chronic pancreatitis be given?

Answer 27

Suspicion of malignancy | End stage disease with intractable pain

Question 28

What is the prognosis of chronic pancreatitis in patients who continue to drink alcohol?

Answer 28

50% 10 year survival rate

Question 29

What is the main histological type of pancreatic carcinoma?

Answer 29

Duct cell mucinous adenocarcinoma (75%)

Question 30

What location in the pancreas is the most common site of carcinomas?

Answer 30

Head of the pancreas (60%)

Question 31

What are the histological types of pancreatic carcinoma?

Answer 31

Duct cell mucinous adenocarcinoma Carcinosarcoma Cystadenocarcinoma Acinar cell carcinoma

Question 32

What histological type of pancreatic cancer has the best prognosis?

Answer 32

Cystadenocarcinoma

Question 33

What are the three main common presentations of pancreatic carcinoma?

Answer 33

``` Upper abdominal pain (75%) Painless obstructive jaundice (25%) Weight loss (90%) ```

Question 34

What are the possible physical signs of pancreatic carcinoma?

Answer 34

``` Hepatomegaly Jaundice Abdominal mass and/or tenderness Ascites Splenomegaly Supraclavicular lymphadenopathy Palpable gall bladder (ampullary carcinoma) ```

Question 35

What investigations would be done if suspecting pancreatic carcinoma?

Answer 35

``` USS/EUS CT MRI ERCP Percutaneous needle biopsy Laparoscopic/laparotomy investigation ```

Question 36

What percentage of pancreatic carcinomas are operable at the stage of presentation?

Answer 36

10%

Question 37

What is are the main treatments of pancreatic carcinoma?

Answer 37

Palliative care for jaundice - stent, palliative surgery | Pain control - opiates, coeliac plexus block, radiotherapy

Question 38

What is the mean survival of patients with inoperable pancreatic carcinoma?

Answer 38

< 6 months

Question 39

What is the 5 year survival rate of patients with ampullary tumours?

Answer 39

30-50%

Question 40

What are the surgical management options for pancreatic carcinoma?

Answer 40

PPPD Palliative drainage via ERCP, PTC stenting, or palliative bypass Palliative bypass or duodenal stent for duodenal obstruction Palliative bypass at the time of surgery in the event of a failed resection