Surgery of Pancreatic Disorders

Question 1

What is ERCP?

Answer 1

Endoscopic Retrograde Cholangiopancreatography

Question 2

What is MRCP?

Answer 2

Magnetic Resonance Cholangiopancreatography

Question 3

In what age group is pancreatic cancer most common and what is the 5year survival rate?

Answer 3

60-80year olds

0.4%

Question 4

What is the aetiology for pancreatic cancer?

Answer 4

Smoking
Chronic pancreatitis
Hereditary pancreatitis
Inherited predisposition

Question 5

How does pancreatic cancer present? (7)

Answer 5

Obstructive jaundice - Main one
Diabetes
Abdominal/back pain
Anorexia
Vomiting 
Weight loss
Recurrent bouts of pancreatitis

Question 6

What investigations should be done for pancreatic cancer?

Answer 6

CXR
Blood test
Tumour markers - CA19-9
CT-MRI
Biopsy

Question 7

Is patient fit enough for surgery?

Answer 7

History and Examination
CXR
ECG
Respiratory function
Physiological "scoring system"

Question 8

What is Whipple’s surgery?

Answer 8

Remove half of the stomach and the head of the pancreas and some of the duodenum to make an anastamosis with a loop of the jejunum

Question 9

In Whipple’s, if what is retained will there be a better outcome from a gastric point of view?

Answer 9

Pylorus

Question 10

What can occur for obstructive jaundice or duodenal obstruction?

Answer 10

Palliative bypass plus astent

Question 11

What is acute pancreatitis?

Answer 11

Acute inflammation of the pancreas, with variable involvement of other regional tissues or remote organ systems

Question 12

What is the difference between mild and severe acute pancreatitis?

Answer 12

Mild - Minimal organ disruption and uneventful recovery

Severe - Associated with organ failure or local complication

Question 13

What are the possible complications of acute pancreatitis?

Answer 13

Acute fluid collections
Pseudocyst
Pancreatic abscess/necrosis

Question 14

What is the aetiology of acute pancreatitis?

Answer 14

Gallstones
Tumour
Alcohol
Ischaemia
Anatomical abnormalities
Drugs

Question 15

What is the pathophysiology of acute pancreatitis?

Answer 15

Direct injury
Increased sensitivity to stimulation
Oxidation products 
Non-oxidative metabolism
Gallstone blockage
ERCP can caused increased pancreatic ductal pressure

Question 16

What are the symptoms of acute pancreatitis?

Answer 16

Abdominal pain
Nausea/Vomiting
Collapse

Question 17

What are the signs of acute pancreatitis?

Answer 17

Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure

Question 18

What investigations should be done for acute pancreatitis? (7)

Answer 18

FBC, U+E's, LFTs & Amylase
Gluscose
Clotting
CXR
USS
CT
ABG

Question 19

What indicates that acute pancreatitis is severe? (8)

Answer 19

Glucose > 10 mmol/L
Serum [Ca2+]  15000/mm3
Albumin 700 IU/L
Urea > 16 mmol/L
AST/ALT > 200 IU/L Arterial pO2

Question 20

What precipitating factors should be managed for acute pancreatitis?

Answer 20

Cholelithiasis
Alcohol
Ischaemia
Malignancy
Hyperlipidaemia
Anatomical abnormalities 
Drugs

Question 21

What are late complications of acute pancreatitis?

Answer 21

Haemorrhage
Portal hypertension
Pancreatic duct stricture

Question 22

What is the problem for those who get pancreatitis from drinking?

Answer 22

If they stop it may go away but if they start drinking again it will come back

Question 23

What is chronic pancreatitis?

Answer 23

Continuing chronic inflammation of the pancreas, characterized by irreversible morphological changes leading to chronic pain and / or impairment of endocrine and exocrine function of the pancreas

Question 24

What is chronic pancreatitis associated with and in what sex is it more prominent?

Answer 24

Alcohol consumption

Males

Question 25

What are the causes of chronic pancreatitis?

Answer 25

``` Obstruction of MPD e.g. Tumour, Trauma etc. Autoimmune Toxin - Ethanol Idiopathic Genetic Environmental Recurrent injuries ```

Question 26

What are the features of chronic pancreatitis?

Answer 26

``` Pain Pancreatic exocrine insufficiency Diabetes Jaundice Duodenal obstruction Upper GI haemorrhage ```

Question 27

What investigation should be done for chronic pancreatitis?

Answer 27

CT ERCP/MRCP Faecal/serum enzymes Diagnostic enzyme replacment

Question 28

How should chronic pancreatitis be managed? (8)

Answer 28

``` Counselling Alcohol abstinence Analgesia Avoid fat, high protein diet Pancreatic supplmentation Diabetes Steatorrhoea Anti-oxidant therapy ```

Question 29

Under what circumstances should surgery be done for chronic pancreatitis?

Answer 29

Suspicion of malignancy Intractable pain Complications e.g. Cyst/Pancreatic duct stenosis *Drainage or resection can also occur*

Question 30

What is the prognosis of chronic pancreatitis?

Answer 30

Mortality of 50% for over 20-25 years old | *20% die of complications*

Question 31

Under what conditions should an intervention of chronic pancreatitis occur?

Answer 31

CBD stenting or bypass Management of chronic pseudocyst PD stenosis and obstruction