p.16
Clinical Presentation and Diagnosis of Acute Pancreatitis
How is walled-off necrosis (WON) confirmed?
It is confirmed by CT scan and CT-guided aspiration, with collected fluid sent for culture.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What are some causes of pancreatic duct obstruction?
Biliary tract stones, duodenal ulcer, duodenal Crohn’s, and trauma.
p.12
Management and Treatment of Acute Pancreatitis
What type of antibiotics are recommended for acute pancreatitis?
Prophylactic or therapeutic antibiotics such as third generation cephalosporins, imipenem, meropenem, and cefuroxime.
p.18
Management and Treatment of Acute Pancreatitis
When should surgery be delayed for a sterile necrotic pancreas?
Surgery should be delayed until as late as possible for demarcation/organization of necrotic areas.
p.1
Anatomy and Location of the Pancreas
Where does the main pancreatic duct join the bile duct?
The main pancreatic duct joins the bile duct in the wall of the second part of the duodenum to form the hepatopancreatic ampulla (Ampulla of Vater).
p.15
Management and Treatment of Acute Pancreatitis
What management options are available for pseudocysts?
Management includes observation for spontaneous resolution, ERCP for ductal anatomy, endoscopic or ultrasound-guided drainage, and surgical drainage if the cyst is larger than 6 cm or infected.
p.15
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the role of EUS-guided aspiration in the evaluation of pseudocysts?
EUS-guided aspiration is used to analyze fluid for amylase and CEA levels, helping to differentiate between pseudocysts and mucinous neoplasms.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the normal value range for serum lipase?
The normal value for serum lipase is 0 – 50 units/L, but it can depend on the method and laboratory.
p.14
Management and Treatment of Acute Pancreatitis
What is the surgical management approach for infected pancreatic necrosis in severe necrotising pancreatitis?
Surgical management involves removing intra- and extra-pancreatic necrotic materials, pancreatic fluid, and toxins, preserving viable pancreatic tissue. Open surgery is considered the gold standard.
p.1
Anatomy and Location of the Pancreas
What is the location of the Ampulla of Vater?
The Ampulla of Vater is located on the posteromedial wall of the second part of the duodenum, at the level of the spine of the 2nd lumbar vertebra.
p.16
Management and Treatment of Acute Pancreatitis
What are the types of surgery that can be performed for pancreatic conditions?
Surgery can be open, laparoscopic, endoscopic, or percutaneous (radiologically guided).
p.16
Complications of Acute and Chronic Pancreatitis
What complications can arise from pancreatic pseudoaneurysm?
It may rupture and cause life-threatening hemorrhage or massive upper GI bleed.
p.18
Management and Treatment of Acute Pancreatitis
What procedure is performed for infected necrosis?
Wide debridement (Necrosectomy) is performed for infected necrosis.
p.18
Management and Treatment of Acute Pancreatitis
What is the mortality rate for an infected necrotic pancreas without operation?
The mortality rate is 100% without operation.
p.4
Complications of Acute and Chronic Pancreatitis
What is the significance of persistent elevation of amylase levels?
Persistent elevation suggests complications like pseudocyst, ascites, and abscess formation.
p.19
Chronic Pancreatitis: Definition and Types
What are the types of chronic pancreatitis?
The types of chronic pancreatitis include chronic relapsing pancreatitis, chronic persistent pancreatitis, non-calcifying pancreatitis, and calcifying pancreatitis.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What haematocrit level is associated with a worse prognosis in acute pancreatitis?
Haematocrit levels higher than 44% are associated with a worse prognosis.
p.5
Clinical Presentation and Diagnosis of Acute Pancreatitis
What are the criteria for diagnosing acute pancreatitis?
The diagnosis requires 2 of the following 3 features: abdominal pain consistent with epigastric pain, serum lipase/amylase activity at least 3x greater than normal, and characteristic findings on imaging.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What genetic mutation is associated with hereditary pancreatitis?
The genetic mutation causes defective trypsin inhibitors, leading to high concentrations of intrapancreatic active trypsin.
p.15
Complications of Acute and Chronic Pancreatitis
What are some complications associated with pseudocysts?
Infection, rupture leading to pancreatic ascites, pancreaticopleural fistula, erosion into splenic vessels causing hemorrhage, and various other complications like cholangitis and duodenal obstruction.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What is the colocalisation hypothesis in acute pancreatitis?
Trypsinogen within the cytoplasmic vacuoles of acinar cells gets colocalised into lysosomal hydrolases, activating trypsin and leading to intrapancreatic inflammation.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What does an Amylase — creatinine clearance ratio (ACR) greater than 5% suggest?
It suggests acute pancreatitis and may also increase in diabetic ketoacidosis and renal diseases.
p.20
Exocrine and Endocrine Functions of the Pancreas
What are the signs of exocrine dysfunction in chronic pancreatitis?
Diarrhea, asthenia, loss of weight and appetite, steatorrhoea, and malabsorption.
p.13
Management and Treatment of Acute Pancreatitis
What is the purpose of gastric decompression with NGT in patients with pancreatitis?
Gastric decompression with NGT is used if there is persistent vomiting, significant gastroparesis, or intestinal obstruction (ileus).
p.13
Management and Treatment of Acute Pancreatitis
What analgesics should be avoided in acute pancreatitis and why?
NSAIDs should be avoided as they can worsen pancreatitis and cause renal failure due to decreased renal perfusion.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What does a CRP level greater than 150 mg/dL at 48 hours indicate in acute pancreatitis?
A CRP level greater than 150 mg/dL at 48 hours indicates that the pancreatitis is more likely to be severe.
p.2
Blood Supply and Nervous Supply of the Pancreas
What artery arises near the upper neck of the pancreas?
The anterior superior gastroduodenal artery arises near the upper neck at the junction with the head of the pancreas.
p.13
Management and Treatment of Acute Pancreatitis
What are the indications for surgical intervention in acute pancreatitis?
Surgical intervention is indicated if the patient's condition deteriorates despite good conservative treatment.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What might an Erect CXR show in cases of necrotizing pancreatitis?
Air under the diaphragm, air-fluid level in the duodenum, pleural effusion, renal halo sign, obliteration of psoas shadow, localized ground glass appearance, elevated hemidiaphragm, pulmonary infiltrates, or complete whiteout (ARDS).
p.14
Complications of Acute and Chronic Pancreatitis
What is a pancreatic pseudocyst and how does it differ from a true cyst?
A pancreatic pseudocyst is a collection of fluid in a false cavity, lined by granulation tissue but lacking true epithelium, making it not a true cyst. It commonly contains brownish pancreatic enzyme-rich fluid.
p.16
Complications of Acute and Chronic Pancreatitis
What characterizes sterile pancreatic necrosis?
It is a focal/diffuse area of non-viable pancreatic parenchyma with peripancreatic fat necrosis, initially sterile but may become infected.
p.20
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the primary symptom of chronic pancreatitis?
Pain in the epigastric region, which is persistent and severe, often radiating to the back.
p.16
Clinical Presentation and Diagnosis of Acute Pancreatitis
How is pancreatic fistula diagnosed?
It is diagnosed by CT angiogram.
p.7
Complications of Acute and Chronic Pancreatitis
What happens to the left-sided diaphragm in acute pancreatitis?
It gets elevated, leading to left-sided pleural effusion.
p.6
Complications of Acute and Chronic Pancreatitis
What is an encapsulated fluid collection with a well-defined inflammatory wall that occurs more than 4 weeks after the onset of interstitial pancreatitis?
This is known as a walled-off necrosis (WON).
p.18
Complications of Acute and Chronic Pancreatitis
What are some complications that can arise from acute pancreatitis?
Intra-abdominal hemorrhage and pseudocyst are potential complications.
p.8
Etiology and Pathophysiology of Acute Pancreatitis
What causes hypocalcaemia in acute pancreatitis?
Hypocalcaemia sets in because calcium is utilized for saponification.
p.5
Severity grading of acute pancreatitis
What is the definition of severe acute pancreatitis?
Persistent organ failure (>48 hours), which can be single or multiple organ failure, associated with necrosis of >1/3 of the pancreas or local complications.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What condition is associated with autoimmune pancreatitis that causes high levels of circulating IgG4?
Lymphoplasmacytic autoimmune pancreatitis.
p.2
Anatomy and Location of the Pancreas
What is the tail of the pancreas related to?
The tail of the pancreas is the distal part related to the spleen and is enveloped by the splenorenal ligament.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What does a peritoneal tap fluid analysis show in acute pancreatitis?
Peritoneal tap fluid shows high amylase and protein levels, which is a very useful method for diagnosis.
p.3
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the significance of estimating P isoenzyme of amylase?
P isoenzyme estimation is more relevant for diagnosing acute pancreatitis compared to general amylase estimation.
p.14
Management and Treatment of Acute Pancreatitis
When should cholecystectomy be performed in cases of gallstone pancreatitis?
Cholecystectomy should be performed as soon as the patient recovers from the acute attack, preferably during the same admission, 3 to 5 days after pancreatic inflammation resolves.
p.15
Clinical Presentation and Diagnosis of Acute Pancreatitis
What imaging study is considered ideal for diagnosing pseudocysts?
CT scan is the ideal and study of choice for diagnosing pseudocysts.
p.18
Management and Treatment of Acute Pancreatitis
What is done after necrosectomy to decrease infective load?
A lavage and drainage procedure is done after necrosectomy.
p.13
Management and Treatment of Acute Pancreatitis
What medications are used for acid suppression to prevent stress ulcers in pancreatitis patients?
IV ranitidine 50 mg 6th hourly, IV omeprazole 40 mg BD, or IV pantoprazole 80 mg BD are used to prevent stress ulcers and erosive bleeding.
p.6
Complications of Acute and Chronic Pancreatitis
What characterizes an acute necrotic collection (ANC) in the context of pancreatitis?
It is a collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
In which conditions is lipase increased?
Lipase is increased in acute and chronic pancreatitis, pseudocyst, cystic fibrosis, pancreatic cancer, bowel ischemia, renal failure, liver diseases, and alcoholism.
p.13
Management and Treatment of Acute Pancreatitis
What is the recommended treatment for hypocalcaemia in pancreatitis patients?
Calcium gluconate 10 ml 10% IV 8th hourly is given as the patient will be hypocalcaemic.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the significance of the APACHE II score in acute pancreatitis?
The APACHE II score takes into account 12 continuous variables and can be used to monitor a patient’s response to therapy.
p.2
Blood Supply and Nervous Supply of the Pancreas
What forms the portal vein behind the neck of the pancreas?
The superior mesenteric vein joins the splenic vein to form the portal vein behind the neck of the pancreas.
p.3
Exocrine and Endocrine Functions of the Pancreas
What is the primary exocrine function of the pancreas?
The secretion of pancreatic juice which aids in the digestion of proteins, carbohydrates, and fats.
p.8
Clinical Presentation and Diagnosis of Acute Pancreatitis
What neurological symptoms can occur due to acute pancreatitis?
Neurological derangements can range from mild psychosis to coma due to toxaemia, fat embolism, and hypoxia.
p.3
Exocrine and Endocrine Functions of the Pancreas
What is the main trigger for pancreatic juice secretion during the intestinal phase?
It is mediated by the release of secretin due to duodenal acidification and by the release of bile and cholecystokinin following the entry of fat and proteins in the duodenum, accounting for 75% of secretion.
p.9
Diagnostic Investigations
What does a non-enhancement finding on CECT indicate?
A non-enhancement finding is typical of pancreatic necrosis (WON).
p.17
Management and Treatment of Acute Pancreatitis
What intervention is mentioned for local complications of acute pancreatitis?
ERCP is mentioned as an intervention for local complications.
p.1
Embryology of the Pancreas
What embryological structures develop into the pancreas?
The pancreas develops from the dorsal and ventral buds.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What is the probable cause of idiopathic pancreatitis?
It is probably due to gallbladder sludge or microcrystals.
p.16
Complications of Acute and Chronic Pancreatitis
What are the potential outcomes of walled-off necrosis (WON)?
WON may form a pseudocyst, abscess, or be replaced by fibrous tissue during healing.
p.12
Management and Treatment of Acute Pancreatitis
What is the cornerstone of therapy in acute pancreatitis?
The cornerstone of therapy in acute pancreatitis is the prevention of pancreatic stimulation, which involves keeping the patient NBM (nil by mouth).
p.20
Clinical Presentation and Diagnosis of Acute Pancreatitis
What are the two types of pain associated with chronic pancreatitis?
Type A pain is short relapsing episodes lasting days to weeks, while Type B pain is prolonged, severe, and unrelenting.
p.20
Clinical Presentation and Diagnosis of Acute Pancreatitis
What causes the gradual diminish in pain over years in chronic pancreatitis?
It is due to 'pancreatic burnout' caused by extensive calcifications and exocrine and endocrine insufficiency.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
In which conditions is a rise in amylase level common?
Acute pancreatitis, pseudocyst of pancreas, pancreatic trauma, and after ERCP.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What conditions can lead to low amylase levels?
Cystic fibrosis, liver damage, pancreatic cancer, and pregnancy with toxaemia.
p.20
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the triad of chronic pancreatitis?
Pancreatic calcification, steatorrhoea, and diabetes mellitus.
p.12
Management and Treatment of Acute Pancreatitis
What should be done if there is evidence of ongoing biliary obstruction in acute pancreatitis?
Definitive treatment such as ERCP may be required.
p.20
Chronic Pancreatitis: Definition and Types
What is the condition of Stage C chronic pancreatitis?
It is the end stage where pancreatic fibrosis has led to loss of clinical exocrine and/or endocrine function.
p.18
Etiology and Pathophysiology of Acute Pancreatitis
What is the recurrence risk for patients with biliary pancreatitis who do not undergo cholecystectomy?
There is a 40% 6-week recurrence risk.
p.8
Clinical Presentation and Diagnosis of Acute Pancreatitis
What signs indicate bleeding in the flanks and around the umbilicus in acute pancreatitis?
Grey-Turner’s sign indicates bleeding in the flanks, while Cullen’s sign indicates discoloration around the umbilicus.
p.2
Anatomy and Location of the Pancreas
What are the anterior relations of the body of the pancreas?
The anterior relations of the body of the pancreas include the stomach, posterior wall of the omental bursa, transverse colon, and middle colic artery.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What does hypocalcaemia indicate in the context of acute pancreatitis?
Hypocalcaemia can occur in acute pancreatitis and is assessed through serum calcium levels.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the significance of methemalbuminemia in acute pancreatitis?
Methemalbuminemia, when it occurs in acute pancreatitis, indicates poor prognosis.
p.9
Diagnostic Investigations
How does serum lipase compare to serum amylase in acute pancreatitis?
Serum lipase is more sensitive and specific than serum amylase, rising within 4-8 hours and staying elevated for 8-14 days.
p.15
Complications of Acute and Chronic Pancreatitis
What are the characteristics of a swelling in the epigastric region indicative of a pseudocyst?
Hemispherical, smooth, soft, not moving with respiration, upper margin diffuse, lower margin well defined, resonant or impaired resonant on percussion, with transmitted pulsation confirmed by knee-elbow position.
p.1
Anatomy and Location of the Pancreas
What are the posterior relations of the pancreas?
The posterior relations of the pancreas include the hilum of the right kidney, right renal vessels, IVC, left renal vein, right crus of diaphragm, posterior pancreaticoduodenal arcade, right gonadal vein, and distal common bile duct (CBD).
p.15
Complications of Acute and Chronic Pancreatitis
What is the mortality risk associated with pseudocysts following biliary pancreatitis compared to alcoholic pancreatitis?
Pseudocysts following biliary pancreatitis have four times more mortality than those following alcoholic pancreatitis.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What is a common etiological factor for acute pancreatitis?
Biliary stone induced pancreatic ductal obstruction and ductal hypertension.
p.12
Management and Treatment of Acute Pancreatitis
What is the recommended fluid management in the first 24 hours for acute pancreatitis?
Aggressive early hydration using 400 ml/hour of crystalloids (Ringer lactate, normal saline) to achieve rapid repletion of severe volume depletion.
p.12
Management and Treatment of Acute Pancreatitis
What is the purpose of nasogastric tube insertion in acute pancreatitis?
To prevent vomiting secondary to ileus.
p.13
Management and Treatment of Acute Pancreatitis
Why is prolonged NBM considered detrimental in pancreatitis management?
Prolonged NBM results in poorer recovery due to nutritional debilitation.
p.18
Etiology and Pathophysiology of Acute Pancreatitis
What lifestyle changes are recommended to prevent recurrence of pancreatitis?
Avoid alcohol, stop all offending medication, and control hyperlipidemia.
p.19
Embryology of the Pancreas
What is pancreas divisum?
Pancreas divisum is the most common congenital anomaly of the pancreas, occurring in 3-10% of individuals, due to the absence of fusion between the dorsal and ventral duct systems during the 6th week of development.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What does the acronym 'I GET SMASHED' represent in the etiology of pancreatitis?
It stands for Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps and other infections, Autoimmune, Scorpion toxin and other toxins, Hypercalcaemia, hypertriglyceridemia, ERCP, and Drugs.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
What are common laboratory findings in acute pancreatitis?
Common findings include raised total count with neutrophilia, thrombocytopaenia, raised FDP, decreased fibrinogen, and prolonged partial thromboplastin time and PT. DIC can develop later.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the relevance of serum lactescence in acute pancreatitis?
Serum lactescence is most specific in hereditary hyperlipidaemia or alcohol pancreatitis.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What signs can be observed on a Supine AXR in necrotizing pancreatitis?
The 'sentinel loop sign' (dilated proximal jejunal loop near the pancreas) or 'colon cut-off sign' (distension of transverse colon with collapse of descending colon).
p.8
Chronic Pancreatitis: Definition and Types
What biochemical change is revealed after fluid correction in chronic pancreatitis?
Hypoalbuminaemia is more revealed after fluid correction in chronic pancreatitis.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is assessed in the Glasgow scoring system for pancreatitis?
PaO2, Age, Neutrophil/WBC, Calcium, Renal (urea), Enzymes LDH or AST/ALT, Albumin, and Sugar (Glucose).
p.14
Complications of Acute and Chronic Pancreatitis
What characterizes an acute pseudocyst?
An acute pseudocyst is a collection of fluid with pancreatic juice localized by a thin fibrin wall or granulation tissue, usually occurring within 2 weeks and often resolving spontaneously.
p.1
Anatomy and Location of the Pancreas
What is the accessory pancreatic duct also known as?
The accessory pancreatic duct is also known as the duct of Santorini.
p.7
Management and Treatment of Acute Pancreatitis
How can idiopathic pancreatitis be treated?
It can be treated by cholecystectomy and sphincterotomy.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What condition is indicated by an ACR less than 1%?
It indicates macroamylasaemia, where amylase binds with large abnormal circulating albumin-like proteins.
p.18
Management and Treatment of Acute Pancreatitis
What is the purpose of CT-guided aspiration of pancreatic necrosis?
It helps differentiate between sterile and infected necrosis.
p.12
Management and Treatment of Acute Pancreatitis
When should a CVP line be used in acute pancreatitis management?
A CVP line is essential for monitoring rapid fluid therapy and for Total Parenteral Nutrition (TPN).
p.19
Chronic Pancreatitis: Definition and Types
What is the definition of chronic pancreatitis?
Chronic pancreatitis is long-standing inflammation of the pancreas with diffuse scarring and structuring in the pancreatic duct, leading to irreversible destruction of the exocrine and, in the late stage, the endocrine parenchyma.
p.20
Chronic Pancreatitis: Definition and Types
What defines Stage B chronic pancreatitis?
It is the intermediate stage where complications have developed, but clinical exocrine and endocrine function is still preserved.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the half-life of lipase compared to amylase?
Lipase has a half-life of 10 hours, which is much longer than that of amylase.
p.8
Complications of Acute and Chronic Pancreatitis
What is a severe complication of acute pancreatitis that has a high mortality rate?
Acute haemorrhagic necrotising pancreatitis (Fulminant pancreatitis) is a severe complication with high mortality.
p.5
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is an acute pancreatic fluid collection (APFC)?
Peripancreatic fluid collection with interstitial pancreatitis, no necrosis, no wall formation, occurring within 4 weeks.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What can trigger acute pancreatitis during major surgeries?
Major surgeries can activate pancreatic enzymes, leading to acute pancreatitis.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
What can cause hyperbilirubinaemia in acute pancreatitis?
Hyperbilirubinaemia may be due to biliary stone/obstruction, cholangitis, or non-obstructive cholectasis.
p.9
Diagnostic Investigations
What is the sensitivity of serum amylase in diagnosing acute pancreatitis?
Serum amylase is moderately sensitive for acute pancreatitis, rising within 6-12 hours, peaking at 24 hours, and normalizing in 3-7 days.
p.3
Clinical Presentation and Diagnosis of Acute Pancreatitis
What happens to serum amylase levels in acute pancreatitis?
It increases more than 1000 units, and the raising titer is more useful for diagnosis.
p.17
Complications of Acute and Chronic Pancreatitis
What methods are used to confirm the presence of a pancreatic fistula?
The presence of a pancreatic fistula is confirmed by biochemical analysis, ERCP, and CT fistulogram.
p.1
Anatomy and Location of the Pancreas
What is the main pancreatic duct also known as?
The main pancreatic duct is also known as the duct of Wirsung.
p.15
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the significance of a high amylase level in cyst fluid?
An amylase level greater than 5000 units/mL indicates a pseudocyst.
p.16
Management and Treatment of Acute Pancreatitis
What is the advantage of Roux-en-Y cystojejunostomy over cystogastrostomy?
Roux-en-Y cystojejunostomy has a lesser recurrence rate than cystogastrostomy.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What causes the unregulated activation of trypsin in acute pancreatitis?
It is caused by the activation of pro-enzymes leading to auto-digestion and an inflammatory cascade.
p.16
Management and Treatment of Acute Pancreatitis
What is the typical treatment approach for infected pancreatic necrosis?
It is ideally treated with laparotomy and debridement, removing all necrotic tissue with adequate drainage.
p.18
Management and Treatment of Acute Pancreatitis
When should ERCP be performed for maximum benefit?
ERCP should be done within the first 48 - 72 hours.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
When is serum amylase considered elevated?
Serum amylase is considered elevated if the level is more than three times the upper limit of normal.
p.20
Exocrine and Endocrine Functions of the Pancreas
What endocrine dysfunction is commonly associated with chronic pancreatitis?
Diabetes mellitus, which may be brittle due to glucagon deficiency.
p.12
Management and Treatment of Acute Pancreatitis
What is the aim for urine output in patients with acute pancreatitis?
The aim for urine output is greater than 0.5ml/kg/hr.
p.13
Management and Treatment of Acute Pancreatitis
What is the role of nasojejunal tube placement in pancreatitis treatment?
Nasojejunal tube placement and feeding should be started as early as possible once ileus subsides to reduce infection rates and improve nutritional status.
p.2
Anatomy and Location of the Pancreas
What is the length of the neck of the pancreas?
The neck of the pancreas measures 1.5 cm in length and is located between the celiac trunk (above) and superior mesenteric vessels (below).
p.13
Management and Treatment of Acute Pancreatitis
When are antibiotics indicated in acute pancreatitis?
Antibiotics are indicated prophylactically in severe acute pancreatitis to prevent infection of necrosis and therapeutically in cholangitis or infection of pancreatic necrosis/pseudocyst.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What imaging techniques are useful in severely ill patients with suspicion of necrotizing pancreatitis?
Erect CXR and Supine AXR, but they cannot confirm the diagnosis.
p.2
Blood Supply and Nervous Supply of the Pancreas
What is the blood supply to the tail of the pancreas?
The blood supply to the tail of the pancreas comes from the splenic artery through pancreatic branches.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the role of MRI/MR cholangiopancreatography (MRCP) in pancreatitis?
It serves as a substitute for CT scan in patients allergic to iodinated contrast or in acute renal failure and is good for visualizing cholelithiasis.
p.9
Diagnostic Investigations
What is the role of Contrast-Enhanced CT Abdomen (CECT) in diagnosing pancreatitis?
CECT is useful in confirming the diagnosis of pancreatitis if hematological results are inconclusive, assessing severity, and detecting local complications.
p.17
Complications of Acute and Chronic Pancreatitis
How can pancreatic fistulas be classified based on output?
Fistulas may be classified as low (<200 ml) or high (>200 ml) output.
p.17
Complications of Acute and Chronic Pancreatitis
What gastrointestinal complications can arise from acute pancreatitis?
Gastrointestinal complications include severe ileus and sequestration of fluid.
p.14
Complications of Acute and Chronic Pancreatitis
What are the local complications associated with acute pancreatitis?
Local complications include acute fluid collections, acute pseudocysts, and pancreatic pseudocysts, with acute fluid collections occurring in 30-50% of cases.
p.1
Anatomy and Location of the Pancreas
Where is the pancreas located in relation to the stomach?
The pancreas is located deep in the abdomen, retroperitoneal, behind the stomach, between the duodenum and spleen.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
How does alcohol contribute to acute pancreatitis?
Alcohol causes direct toxicity, hypersecretion of gastric and pancreatic juices, and spasm of the sphincter of Oddi.
p.7
Etiology and Pathophysiology of Acute Pancreatitis
What is the common pathway in the development of acute pancreatitis?
Either causes spasm of the sphincter of Oddi or increased secretion of pancreatic enzymes.
p.7
Complications of Acute and Chronic Pancreatitis
What are some complications of acute pancreatitis?
Acute tubular necrosis, hypovolemic shock, and pulmonary insufficiency.
p.5
Acute Pancreatitis: Definition and Types
What is the definition of acute pancreatitis?
An acute inflammation of the prior normal gland parenchyma leading to reversible pancreatic parenchymal damage of varying severity with raised pancreatic enzyme levels in blood and urine.
p.5
Acute Pancreatitis: Definition and Types
What are the two phases of acute pancreatitis?
The early phase lasts for 2 weeks with oedematous pancreatitis or sterile necrosis, while the late phase occurs after 2-3 weeks with pancreatic abscess or infective necrosis.
p.6
Clinical Presentation and Diagnosis of Acute Pancreatitis
What percentage of patients with acute pancreatitis experience a mild form that resolves without serious morbidity?
In 80% of patients, acute pancreatitis is mild and resolves without serious morbidity.
p.18
Management and Treatment of Acute Pancreatitis
What is the role of ERCP and endoscopic sphincterotomy in acute biliary pancreatitis?
They are done in the acute setting (within 72 hours) for patients with severe biliary pancreatitis.
p.19
Complications of Acute and Chronic Pancreatitis
What complications arise from pancreas divisum?
Pancreas divisum can lead to a stenosed or inadequately patent minor papilla, preventing normal drainage of pancreatic secretions and resulting in increased intra-ductal pressure.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
Which laboratory test is the most accurate indicator of acute pancreatitis?
Serum trypsin is the most accurate indicator of acute pancreatitis, although it is not commonly used.
p.8
Clinical Presentation and Diagnosis of Acute Pancreatitis
What are some common clinical features of acute pancreatitis?
Common features include vomiting, high fever, tachypnoea with cyanosis, tenderness, rebound tenderness, guarding, rigidity, and abdominal distension.
p.3
Exocrine and Endocrine Functions of the Pancreas
What is the composition of normal pancreatic juice?
It is a colorless, bicarbonate-rich fluid (pH ~8.0) containing around 15 g of protein and approximately ~2.5 liters secreted per day.
p.3
Exocrine and Endocrine Functions of the Pancreas
What triggers pancreatic juice secretion during the gastric phase?
It is triggered by the distention of the stomach and is mediated by gastrin and vagal stimulation, accounting for 15% of secretion.
p.10
Etiology and Pathophysiology of Acute Pancreatitis
What does an elevation of Br > 5mg/dl that does not fall after 6-12 hours suggest?
Impacted stone in the ampulla of Vater.
p.17
Complications of Acute and Chronic Pancreatitis
What causes pancreatic fistulas?
Pancreatic fistulas occur due to ductal wall disruption and necrosis or after surgical intervention for acute pancreatitis (necrosectomy).
p.17
Clinical Presentation and Diagnosis of Acute Pancreatitis
What renal criteria are used to assess systemic failure in acute pancreatitis?
Renal criteria include urine output <40 ml/hour and an increase in blood urea and serum creatinine.
p.18
Management and Treatment of Acute Pancreatitis
What are the indications for performing ERCP in severe pancreatitis?
Severe pancreatitis, evidence of ductal stones, cholangitis, and no response to treatment within 48 hours.
p.12
Management and Treatment of Acute Pancreatitis
What should be monitored in patients with severe acute pancreatitis?
Monitoring should include vitals (SpO2, BP, HR, Temp.), urine output (aim: >0.5ml/kg/hr), and frequent electrolyte levels, including calcium.
p.12
Management and Treatment of Acute Pancreatitis
What type of analgesics should be avoided in acute pancreatitis management?
Morphine and NSAIDs should be avoided as they can cause spasm of the sphincter of Oddi.
p.4
Clinical Presentation and Diagnosis of Acute Pancreatitis
What can cause a false positive elevation in serum amylase levels?
Macroamylasaemia can cause a false positive elevation in serum amylase levels.
p.20
Chronic Pancreatitis: Definition and Types
What characterizes Stage A chronic pancreatitis?
It is the early stage where complications have not yet appeared, and clinical exocrine and endocrine function is preserved.
p.5
Acute Pancreatitis: Definition and Types
What characterizes mild acute interstitial oedematous pancreatitis?
It is common with mortality less than 1%, and 80% of cases are mild.
p.2
Anatomy and Location of the Pancreas
What is the uncinate process of the pancreas?
The uncinate process is the lower posterior extension of the head of the pancreas, passing behind the superior mesenteric vessels and anterior to the IVC and aorta. It usually does not extend beyond the right renal hilum.
p.18
Management and Treatment of Acute Pancreatitis
Why is there reluctance to perform surgery early in patients with severe pancreatitis?
There is a reluctance due to the risk of complications that may require surgical intervention.
p.8
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is the typical pain presentation in acute pancreatitis?
Patients experience sudden onset of severe, agonizing upper abdominal pain that may radiate to the back and is often relieved by leaning forward.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
How does insulin and glucagon secretion change in acute pancreatitis?
There is reduced insulin secretion and increased glucagon and catecholamine secretion, leading to hyperglycaemia, especially in diabetic patients.
p.3
Exocrine and Endocrine Functions of the Pancreas
How is pancreatic juice secretion regulated during the cephalic phase?
It is triggered by the sight, smell, or thought of food and is mediated by acetylcholine, accounting for 10% of secretion.
p.9
Diagnostic Investigations
What does an amylase creatinine clearance ratio greater than 6% indicate?
An amylase creatinine clearance ratio greater than 6% signifies acute pancreatitis.
p.10
Clinical Presentation and Diagnosis of Acute Pancreatitis
What laboratory finding is associated with worse prognosis in pancreatitis?
Elevated white cell count (WCC).
p.17
Chronic Pancreatitis: Definition and Types
What are the late sequelae of chronic pancreatitis?
Late sequelae of chronic pancreatitis can include pancreatic endocrine (15%) and exocrine (20%) insufficiency.
p.19
Etiology and Pathophysiology of Acute Pancreatitis
What is the most common cause of chronic pancreatitis?
The most common cause of chronic pancreatitis is alcohol abuse, accounting for 80% of cases.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What is the mortality rate associated with severe forms of acute pancreatitis?
The mortality rates can be as high as 40% to 100%.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is hypocalcaemia and its prognosis related to ionized calcium?
Hypocalcaemia can be due to decreased albumin level or specific loss of ionized calcium. Hypocalcaemia due to reduced ionized calcium carries a poor prognosis.
p.11
Clinical Presentation and Diagnosis of Acute Pancreatitis
What does a combination of the Glasgow score and CRP improve?
The combination of the Glasgow score and CRP improves the overall prognostic value in acute pancreatitis.
p.8
Clinical Presentation and Diagnosis of Acute Pancreatitis
What signs may indicate shock and dehydration in acute pancreatitis?
Features of shock and dehydration include oliguria, hypoxia, and acidosis.
p.2
Blood Supply and Nervous Supply of the Pancreas
What is the nerve supply to the pancreas?
The parasympathetic supply is from the vagus nerve, and the sympathetic innervation is from the splanchnic nerves.
p.3
Exocrine and Endocrine Functions of the Pancreas
What do the β cells of the Islets of Langerhans secrete?
Insulin, which lowers blood glucose levels.
p.17
Clinical Presentation and Diagnosis of Acute Pancreatitis
What are the cardiac criteria for systemic failure in acute pancreatitis?
Cardiac criteria include hypotension, pulse >130/minute, arrhythmias, and ECG changes.
p.9
Clinical Presentation and Diagnosis of Acute Pancreatitis
What metabolic condition is common due to repeated vomiting in acute pancreatitis?
Hypochloraemic metabolic alkalosis is common due to repeated vomiting.
p.6
Etiology and Pathophysiology of Acute Pancreatitis
What metabolic causes can lead to pancreatitis?
Hypercalcaemia and hyperlipidaemia type I, IV, V can cause pancreatitis.
p.8
Etiology and Pathophysiology of Acute Pancreatitis
What metabolic change is observed due to diffuse capillary leak in acute pancreatitis?
Hypovolaemia occurs due to diffuse capillary leak and vomiting, leading to raised haematocrit, blood urea, and serum creatinine levels.
p.3
Exocrine and Endocrine Functions of the Pancreas
What is the normal value range for serum amylase?
200 – 250 Somogyi units (40 – 140 IU/L).
p.3
Clinical Presentation and Diagnosis of Acute Pancreatitis
What is required for accurate urinary amylase estimation?
Adequate hydration is a must while estimating urine amylase.
p.17
Clinical Presentation and Diagnosis of Acute Pancreatitis
What pulmonary criteria indicate systemic failure in acute pancreatitis?
Pulmonary criteria include PaO2 >60 mm Hg and ARDS.
p.17
Complications of Acute and Chronic Pancreatitis
What surgical interventions are performed if a pancreatic fistula persists for 6 months?
If a fistula persists for 6 months, sphincterotomy, resection of the fistula with pancreatic resection, and pancreaticojejunostomy are performed.
p.17
Complications of Acute and Chronic Pancreatitis
What are the respiratory complications associated with acute pancreatitis?
Respiratory complications include distension of the abdomen, diaphragmatic elevation, pleural effusion, reduced surfactant activity, severe pain, and ARDS.
p.17
Complications of Acute and Chronic Pancreatitis
What is emphysematous pancreatitis?
Emphysematous pancreatitis is characterized by gas in the pancreatic parenchyma and is a dangerous type that can be diagnosed by CT scan.
