chapter 5
Pancreatic disorders
Questions
1.A 37-year-old woman with type 1 diabetes mellitus presented to the emergency department with a four-hour history of severe epigastric pain radiating through to the back.
Investigations:
| Serum bilirubin | 36 µmol/L |
| Serum alanine aminotransferase (ALT) | 152 U/L |
| Serum alkaline phosphatase (ALP) | 168 U/L |
| Serum albumin | 30 g/L |
| Serum amylase | 1,200 U/L |
| HbA1c | 72 mmol/mol |
| Serum triglycerides | 9 mmol/L |
What is the most likely aetiology of this patient’s acute pancreatitis?
2.A 38-year-old man with ileocaecal Crohn’s disease presented to the emergency department with severe abdominal pain and a serum amylase of 2,134 U/L. He was recently started on azathioprine 250 mg once a day.
B. It is a dose-independent complication
C. It usually manifests as severe acute pancreatitis
D. It usually occurs after more than three months of treatment
E. There is a low rate of repeat pancreatitis on re-exposure
4.A 57-year-old male is admitted to hospital with severe acute epigastric pain that radiates through to the back.
Investigations:
| Haemoglobin | 122 g/L |
| White cell count | 14.6 × 109/L |
| Platelet count | 198 × 109/L |
| Serum sodium | 135 mmol/L |
| Serum potassium | 4.3 mmol/L |
| Serum urea | 5.5 mmol/L |
| Serum creatinine | 83 µmol/L |
| Serum C-reactive protein (CRP) | 180 mg/L |
| Serum bilirubin | 20 µmol/L |
| Serum alanine transferase (ALT) | 66 U/L |
| Serum alkaline phosphatase (ALP) | 179 U/L |
| Serum albumin | 21 g/L |
| Serum amylase | 1,011 U/L |
Which radiological investigation is most appropriate in the acute setting?
B. Computed tomography (CT) abdomen and pelvis with contrast
D. Magnetic resonance cholangiopancreatography (MRCP)
Observations and investigations:
| Temperature | 38.2°C |
| Heart rate | 119 beats per minute |
| Blood pressure | 90/52 mmHg |
| Respiratory rate | 24 breaths per min |
| Patient weight | 75 kg |
| Oxygen saturations (Fi02 28%) | 94% |
| Haemoglobin | 138 g/L |
| White cell count | 14 × 109/L |
| Platelet count | 390 × 109/L |
| Serum amylase | 1,209 U/L |
What would be the best initial resuscitation strategy?
A. 1.5L Ringer’s lactate over one hour
B. 1L hydroxyethyl starch (HES) over one hour
C. 750 ml Ringer’s lactate over one hour
D. Prophylactic antibiotics and 1.5L normal saline over one hour
E. Prophylactic antibiotics and 750 ml Ringer’s lactate over one hour
6.A 32-year-old woman with a history of excessive alcohol consumption is admitted to hospital with acute abdominal pain.
Observations and investigations:
| Temperature | 38.2°C |
| Heart rate | 104 beats per minute |
| Blood pressure | 113/76 mmHg |
| Respiratory rate | 21 breaths per minute |
| Patient weight | 75 kg |
| Oxygen saturations (Fi02 28%) | 94% |
| Haemoglobin | 138 g/L |
| White cell count | 11.8 × 109/L |
| Platelet count | 388 × 109/L |
| Serum amylase | 980 U/L |
What is the most appropriate nutritional strategy?
B. Enteral feeding via nasogastric tube
D. Oral diet when abdominal pain and inflammatory markers begin to improve
Investigations:
| Haemoglobin | 130 g/L |
| White cell count | 17 × 109/L |
| Neutrophil count | 14 × 109/L |
| Serum amylase | 3,014 U/L |
| C-reactive protein | 206 mg/L |
| Serum bilirubin | 95 umol/L |
| Serum alanine transferase (ALT) | 76 U/L |
| Serum alkaline phosphatase (ALP) | 205 U/L |
| Abdominal ultrasound | increased pancreatic volume with marked parenchymal heterogeneity consistent with acute pancreatitis. One 5 mm gallstone in the distal common bile duct with proximal dilation to 9 mm. |
What would be the most appropriate timing of ERCP?
Investigations:
Which of the following would be the best management option?
B. Conventional endoscopic transmural drainage
C. Endoscopic ultrasound (EUS)-guided transmural drainage
9.A 52-year-old man presented with a history of intermittent abdominal pain over the last six-months.
What is the diagnosis shown in the MRCP (Fig.5.2)?
Fig. 5.1 MRCPImage courtesy of Dr Andrew Slater, Consultant Radiologist, OUH NHS Trust andrew.slater@ouh.nhs.uk
10.
Fig. 5.2 MRCPImage courtesy of Dr Helen Bungay, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust
Which cells are responsible for the secretion of secretin?
A. Acinar cells of the pancreas
B. Alpha cells of the pancreas
C. Delta cells of the pancreas
D. Enteroendocrine cells in the duodenum
Which of the following options regarding CP is true?
A. CT has a specificity of 75% for CP
B. Hereditary CP carries a low risk of pancreatic cancer
E. Progression to CP after a single attack of acute pancreatitis occurs in 10% of patients
12.A 65-year-old-man with a long history of heavy smoking described 9-months of worsening offensive loose stool and weight loss.
Which of the following statements regarding pancreatic exocrine insufficiency (PEI) is correct?
A. Co-efficient of fat absorption is the gold standard for detection of mild PEI
B. FE >200 microgram/g has a high negative predictive value for mild–moderate PEI
C. MRCP with secretin has highest sensitivity for diagnosis
D. Severe PEI usually occurs within five years of the onset of CP
E. Vitamin deficiencies can occur in the absence of steatorrhoea
13.
Which of the following is most correct regarding pain in CP?
B. Pain improves with pancreatic enzyme supplementation
C. Pain usually ‘burns out’ after more than 10 years from diagnosis
D. Pain usually presents after the development of steatorrhoea
14.A 58-year-old man presented with a four-week history of jaundice, pruritus, and weight loss. He had a history of eczema and allergic rhinitis. A CT scan revealed a bulky head of the pancreas, an irregular main pancreatic duct, distal common bile duct obstruction, localized lymphadenopathy and bilateral enlarged kidneys.
Which of the following is the best treatment option?
Investigations:
| Haemoglobin | 13 g/L |
| White cell count | 15.1 × 10⁹/L |
| Serum C-reactive protein (CRP) | 120 mg/L |
| Serum bilirubin | 25 µmol/L |
| Serum alanine transferase (ALT) | 50 U/L |
| Serum alkaline phosphatase (ALP) | 120 U/L |
| Serum amylase | 180 U/L |
| CT abdomen with contrast | focal thickening and abnormal enhancement of the second portion of the duodenum with an enlarged pancreatic head |
| Gastroscopy | duodenal wall oedema and stenosis from D1 to D2. |
| Duodenal histology | Brunner’s gland hyperplasia with multiple spindle cells |
Which of the following statements regarding this condition is correct?
A. Endoscopic stenting of the minor papilla is the mainstay of treatment
B. High-dose prednisolone is the optimal first-line therapy
C. Pancreatoduodenectomy is often required
D. Serum levels of CA 19-9 are often elevated
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