Q3. Which of the following is not an indication of surgery in Pancreatic ascites
a) Persistent or recurrent accumulation of ascitic fluid
b) Sudden deterioration of symptoms
c) Failure of medical therapy
d) After control of leak after pancreatic duct stenting
Q 4. The most common Vein to be involved in Extrahepatic portal hypertension in chronic pancreatitis is
a) Portal vein
b) Splenic vein
c) Superior mesenteric vein
d) Inferior mesenteric vein
Q 5. Which of the following is not an indication for surgery in Chronic pancreatitis
a) Extra hepatic portal hypertension
b) Recurrent pain abdomen
c) Duodenal obstruction
d) Biliary obstruction without jaundice
Answers
1. a
Main factor for CBD stricture in chronic pancreatitis is the close association of CBD with the head of pancreas.
A pseudocyst compressing the CBD is a rare cause
Most of the patients are asymptomatic or have rise in alkaline phosphatase or bilirubin or both
Surgical therapy is indicated in almost all cases
Endoscopic stenting is not the primary therapy. Stents should be inserted in patients who are unfit for surgery. Stents have their own problems like infection, stent displacement and stent occlusion.
Concomitant malignancy should be ruled out
Schakelford 6th edition page 1311
2. c
Duodenal obstruction occurs in 12% of all cases of chronic pancreatitis and 25% cases operated for CBD obstruction also have duodenal obstruction. It can occur both due to the inflamatory mass and pseudocyst. patient has history of long standing nausea and vomiting. Endoscopy shows a concave extraluminal impression without mucosal involvement. Conservative treatment should be given for 2 weeks only
Schakelford 6th edition page 1311
3. d
4% of patients with chronic pancreatitis have ascites and 12% with pancreatic pseudocyst develop pancraetic ascites. After making a diagnosis, ERCP should be done for defining the site of leak and going for a therapeutic procedue such as endoscopic stenting. Simultaneous use of octreotide, diuretics and repeated paracentesis also helps.
Surgery is not the primary treatment and is indicated when medical management fails, or despite adequate attempt asictes persists or recurs.
4. b
EPH or extrahepatic portal hypertension is the most common vascular complication of chronic pancreatitis. Any part of splenomesentericoportal venous axis may be involved resulting in either occlusive or non occlusive portal hypertension
Splenic vein is the most frequently involved
Common causes of venous thrombosis are
Inflamatory process causing danage to vessel wall with vasospasm, venous stasis and thrombosis
Progressive fibrosis of Chronic pancreatitis
Extrinsic compression by pseudocyst
5. a
EPH as described above as such is not an indication of surgery in chronic pancreatitis. Recurrent pain abdomen and obstruction of surrounding structures form the main indication for surgery.
In case bleeding occurs due to EPH endoscopic sclerotherapy, variceal ligation and porto systemic shunting procedures are the treatment of choice.
