Q21) All are true about ERCP in pancreatitis except
a) Not useful in patient with multiple strictures and stones
b) Ductal stenting associated with changes of c/c pancreatitis in 50%
c) In pts with pancreas divisum minor duct sphincterotomy causes significant pain relief irrespective of size of duct
d) Pain relief with endoscopic intervention occurs irrespective of relief of ductal pressure/ decrease in duct size
Q 22 Regarding islet cell of pancreas true is
a) Cells in descending order of frequency is B,D,A,F
b) B cells are more common in the periphery of islets
c ) Peri islet acinar cells same as acinar cells else where
d) Portal flow from islet to acinar cell helps to control secretions
Q 23 . All are true regarding enzyme supplementation in chronic pancreatitis except
a) Lipase to be given 30000U before or after meal
b) H2 blocker is mandatory with enteric coated tablets
c) Main cause of failure is inadequate dosage
d) In cases of failure of enzyme replacement feeding of medium chain Triglycerides are helpful
A 21) c
c is false
Pancreatic ductal obstruction by fibrotic stenoses and/or calculi are the most frequent indications for endoscopic therapy.
Multiple strictures and stones are not amenable for endoscopic therapy and surgery is preferred. ERCP is contraindicated in multiple stones, intrahepatic stones, biliary anomalies and strictures.
Indications of ERCp in pancreatitis is cholangitis or sepsis. Ductal stenting for prolonged periods have been associated with pancreatitis (Somogyi and Forsmark 1998)
In pancreas divisum, minor duct sphincterotomy does not cause causes good pain relief. Published results consistently show less benefit after minor papilla therapy in those with chronic pancreatitis or chronic pain compared with those with recurrent acute pancreatitis.
The islets are composed of four cell types: A (alpha), B (beta), D, and F cells. The four cell types are
not evenly distributed within the islets or throughout the pancreas
Order is BADF
B cells are located centrally in islets and not in periphery. A and F cells are in periphery where as D cells are evenly distributed.
The rich portal microcirculation of the pancreatic islets allows for the endocrine-to-endocrine cell signaling necessary for hormonal regulation. Aﬀerent arterioles enter the islet in an area of discontinuity in the peripheral, non–B cell mantle of cells. The order of islet cellular perfusion and interaction is from the B cell core outward to the mantle, which is further subordered with most D cells downstream or distal to most A cells. This order allows B cells to inhibit A cell secretion and A cells to stimulateD cell secretion.
REf Sabiston page 941
23 ) b
Indications of enzyme supplementation are -
- Weight loss, steatorrhea (15g/day ) or both
- Dyspepsia, Diarrhoea, bloating, malabsorption of proteins and carbohydrates
- Pain abdomen
Enteric coated microsphere preparations ( these are special tablets that are coated by polymer and remain unaffected at low gastric ph) are better to decrease stool fat excretion than uncoated tablets. Uncoated tablets are inactivated by gastric enzymes. So with enteric coated tablets, use of H2 antagonists and PPIs is not required.
All other choices are true