Pancreas 11-15

              Questions on Pancreas Surgery 

Pancreatic Carcinoma

Pancreatitis

Pancreatic trauma

Pancreas q 21-25

Pancreas Q 26-30

Pancreas 31-40

Endocrine tumor


Q11. Which of the following regarding biliary strictures in chronic pancreatitis is not true?
a) Endoscopic stenting is a primary modality of management
b) Most of the patients are asymptomatic
c) All patients should undergo evaluation to rule out malignancy
d) Main factor for development of chronic pancreatitis is the proximity to head of pancreas

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Answer

11. 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

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Q12. True about duodenal obstruction in chronic pancreatitis
 
a) Duodenal obstruction is caused by pancreatic pseudeocyst alone
b) Endoscopy cannot diagnose this condition
c) 25% of patients with common bile duct stenosis need surgery for duodenal obstruction also
d) Conservative treatment should be given for a month

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Answer

12. 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

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Q13. 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
Answer 

13. d

4% of patients with chronic pancreatitis have ascites and 12% with pancreatic pseudocyst develop pancreatic ascites. After making a diagnosis, ERCP should be done for defining the site of leak and going for a therapeutic procedure 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 ascites persists or recurs.

 

Q 14. 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

14. 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

 Q15. Most common cause of nausea and vomiting in patients with carcinoma head of pancreas is
 
a) Tumor infiltration of coeliac nerve plexus
b) Direct tumor infiltration of duodenum
c) Tumor infiltration around Superior Mesentary artery
d) External Compression of duodenum

15. a
Nausea and vomiting occurs in upto 50% of patients in carcinoma head of pancreas. Obstructive jaundice in 90%. The most common cause of nausea and vomiting is motility disturbance of stomach and duodenum due to infiltration of coeliac nerve plexus. Rest of the choices are other causes. Small intestine motility disturbcance can occur due to tumor infiltrating the SMA ( Superior Mesenteric  Artery)
Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th ed.
 
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