Pancreas

Post Whipple’s Bleeding

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Q) 50 year old male undergoes Whipple pancreaticoduodenectomy.  On post op day 4 patient presented with fever, tachycardia and pain. Ultrasound showed collection in lesser sac  which was drained percutaneously. On pod 10 there is frank blood of 100ml in drain, What is the next line of management?

a. CT angiography

b. Emergency laparotomy

c. Flush the drain with noradrenaline

d. Observe

Ans a 

This is extraluminal bleed on 10th POD following most likely a pancreatic fistula.

Clinical condition is mentioned for day 4 which is  because of pancreatic leak.

  A pancreatic fistula can cause vascular pseudo aneurysm so answer is A CT angiography

Early extraluminal PPH requires reexploration.

Intraluminal bleeding may manifest as extraluminal if there is associated anastomotic breakdown and this may be amenable to angiographic intervention when involving the pancreaticojejunostomy.

Patients present with septic complications and/or a sentinel  bleed. Radiographic embolization has become a more successful modality, with up to 80% success,13 but is limited by the initially intermittent nature of the bleeding

Exploration - if patient is not stable

PPH can result from vascular erosion or pseudoaneurysm formation, commonly in the gastroduodenal artery or other surrounding vessels.

In this scenario, a CT angiography is indicated as the next step to:

  • Identify the source of bleeding.
  • Determine if there is a vascular injury or pseudoaneurysm, which may allow for endovascular intervention, such as embolization, rather than an emergency surgery.

Emergency laparotomy (Option b) is generally reserved for cases where endovascular management is unavailable or ineffective.

Observation (Option d) and Flushing the drain with noradrenaline (Option c) are inappropriate, as they do not address the source of bleeding and may worsen the patient's condition.

Questions on Pancreas 

Association of carcinoma pancreas

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Q) Least common association of Carcinoma Pancreas is with 

a) Smoking

b) Male gender

c) Obesity

d) Lynch Syndrome

Severe Pancreatitis – Scoring

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Q) Not a consistent feature of  severe acute pancreatitis 

a) Persistent organ failure

b) CRP more than 150 mg/dl at 48 hours

c) Single organ failure

d) LDH >350 U /L

Another question on severe pancreatitis

MCN

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Q) All about MCN of pancreas are true except?
1.Presence of eggshell calcification in CT is suggestive  of malignancy
2.cyst fluid analysis can diagnose accurately in 80%
3.invasive MCN is very aggressive with 30%  5YR Survival compared to adeno carcinoma
4. If MCN is non invasive, surgery  is curative

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Borderline resectable pancreatic malignancy

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Q)False in Borderline resectable Pancreatic malignancy

a) Solid tumor contact with the IVC <180

b) Solid tumor contact with the SMA of ≤180 degree

c) Solid tumor with CHA involvement of 2.5 CM

d) Solid tumor contact with the SMV or PV of >180 degrees

 

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Pancreatic ascitis

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Answer

 

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Genetic mutation in sporadic pancreatic cancer

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Q) Initializing mutation in Carcinoma head of pancreas is of which gene?  Questions on pancreas

a) p53

b) Kras 

c) CDKN 2A

d) DPC 4

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