General Surgery
Pancreas
MBBS surgery notes on the pancreas: acute and chronic pancreatitis and pancreatic cancer including Courvoisier law, mapped to NMC codes SU24.1 to SU24.3.
MedNext Academy | 3 min read
Pancreas
MBBS surgery notes on the pancreas: acute and chronic pancreatitis and pancreatic cancer including Courvoisier law, mapped to NMC codes SU24.1 to SU24.3.
This chapter covers the surgical diseases of the pancreas: acute and chronic pancreatitis and pancreatic cancer. It emphasises the recognition and severity assessment of acute pancreatitis and the classic presentation of pancreatic head cancer.
High-yield: Pancreas
- The commonest causes of acute pancreatitis are gallstones and alcohol.
- Acute pancreatitis presents with severe epigastric pain radiating to the back, vomiting and a raised serum amylase or lipase.
- Serum lipase is more specific and stays raised longer than amylase in acute pancreatitis.
- Severity is assessed with scores such as the modified Glasgow and APACHE II rather than the enzyme level.
- A contrast computed tomography scan defines pancreatic necrosis and complications and is best delayed a few days for accuracy.
- Grey Turner sign, flank bruising, and Cullen sign, periumbilical bruising, indicate severe haemorrhagic pancreatitis.
- Early management is supportive with fluids, analgesia, oxygen and nutrition, as there is no specific drug cure.
- A pancreatic pseudocyst is a late collection of pancreatic fluid without an epithelial lining, often after acute pancreatitis.
- Infected pancreatic necrosis is a serious complication that may need image-guided drainage or necrosectomy.
- Chronic pancreatitis, most often alcohol related, causes chronic pain, malabsorption with steatorrhoea and diabetes.
- Pancreatic cancer is usually a ductal adenocarcinoma and most often arises in the head of the gland.
- Cancer of the pancreatic head causes painless obstructive jaundice, often with a palpable non-tender gallbladder.
- Courvoisier law states that a palpable, non-tender, distended gallbladder with jaundice is unlikely to be due to stones.
- The Whipple pancreaticoduodenectomy is the resection offered for operable cancer of the pancreatic head.
- The carbohydrate antigen 19-9 is a tumour marker used to support diagnosis and monitor pancreatic cancer.
Pancreatic disease at a glance
- **Acute pancreatitis:** Gallstones and alcohol; epigastric pain to the back; raised amylase or lipase; supportive care.
- **Pseudocyst:** Late fluid collection without epithelial lining after acute pancreatitis.
- **Chronic pancreatitis:** Often alcohol; chronic pain, steatorrhoea and diabetes.
- **Pancreatic cancer:** Head adenocarcinoma; painless obstructive jaundice; Whipple resection if operable.
NMC competencies in this chapter
- **SU24.1:** Acute pancreatitis: causes, features and management
- **SU24.2:** Chronic pancreatitis and its complications
- **SU24.3:** Pancreatic tumours and their management
Frequently Asked Questions
What are the commonest causes of acute pancreatitis?
Gallstones and alcohol account for most cases. The diagnosis rests on the clinical picture with a raised serum amylase or the more specific and longer-lasting lipase.
How is the severity of acute pancreatitis judged?
By scoring systems such as the modified Glasgow and APACHE II and by markers of organ dysfunction, not by the height of the amylase or lipase.
How does pancreatic head cancer present?
Classically with painless obstructive jaundice and often a palpable non-tender gallbladder, in keeping with Courvoisier law, along with weight loss and anorexia.
What is a pancreatic pseudocyst?
A collection of pancreatic fluid without a true epithelial lining that develops weeks after acute pancreatitis and may need drainage if large or symptomatic.
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