Pancreatic Surgery Practice Questions

Q: A 66-year-old man presents with obstructive jaundice and is found on ERCP to have periampullary carcinoma. He is otherwise in excellent physical condition with no evidence of metastasis. What is the most appropriate treatment?

Radical excision (Whipple procedure) where feasible. **Explanation:** The patient presents with **periampullary carcinoma**, a term encompassing tumors arising within 2 cm of the ampulla of Vater (including the head of the pancreas, distal common bile duct, ampulla, and duodenum). **1. Why Option A is Correct:** For localized periampullary carcinoma in a patient with a good performance status and no distant metastasis, **surgical resection** offers the only chance for a long-term cure. The standard procedure is the **Pancreaticoduodenectomy (Whipple procedure)**. This involves the radical excision of the pancreatic head, duodenum, gallbladder, distal CBD, and sometimes the gastric antrum. Because these tumors often present early with obstructive jaundice, they have a higher resectability rate and a better prognosis compared to tumors in the body or tail of the pancreas. **2. Why Other Options are Incorrect:** * **Option B:** Local excision is inadequate for malignancy as it fails to address regional lymph node spread and has high recurrence rates. Radiotherapy alone is not curative. * **Options C & D:** External or internal radiation are primarily used as **palliative measures** or as part of neoadjuvant/adjuvant protocols. They cannot replace surgery in a fit patient with resectable disease. **Clinical Pearls for NEET-PG:** * **Most common periampullary tumor:** Pancreatic head carcinoma (but Ampullary CA has the best prognosis). * **Double Duct Sign:** Dilatation of both the CBD and the Pancreatic duct, often seen on imaging in these cases. * **Courvoisier’s Law:** In a patient with obstructive jaundice, if the gallbladder is palpable, the obstruction is unlikely to be due to stones (suggests malignancy). * **Whipple’s Triad** is for Insulinoma; do not confuse it with the **Whipple Procedure**.

Q: Which tumor is commonly seen in the area marked below?

Gastrinoma. ### Explanation The question refers to the **Gastrinoma Triangle** (also known as **Passaro’s Triangle**), a critical anatomical landmark for localizing gastrinomas. **1. Why Gastrinoma is Correct:** The Gastrinoma Triangle is defined by three points: * **Superiorly:** Junction of the cystic and common bile duct. * **Inferiorly:** Junction of the 2nd and 3rd portions of the duodenum. * **Medially:** Junction of the neck and body of the pancreas. Approximately **80–90% of gastrinomas** (Zollinger-Ellison Syndrome) are found within this area. While they can occur in the pancreas, the majority are actually found in the **duodenal wall**. **2. Why Other Options are Incorrect:** * **Insulinoma:** These are the most common functional pancreatic neuroendocrine tumors (pNETs). Unlike gastrinomas, they are distributed **evenly** throughout the head, body, and tail of the pancreas and are rarely extrapancreatic. * **Non-functional tumors:** These are typically found in the **head or tail** of the pancreas but do not have a predilection for the Gastrinoma Triangle specifically. * **VIPoma:** These rare tumors (causing Verner-Morrison syndrome) are most commonly located in the **tail** of the pancreas. **3. NEET-PG High-Yield Pearls:** * **Zollinger-Ellison Syndrome (ZES):** Characterized by refractory peptic ulcers, diarrhea, and gastric acid hypersecretion. * **Rule of 1/3rds for Gastrinomas:** 1/3 are associated with **MEN-1** syndrome; 1/3 are metastatic at diagnosis; 1/3 are multiple. * **Localization:** The most sensitive imaging for localization is **Somatostatin Receptor Scintigraphy (Octreoscan)** or **Endoscopic Ultrasound (EUS)**. * **Surgery:** Enucleation is preferred for small tumors, while Whipple’s procedure may be required for large tumors in the head/duodenum.

Q: Which tumor is commonly seen in the area marked below?

Gastrinoma. ***Gastrinoma*** - **Gastrinomas** are predominantly found in the **Gastrinoma Triangle (Passaro's Triangle)**, bounded by the junction of the cystic and common hepatic ducts, the second and third portions of the duodenum, and the neck and body of the pancreas. - This anatomical region accounts for **90%** of gastrinomas, with the **duodenum** being the most common location within this triangle. *Insulinoma* - **Insulinomas** are distributed more evenly throughout the pancreas, with **90%** located in the pancreatic parenchyma rather than the duodenum. - They show **no predilection** for the gastrinoma triangle and can occur in the head, body, or tail of the pancreas with equal frequency. *Non-functional tumors* - **Non-functional pancreatic neuroendocrine tumors** typically occur in the **pancreatic body and tail** rather than the gastrinoma triangle. - They tend to be **larger at presentation** since they lack hormonal symptoms for early detection, unlike gastrinomas which cause **Zollinger-Ellison syndrome**. *VIPoma* - **VIPomas** predominantly occur in the **distal pancreas (body and tail)**, not in the gastrinoma triangle region. - They cause **WDHA syndrome** (watery diarrhea, hypokalemia, achlorhydria) and are rarely found in the duodenal or periampullary region.

Q: A 40-year-old alcoholic presents with severe epigastric pain and hemodynamic collapse. CT abdomen was performed after fluid resuscitation which shows: (Recent NEET Pattern 2016-17)

Severe acute pancreatitis. ***Severe acute pancreatitis*** - The CT scan shows significant **peripancreatic fat stranding** and **fluid collections** (indicated by arrowheads), which are hallmark features of acute pancreatitis - The presence of **hemodynamic collapse** with extensive peripancreatic inflammatory changes indicates **severe acute pancreatitis** (previously called necrotizing pancreatitis) - Clinical context: **alcoholic patient** with severe epigastric pain and shock—classic presentation requiring ICU care - The **revised Atlanta classification** defines severe acute pancreatitis by the presence of organ failure (hemodynamic collapse = cardiovascular failure) *Acute pancreatitis* - While the CT undeniably shows acute pancreatitis, this option is **too non-specific** given the clinical severity - The presence of **hemodynamic collapse** (organ failure) by definition classifies this as **severe** acute pancreatitis, not simple acute pancreatitis - Missing the severity classification could lead to underestimation of disease gravity and inadequate management *Perforation peritonitis* - Would typically show **free intraperitoneal air** (pneumoperitoneum) on CT, which is absent here - The CT findings are specifically pancreatic: **peripancreatic inflammation and fluid collections**, not diffuse peritoneal contamination - While severe epigastric pain and collapse can occur with perforation, the imaging is diagnostic for pancreatic pathology *Pseudo-pancreatic cyst* - Pseudocyst is a **late complication** of acute pancreatitis, typically forming **4-6 weeks** after the initial attack - Represents a **mature, well-defined fluid collection** with a fibrous wall, not acute inflammatory changes - The patient's **acute presentation** with immediate pain and hemodynamic collapse, along with diffuse peripancreatic inflammatory changes (not a discrete encapsulated collection), excludes this diagnosis

Q: A 30-year-old alcoholic presented with features of acute abdomen. Examination finding is shown below. What is the diagnosis?

Acute pancreatitis, Grey Turner sign. ***Acute pancreatitis, Grey Turner sign*** - The image shows **ecchymosis** and discoloration on the **flank** (side of the abdomen), characteristic of **Grey Turner sign**. - This sign indicates **retroperitoneal hemorrhage** and is associated with severe **acute pancreatitis**. *Acute pancreatitis, Cullen sign* - **Cullen sign** involves periumbilical ecchymosis (discoloration around the navel), which is not depicted in the image. - While also indicative of retroperitoneal hemorrhage in acute pancreatitis, its location is distinct from the image. *Acute pancreatitis, Fox sign* - **Fox sign** is ecchymosis appearing on the superior aspect of the thigh and is a rare sign of retroperitoneal hemorrhage. - The image clearly shows discoloration on the flank, not the thigh. *Renal colic, Dietl's crisis* - **Renal colic** is severe flank pain caused by kidney stones, and **Dietl's crisis** is a rare condition involving severe intermittent flank pain due to kinking of the ureter. - Neither of these conditions is typically associated with the visible ecchymosis shown in the image.

Q: A patient with obstructive jaundice has the following imaging findings suggestive of pancreatic cancer. Which is the most appropriate method for obtaining tissue diagnosis?

EUS guided trans-gastric biopsy. ***EUS guided trans-gastric biopsy*** - **Endoscopic Ultrasound (EUS)** provides high-resolution imaging of the pancreas and surrounding structures, allowing for precise targeting of lesions for biopsy. - EUS-guided fine-needle aspiration (FNA) can accurately diagnose pancreatic tumors causing **obstructive jaundice** with minimal risk of tumor seeding. *CECT guided biopsy* - While computed tomography (CECT) can identify pancreatic masses, **percutaneous CECT-guided biopsy** carries a higher risk of complications such as bleeding, pancreatitis, and tumor seeding, especially for lesions near vital structures. - This method is less accurate for small lesions and may not always provide sufficient tissue for complete diagnosis compared to EUS-FNA. *MRI guided biopsy* - **MRI-guided biopsy** is not a standard or preferred method for biopsying pancreatic lesions due to technical challenges and the availability of more efficient and less invasive alternatives like EUS-FNA. - While MRI is excellent for imaging tissue characteristics, its real-time guidance capabilities for biopsy are limited compared to ultrasound. *Laparoscopic biopsy* - **Laparoscopic biopsy** is a more invasive surgical procedure compared to EUS-FNA and is typically reserved for cases where less invasive methods have failed or when **surgical staging** is required. - It involves general anesthesia, longer recovery, and higher risks of complications, making it less appropriate for obtaining a primary tissue diagnosis in obstructive jaundice due to a pancreatic mass.

Q: Which of the following are local complications of acute pancreatitis? 1. Pseudocyst 2. Pleural effusion 3. Ileus 4. Acute fluid collection Select the correct answer using the code given below.

1, 2 and 4. ***1, 2 and 4*** - **Pseudocyst**, **acute fluid collections**, and **pleural effusions** are all recognized **local complications** of acute pancreatitis due to their direct anatomical proximity or fluid spread from the pancreas [1]. - **Ileus** is a common **systemic complication** rather than a local one, and it arises from inflammation and irritation of the bowel. *2, 3 and 4* - This option correctly identifies **pleural effusion** and **acute fluid collection** as local complications, but **ileus** is typically classified as a **systemic complication** of acute pancreatitis. - While it includes two correct local complications, the inclusion of ileus makes it incorrect as a complete list of local complications. *1, 3 and 4* - This option correctly identifies **pseudocyst** and **acute fluid collection** as local complications, but incorrectly lists **ileus** as a local complication when it is a **systemic complication** [1]. - It also fails to include **pleural effusion**, which is a significant local complication. *1, 2 and 3* - This option correctly identifies **pseudocyst** and **pleural effusion** as local complications but incorrectly includes **ileus**, which is a **systemic complication**. - It also omits **acute fluid collection**, an important local complication of acute pancreatitis.

Q: Which of the following is included in Ranson scoring system to predict the severity of acute pancreatitis at the time of admission? A. WBC count > 15 x 10^3/L B. Blood glucose > 200 mg/dL C. LDH > 350 units/L D. AST > 250 units/L

WBC count > 15,000/mm³. ***WBC count > 15,000/mm³*** - A **high white blood cell count** upon admission is one of the initial criteria in the Ranson scoring system indicating more severe inflammation [1]. - This parameter helps to assess the systemic inflammatory response in acute pancreatitis. *LDH > 350 units/L* - The Ranson criteria specify an **LDH level greater than 350 units/L** as a predictor of severity for acute pancreatitis, but it is assessed **at 48 hours after admission**, not at admission. - This value reflects ongoing tissue damage and enzyme release. *Blood glucose > 200 mg/dL* - A blood glucose level > 200 mg/dL is a criterion for the Ranson score, but it is assessed **at 48 hours after admission**, not at the time of admission. - This can indicate significant pancreatic damage impacting insulin production. *AST > 250 units/L* - While an elevated AST level can be present in acute pancreatitis, the specific Ranson criterion for AST is **> 250 units/L**, and it is assessed **at 48 hours after admission**, not upon admission. - This elevation can suggest hepatobiliary involvement or severe pancreatic necrosis.

Q: Which of the following scoring systems are PRIMARILY designed for assessing the severity of acute pancreatitis?

1. Ranson and Glasgow score. ***Ranson and Glasgow score*** - The **Ranson criteria** and the **Glasgow Coma Scale** (also known as the Imrie score) are classical scoring systems specifically developed and widely used to assess the **severity of acute pancreatitis** [1]. - Both scores incorporate multiple clinical and laboratory parameters evaluated at admission and within the first 48 hours to predict the likelihood of complications and mortality in acute pancreatitis. *APACHE score* - The **Acute Physiology, Age, Chronic Health Evaluation (APACHE) score** (e.g., APACHE II, APACHE III) is a general severity-of-illness classification system for critically ill patients and is not specific to acute pancreatitis. - While it can be applied to patients with acute pancreatitis in the ICU, it's designed for a **broader range of critical illnesses** rather than primarily for pancreatitis. *MELD score* - The **Model for End-Stage Liver Disease (MELD) score** is used to assess the severity of **chronic liver disease** and predict prognosis, particularly for patients awaiting liver transplantation. - It is **not designed for acute pancreatitis** and is irrelevant in this context. *Modified Marshall score* - The **Modified Marshall scoring system** is primarily used to assess **organ dysfunction** in acute pancreatitis, especially in clinical trials or for defining severe acute pancreatitis. - While relevant to pancreatitis severity, it is more focused on **specific organ systems' failure** rather than providing a global predictive score for overall severity and mortality in the same way Ranson or Glasgow scores do.

Question 1

Which of the following is NOT true for annular pancreas?

Accepted Answer

Upper GI series is the investigation of choice

Answer

Duodenal obstruction may be present

Answer

ERCP can be performed

Answer

Non-rotation of the gut is associated

Question 2

A 66-year-old man presents with obstructive jaundice and is found on ERCP to have periampullary carcinoma. He is otherwise in excellent physical condition with no evidence of metastasis. What is the most appropriate treatment?

Accepted Answer

Radical excision (Whipple procedure) where feasible

Answer

Local excision and radiotherapy

Answer

External radiotherapy

Answer

Internal radiation seeds via catheter

Question 3

Which tumor is commonly seen in the area marked below?

Accepted Answer

Gastrinoma

Answer

Insulinoma

Answer

Non-functional tumors

Answer

VIPoma

Question 4

Which tumor is commonly seen in the area marked below?

Accepted Answer

Gastrinoma

Answer

Insulinoma

Answer

Non-functional tumors

Answer

VIPoma

Question 5

A 40-year-old alcoholic presents with severe epigastric pain and hemodynamic collapse. CT abdomen was performed after fluid resuscitation which shows: (Recent NEET Pattern 2016-17)

Accepted Answer

Severe acute pancreatitis

Answer

Acute pancreatitis

Answer

Perforation peritonitis

Answer

Pseudo-pancreatic cyst

Question 6

A 30-year-old alcoholic presented with features of acute abdomen. Examination finding is shown below. What is the diagnosis?

Accepted Answer

Acute pancreatitis, Grey Turner sign

Answer

Acute pancreatitis, Cullen sign

Answer

Acute pancreatitis, Fox sign

Answer

Renal colic, Dietl's crisis

Question 7

A patient with obstructive jaundice has the following imaging findings suggestive of pancreatic cancer. Which is the most appropriate method for obtaining tissue diagnosis?

Accepted Answer

EUS guided trans-gastric biopsy

Answer

CECT guided biopsy

Answer

MRI guided biopsy

Answer

Laparoscopic biopsy

Question 8

Which of the following are local complications of acute pancreatitis?

1. Pseudocyst
2. Pleural effusion
3. Ileus
4. Acute fluid collection

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 3

Question 9

Which of the following is included in Ranson scoring system to predict the severity of acute pancreatitis at the time of admission?

A. WBC count > 15 x 10^3/L
B. Blood glucose > 200 mg/dL
C. LDH > 350 units/L
D. AST > 250 units/L

Accepted Answer

WBC count > 15,000/mm³

Answer

LDH > 350 units/L

Answer

Blood glucose > 200 mg/dL

Answer

AST > 250 units/L

Question 10

Which of the following scoring systems are PRIMARILY designed for assessing the severity of acute pancreatitis?

Accepted Answer

1. Ranson and Glasgow score

Answer

2. APACHE score

Answer

3. MELD score

Answer

4. Modified Marshall score

Pancreatic Surgery — MCQs

Pancreatic Surgery — MCQs

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