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מבחן גמר בכירורגיה > לבלב > Flashcards

לבלב Flashcards

1
Q

מהי הסיבה הכי שכיחה לפאנקריאטיטיס אקוטית

A

אבנים בכיס מרה

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2
Q

What are the main causes of acute pancreatitis

I GET SMASHED

A

I- idiopathic

G- gallstones
E- etanhol (alcohol)
T- trauma

S- steroids
M- mumps
A- autoimmune
S- scorpion sting/ spider sting
H- Hyperlipidemia / Calcemia
E- ERCP
D- Drugs

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3
Q

Which level of Renson for severity of pancreatitis is consider secere?

A

Renson > 3
(out of 10)

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4
Q

מהו הטיפול בפאנקריאטיטיס?

A

שמרני- צום, נוזלים, משככי כאבים חמצן וניטול
נעדיף הזנה אנטרלית פוסט פילורית תוך 24 שעות מהאשפוז

הזנה מוקדמת- מפחיתה סיבוכים וזיהומים

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5
Q

Tx for
* פאנקריאטיטיס קלה בגלל אבנים בכיס מרה
* פאנקריטיטיס קשה בגלל אבנים ביכיס מרה

A
  • במצב קל- כריתת כיס מרה באשפוז
  • במצב קשה- כריתה אלקטיבית לאחר 6 שבועות
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6
Q

מהו % החולים עם פאנקריאטיטיס חריפה שיפתחו נמק?
לרוב איזה חיידקים יהיו מעורבים?

A

20%

חיידקים גרם שליליים- e.coli, klabsiella, pseudomonas

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7
Q

כיצד נאבחן ונטפל ב-
pancreatic necrosis

A

Dgx
CT - אזורי היפופרפוזיה ( אזורים היפודנסיים)
Tx
אנטיובטיקה- Carbapenem- חודרת רקמה נמקית
+
ניקוז פרקטונאי / אנדוסקופי

קו שני
הטריה (נקרוסטומיה) פתוחה

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8
Q

מהו המבנה של פסואודוציסטה בלבלב ומתי מופיעה לרוב?

A

קולקציית נוזל מוקפת רקמת גרנולציה וקולגן (לא אפיתל)

חודש חודשיים לאחר פאנקריאטיטיס חריפה

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9
Q

A 45-year-old male with a history of chronic pancreatitis presents with abdominal discomfort and early satiety. On examination, there is mild abdominal tenderness. A CT scan reveals a well-defined 5 cm pseudocyst located in the tail of the pancreas. The patient is asymptomatic other than the mild discomfort and denies any fever, nausea, or significant pain.

What is the most appropriate next step in the management of this patient?

A) Surgical drainage with cystogastrostomy
B) Observation with serial imaging
C) Percutaneous drainage
D) Immediate endoscopic retrograde cholangiopancreatography (ERCP)
E) Resection of the cyst

A

Observation with serial imaging

Asymptomatic pancreatic pseudocysts less than 6 cm in size can be managed conservatively with observation. Many pseudocysts, especially smaller ones, regress spontaneously, particularly in the absence of symptoms. Only when pseudocysts are symptomatic, enlarging, or associated with complications (such as infection, hemorrhage, or obstruction) is intervention required .

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10
Q

A 58-year-old man presents with a history of severe acute pancreatitis one month ago. He now complains of abdominal pain, early satiety, and weight loss. CT scan reveals a 9 cm pancreatic pseudocyst in the head of the pancreas with compression of the adjacent duodenum. Endoscopic drainage is attempted but fails to improve the patient’s symptoms.

What is the next best step in management?

A) Continued observation
B) Percutaneous drainage
C) Surgical drainage with cystoduodenostomy
D) Resection of the pancreatic head
E) Endoscopic stenting of the cyst

A

urgical drainage with cystoduodenostomy

Large pseudocysts (>6 cm) that are symptomatic, causing obstruction, or fail to regress spontaneously after conservative management often require surgical intervention. In this case, the pseudocyst is compressing the duodenum, causing obstructive symptoms, making cystoduodenostomy (surgical drainage into the duodenum) the appropriate next step. Endoscopic and percutaneous drainage are not appropriate given the size and location of the pseudocyst and the failure of previous endoscopic attempts .

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11
Q

מהו הטיפול בפסואו-ציסט בלבלב?

A

Pseudocysts < 6 cm and asymptomatic can be managed with observation and follow-up imaging, as many will resolve spontaneously.
Pseudocysts >6 cm or those that persist beyond 6 weeks typically require intervention due to the higher risk of complications.

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12
Q

מתי נבצע ניקוז אנדוסקופי ומתי ניתוחי בפסואו-ציסט באינדיקציה ניתוחית?

A
  • Endoscopic drainage is preferred for pseudocysts >6 cm that are adjacent to the stomach or duodenum, accessible, and without complications like infection or hemorrhage.
  • Surgical drainage is indicated when endoscopic drainage fails, the pseudocyst is complicated (e.g., infection, obstruction), or it’s in a location inaccessible by endoscopy.

ניקוז ניתוחי = ציסטגסטרוסטומיה / ציסטדאודנוסטומיה

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13
Q

Epigastric pain with jaundice and new onset of DM should raise a suspect of?

How we Dgx?

A

Chronic pancriatitis

Dgx- ERCP. most common reason - alcohol (80%)

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14
Q

Which pancreatic cysts has starburst appearance with multiple small cysts?

A

Serous cystic neoplasm

הסתיידות מרכזית השולחת ספטות רדיאליות

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15
Q

Which pancreatic cysts is a/w eggshell apperance and calcification?

A

Mucinous cystic neoplasm

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16
Q

Tx for mucinous cystic neoplasm?

A

pancreatectomy of involve part

consider adjvant therapy (if malignant)

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17
Q

what is the lesion a/w cytic enlargment of wirsong duct with metaplasia and mucous secretion?

A

Main duct IPMN

Dgx- CT

18
Q

Which cyst are a/w mucin production and high levels of CEA?

A

Mucinous cysts neoplasm
+
IPMN (intraductal mucnious neoplasm)

CEA is going with mucinous secreted lesions

19
Q

Which pancreatic cysts are a/w high amylase levels?

A
  • psuedo-cysts
  • IPMN

in IPMN- everything is high, so if CEA low = must be psuedo-cysts

20
Q

in IPMN, what are the indication of resection of involved part?

Whippel procedre- pancreaticodudunectomy

A
  1. symptomatic
  2. Cysts > 3 cm
  3. high risk for malignancy jaundice, solid , wirsong > 1 cm, 15% cystd as side brance)
  4. main duct IPMN
21
Q

A 55-year-old woman presents with vague abdominal discomfort. She has no history of pancreatitis or abdominal trauma. A CT scan shows a solitary, thin-walled cyst in the body of the pancreas, measuring 4.5 cm. The cyst fluid analysis reveals high CEA levels and low amylase levels.

What is the most appropriate next step in management?

A) Observation and follow-up imaging
B) Surgical resection
C) Endoscopic drainage
D) Percutaneous biopsy
E) Chemotherapy

A

Surgical resection

This patient has a mucinous cystic neoplasm (MCN), which is characterized by a solitary cyst, high CEA, and low amylase. Due to its malignant potential, the appropriate management is surgical resection, especially when the cyst is >4 cm.

22
Q

A 65-year-old woman presents with an incidental finding of a pancreatic cyst on CT during evaluation for gallbladder disease. The cyst measures 3 cm and is located in the head of the pancreas. The cyst fluid analysis shows low CEA levels and low amylase. The CT shows multiple small cysts with central calcifications.

What is the most likely diagnosis?

A) Pancreatic pseudocyst
B) Intraductal papillary mucinous neoplasm (IPMN)
C) Mucinous cystic neoplasm (MCN)
D) Serous cystic neoplasm (SCN)
E) Pancreatic adenocarcinoma

A

** Serous cystic neoplasm (SCN)**

This patient has a serous cystic neoplasm, characterized by low CEA, low amylase, and a “starburst” calcification pattern. SCNs are usually benign, and treatment is often unnecessary unless symptomatic.

23
Q

A 70-year-old man presents with painless jaundice. A CT scan shows dilation of the main pancreatic duct and multiple cystic lesions within the head of the pancreas. The fluid analysis shows high CEA and high amylase levels.

What is the most appropriate management?

A) Observation with serial imaging
B) Endoscopic drainage
C) Surgical resection
D) Chemotherapy
E) Percutaneous aspiration

A

Surgical resection

This patient likely has a main duct intraductal papillary mucinous neoplasm (IPMN), characterized by ductal dilation and high CEA and amylase levels. Main duct IPMNs carry a high risk of malignancy, so surgical resection is the appropriate treatment.

24
Q

A 48-year-old male with a history of alcohol-induced acute pancreatitis presents with worsening abdominal discomfort. A CT scan reveals a 6 cm fluid-filled collection in the tail of the pancreas. Fluid analysis shows high amylase and low CEA.

What is the most likely diagnosis?

A) Serous cystic neoplasm
B) Mucinous cystic neoplasm
C) Pancreatic pseudocyst
D) Main duct IPMN
E) Pancreatic adenocarcinoma

A

Pancreatic pseudocyst

This patient’s history of pancreatitis and the findings of a fluid-filled cyst with high amylase and low CEA are consistent with a pancreatic pseudocyst. Pseudocysts are typically managed conservatively unless symptomatic or complicated.

25
Q

מהו המעקב הנדרש בגילוי של
Serous cystic neoplasm?

A

CT after 6 months

26
Q

גורם הסיכון המשמעותי ביותר לאדנוקרצינומה של הלבלב

A

עישון

27
Q

Which syndromes a/w pancreatic adenocarcinoma?

A

CF
FAP
lynch
BRCA2
Peutz-Jeghers

Peutz-Jeghers- ביטוי מלנוציטי, כפות ידיים, שפתיים, כפות רגליים, פה וגניטליה

28
Q

Dgx of pancreatic adenocarcinoma?

A

CT for staging (gold standart)
EUS and biopsy
MRCP / ERCP- ductal involvment

eleveted CA 19-9

29
Q

What is the TNM of pancreatic adenocarcinoma?

A

T1- tumor < 2cm (confine to pacnreas)
T2- tumor > 2cm still confine to pancreas
T3- beyond pancreas but not to major vessels
T4- involve Celiac axis or SMA = unresectable

N1- involvment of regional LN

30
Q

When we will give neoadjuvat therapy in pacnreatic adenocarcinoma

A

borderline resectable tumors (involving vessels like the superior mesenteric vein)

FOLFIRINOX

31
Q

What is the Tx for Stage I (T1-2 (< 4 cm) ,N0) and Stage II (T3,N1)

pancreatic adenocarcinoma

A
  • Surgical resection: This is the preferred treatment for resectable tumors.
  • Whipple procedure (pancreaticoduodenectomy) for tumors in the head of the pancreas.
  • Distal pancreatectomy for tumors in the body or tail.
  • Adjuvant chemotherapy: Given after surgery to reduce the risk of recurrence.
  • FOLFIRINOX (preferred) or Gemcitabine.

in stage II- adding Adjuvant Chemoradiation- with positive margins or lymph node involvement.

  • Stage I: Surgery (Whipple or distal pancreatectomy) + adjuvant chemotherapy.
  • Stage II: Surgery + adjuvant chemotherapy, possibly with radiation.
  • Stage III: Neoadjuvant chemotherapy, possible surgery if downstaged, or continued chemotherapy/chemoradiation.
  • Stage IV: Palliative chemotherapy and supportive care (no curative surgery).
32
Q

Tx for stage III of pancreatic adenocarcinoma

A
  • Neoadjuvant chemotherapy
  • Surgical resection may be considered if the tumor becomes resectable after neoadjuvant therapy.
  • Chemotherapy or chemoradiation: For unresectable cases, systemic chemotherapy is the main treatment to control tumor growth and palliate symptoms.

  • Stage I: Surgery (Whipple or distal pancreatectomy) + adjuvant chemotherapy.
  • Stage II: Surgery + adjuvant chemotherapy, possibly with radiation.
  • Stage III: Neoadjuvant chemotherapy, possible surgery if downstaged, or continued chemotherapy/chemoradiation.
  • Stage IV: Palliative chemotherapy and supportive care (no curative surgery).
33
Q

what is the most common complicaiton after whipple?

A

Delayed gastric emptying
חוסר סבילות למזון פומי ומצריך זונדה לזמן ארוך

34
Q

What is the clinical triad of insulinoma?

A
  1. Hypoglicemic signs
  2. low glucose levels
  3. resulation after glucose administration
35
Q

How we dgx insulinoma?

A

monitor glucose levels
insulin
pro-insulin
C-peptide in fasting for 72hrs = gold standart

35
Q

Tx for insulinoma?

A

כריתה של הגידול (אנוקלאציה)

36
Q

מהם 3 האינדיקציות לכריתת לבלב חלקית באינסולינומה?

A
  • קרבה לווירסונג < 2 ממ
  • גידול גדול
  • ממאיר

אינסולינומה- 10% ממאירות
10% כחלק מ-MEN1

37
Q

איזה תסמונת בקרולציה לסמונת זולינגר אליסון (גסטרינומה)

A

MEN1 )25%)

always check for Ca and PTH

MEN1- Pancreatc- Gastrinoma, Pituatry, Para-thyroid

38
Q

באדם עם כיבים פפטים חוזרים שלא מגיבים לטיפול יחד עם רמות גסטרין מוגברות בדם בנוכחות חומציות קיבה
PH < 2
במה נחשוד?
מה נראה בגסטרוסקופיה?

ומה הטיפול

A

גסטרינומה
בגסטרוסקופיה- עיבוי רירית קיבה

high dose PPi
2nd line- tumor resection

39
Q

What are the 4D’s a/w Glucogonoma?

A
  • DM
  • Dermatitis
  • Depression
  • DVT

Necrolytic Migratory erythema- 66% of pt. might perform first

40
Q

איזה גידול לבלבי נוירואנדוקריני גורם ל-4 הבאים:
סכרת, היפוכלורידיה, אבני מרה, סטיאטוריאה

A

סומטוסטינומה

41
Q

איזה גידול לבלבי גורם להופעות הבאות:
שלשולים, היפוקלמיה א-כלוריהידריה

A

VIPoma

מבחן גמר בכירורגיה (26 decks)

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