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FRCR 2A (Crack The FRCR 2A) > 3. GI (The Pancreas) > Flashcards

3. GI (The Pancreas) Flashcards

1
Q

Pancreas echogenicity on US

A

Should be greater than normal liver

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2
Q

Pancreas - anatomy

A

Retroperitoneal structure (tail may be intraperitoneal)

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3
Q

Cystic fibrosis (4)

A

Pancreas involved in 85-90%.
Thickened secretions cause proximal duct obstruction, leasing to 2 main changes in CF
1) Fibrosis - decreased T1 and T2 signal
2) less commonly, fatty replacement (increased T1 signal)

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4
Q

CF Pancreatic trivia (3)

A

Complete fatty replacement is most common finding in adult CF.
Markedly enlarged with fatty replacement has been termed lipomatous pseudohypertrophy of the pancreas (buzzword).
Fibrosing colonopathy: wall thickening of proximal colon as a complication of enzyme replacement therapy.

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5
Q

Shwachman-diamond syndrome (3)

A

2nd commonest cause of pancreatic insufficiency in kids (CF is 1).
Kid with diarrhoea, short stature (metaphyseal chondroplasia) and eczema.
Will also cause lipomatous pseudohypertrophy of pancreas.

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6
Q

Pancreatic lipomatosis (4)

A

Most common pathologic condition involving pancreas.
Commonest cause in childhood is CF.
Commonest cause in adults is obesity.
Additional causes are Cushing syndrome, Chronic steroid use, Hyperlipidaemia and Shwachman-Diamond syndrome

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7
Q

Dorsal pancreatic agenesis

A

Leads to diabetes (most beta cells are in tail),
Associated with polysplenia

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8
Q

Pancreatic agenesis vs lipomatosis

A

Lipomatosis has a duct, agenesis doesn’t

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9
Q

Annular pancreas (4)

A

Embryonic failure of ventral bud to rotate with duodenum, causing encacement of duodenum.
Results in duodenal obstruction (10%), typically presents as duodenal obstruction in kids and pancreatitis in adults.
Associated with other vague symptoms (post prandial fullness, symptoms of peptic ulcer disease)
Annular duct encircling the duodenum on imaging.

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10
Q

Pancreatic trauma (4)

A

Pancreas sits infront of vertebral body, susceptible to trauma.
Integrity of the duct is the most important consideration for surgery.
Delayed complications include pancreatic fistula (10-20%) followed by abscess formation.
Injury can be subtle, may include focal pancreatic enlargement or adjacent stranding/fluid.

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11
Q

Pancreatic trauma (imaging) (4)

A

Can be subtle with just focal enlargement of pancreas.
Low attenuation fluid separating 2 portions of enhancing pancreas, this is a laceration, not contusion.
Presence of fluid surrounding pancreas is nonspecific, could be due to injury or aggressive hydration - will show liver and IVC to prove it’s aggressive fluid resuscitation.
Suspected pancreatic duct injury - need MRCP or ERCP.

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12
Q

Acute pancreatitis - cause (10)

A

Gallstones and Alcohol make up 80% of cases worldwide.
Other causes include:
ERCP,
medications (valproate),
trauma (commonest childhood cause),
pancreatic cancer,
infection (post viral in kids),
hypercalcaemia, hyperlipidaemia,
autoimmune pancreatitis,
pancreatic divisum, groove pancreatitis, tropic pancreatitis, parasites, scorpion bites.

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13
Q

Acute pancreatitis - clinical (4)

A

Prognosis estimated with Balthazar score.
Mild (no necrosis) or severe (necrosis).
Necrotic don’t start doing bad until they’re infected, then mortality is 50-70%.
Outcomes otherwise directly correlated with degree of pancreatic necrosis.

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14
Q

Severe acute pancreatitis (4)

A

Biphasic course.
First 2 weeks are pro-inflammatory. Sterile response in which infection rarely occurs.
Weeks 3-4 transition to anti-inflammatory response, in which risk of translocated intestinal flora and subsequent infection increases.

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15
Q

Pancreatic collections - types

A

No necrosis
<4 weeks - acute peripancreatic fluid collection
>4 weeks - pseudocyst
Necrosis
<4 weeks - Acute necrotic collection
>4 weeks - Walled off necrosis

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16
Q

Non-vascular complications

A

Abscess, infection etc.
Gas - as a characteristic sign of infected fluid collection, is only seen in 20% of cases of pancreatic abscess

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17
Q

Vascular complications of acute pancreatitis

A

Splenic and portal vein thrombosis
- Isolated gastric varices can be secondary to splenic vein occlusion
Pseudo-aneurysm of GDA and splenic arteries.

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18
Q

Acute pancreatitis - Ultrasound

A

Ultrasound: inflamed pancreas is hypoechoic to normal liver (normal pancreas is hyperechoic)

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19
Q

Pancreatic divisum (5)

A

2 ducts, a major (Wirsung) and minor (Santorini) duct.
Santorini is superior and smaller.
Wirsung is posterior.
Most common anatomic variant of the pancreas, and occurs when main portion is drained by the minor or accessory papilla.
Clinical significance is increased risk of pancreatitis.

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20
Q

Chronic pancreatitis - general (4)

A

End result of prolonged inflammatory change, leading to irreversible fibrosis of gland.
Acute pancreatitis and chronic pancreatitis are thought of as different disease processes.
Chronic can still get recurrent acute on chronic disease.

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21
Q

Chronic pancreatitis causes - 2

A

Same causes as acute pancreatitis.
Most common are chronic alcohol abuse and cholelithiasis, together result in 90% of cases.

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22
Q

Chronic pancreatitis - imaging

A

Early
- Loss of T1 signal (pancreatitis is normal the brightest T1 structure in the body)
- Delayed enhancement
- Dilated side branches
Late
- Commonly small, uniformly atrophic - but can have focal enlargement
- Pseudocyst formation (30%)
- Dilatation and beading of the pancreatic duct with calcifications (most characteristic finding)

23
Q

Chronic pancreatitis duct dilatation vs pancreatic malignancy duct dilatation

A

Chronic pancreatitis
- Dilatation is irregular
- Duct is <50% of AP gland diameter
Cancer
- Dilatation is uniform (usually)
- Duct is >50% of the AP gland diameter (obstructive atrophy)

24
Q

Complications of chronic pancreatitis (2)

A

Pancreatic cancer (6% risk with 20 years of chronic pancreatitis).
Focal enlargement of the gland induced by a fibrotic inflammatory pseudotumor may be indistinguishable from pancreatic carcinoma.

25
Q

Autoimmune pancreatitis (4)

A

Associated with elevated IgG4.
Absence of attack symptoms.
Responds to steroids.
Sausage shaped pancreas, capsule like delayed rim enhancement around gland (like a scar)

26
Q

Groove pancreatitis

A

Duodenal and biliary obstruction.
Symptom overlap with pancreatic cancer.
Duodenal stenosis and/or strictures of the CBD in 50% of cases.
Soft tissue within pancreaticoduodenal groove, with or without delayed enhancement.

27
Q

Tropic pancreatitis

A

Young age at onset, associated with malnutrition.
Increased risk for adenocarcinoma.
Multiple large calculi within a dilated pancreatic duct.

28
Q

Hereditary pancreatitis

A

Young age at onset.
Increased risk of adenocarcinoma.
SPINK-1 gene.
Similar to tropic pancreatitis.

29
Q

Ascaris induced

A

Most commonly implicated parasite in pancreatitis.
Worm may be seen within the bile ducts.

30
Q

Autoimmune pancreatitis associated with

A

IgG4

31
Q

IgG4 associated with

A

Autoimmune pancreatitis.
Retroperitoneal fibrosis.
Sclerosing cholangitis.
Inflammatory pseudotumour.
Riedel’s thyroiditis.

32
Q

Autoimmune pancreatitis vs Chronic pancreatitis

A

Chronic pancreatitis has ductal dilatation and ductal calcifications.

33
Q

Pancreatic pseudocyst (2)

A

Most common cause of cystic lesions in the pancreas.
Either due to acute or chronic pancreatitis

34
Q

Simple cysts (pancreatic) (2)

A

True epithelial cysts are rare.
Tend to be associated with syndromes such as VHL, Polycystic kidney disease, Cystic fibrosis.

35
Q

Serous cystadenoma (8)

A

Primarily found in old ladies.
Benign, classically described as heterogenous mixed-density lesion made of multiple, small cysts, resembles a sponge.
More commonly located in pancreatic head.
Does not communicate with pancreatic duct (IPMN).
20% will have classic central scar, with or without central calcifications.
Rarely, can be unilocular.
Unilocular cyst with lobulated contour in head of pancreas suggests unilocular macrocystic serous cystadenoma.
Associated with VHL.

36
Q

Mucinous cystic neoplasm (5)

A

Pre-malignant lesion in women in 50s.
All considered pre-malignant and need to come out.
Generally in body and tail of pancreas.
No communication with pancreatic head (IPMN will communicate).
Peripheral calcifications seen in 25%.
Typically unilocular. If multilocular, indicisual cystic spaces tend to be larger than 2cm in diameter (serous tend to be smaller than 2cm)

37
Q

IPMN (Intraductal Papillary Mucinous Neoplasm) (2)

A

Mucin producing tumours in the duct epithelium.
Can be side branch, main branch or both.

38
Q

Side branch IPMN (3)

A

Typically small cystic mass, often in head or uncinate process.
If large amounts of mucin produced, may result in main duct enlargement
Lesions less than 3cm, usually benign

39
Q

Main branch IPMN (4)

A

Produces diffuse dilatation of the main duct.
Atrophy of the gland and dystrophic calcifications may be seen, mimicking chronic pancreatitis.
Much higher % malignancy compared to side branch.
All main ducts are considered malignant and resection should be considered.

40
Q

Concerning features for malignancy in IPMN

A

Main duct >10mm
Diffuse or multifocal involvement
Enhancing nodules
Solid hypovascular mass

41
Q

Solid pseudopapillary tumour of pancreas (4)

A

Very rare, low grade malignant tumour exclusively in young women (30s).
Usually asian or black women.
Large at presentation, prediliction for tail, thick capsule.
Similar to haemangiona, may demonstrate progressive fill in of solid portions.

42
Q

Solid pancreatic lesions - types (2)

A

2 main types of pancreatic cancer
- Ductal adenocarcinoma (hypovascular)
- Islet cell/neuroendocrine (hypervascular)

43
Q

Ductal adenocarcinoma (4)

A

Enlarged gallbladder with painless jaundice is highly suspicious for ductal adenocarcinoma, especially with migratory thrombophlebitis (Trosseau’s syndrome).
Peak incidence in 7th or 8th decade.
Strongest risk factor is smoking.
2/3 arise from pancreatic head.

44
Q

Ductal adenocarcinoma (imaging) (4)

A

US: Obstruction of both CBD and Pancreatic duct, “double duct sign”.
CT: Hypovascular mass, poorly demarcated, with low attenuation compared to background parenchyma.
Staging: key is assessment of SMA and coeliac axis. if involved, it’s unresectable.
Involvement of GDA is OK, because it comes out with Whipples.

45
Q

Pancreatic adenocarcinoma - trivia (3)

A

Tumour marker Ca 19-9
Hereditary syndromes with Pancreatic Ca:
- HNPCC,
- BRCA mutation
- Ataxia-telangectasia
- Peutz-Jehgers
Small bowel follow through: Reverse impression on duodenum “Frostburg’s Inverted 3 sign” or “Wide Duodenal Sweep”.

46
Q

Periampullary tumour (5)

A

Defined as originating within 2cm of major papilla.
Can be difficult to differentiate from conventional pancreatic adenocarcinoma, both obstruct the bile duct and present as mass in pancreatic head.
Rx: Whipple procedure.
Prognosis is better than pancreatic adenocarcinoma.
Associated with Gardner’s syndrome

47
Q

Islet cell/Neuroendocrine tumour

A

Rare, typically hypervascular with brisk enhancement during arterial phase.
Can be functional or non-functional, and then further divided by the hormone they make.
Associated with MEN-1 and VHL.

48
Q

Islet cell tumour types (3)

A

Insulinoma
- Most common (75%).
- usually benign, solitary and small <2cm
Gastrinoma
- 2nd commonest, but commonest associated with MEN.
- Malignant in 30-60%.
- Cause increased gastric acid output and ulcer formation (Zolinger-Ellison syndrome)
- Jejunal ulcer = Zolinger Ellison
Non-functional
- 3rd commonest, usually malignant (80%)
- Large and metastatic at diagnosis, with calcifications

49
Q

Intrapancreatic accessory spleen (6)

A

Pancreatic mass that’s actually just a piece of spleen.
Often due to post traumatic splenosis.
Another clue may be absence of normal spleen.
Imaging
- Mass follows spleen on all image sequences (dark T1, bright T2, diffusion restricts)
- Tiger striped mass on arterial phase CT (like spleen).
- Heat treated RBC and sulfur colloid both taken up (again, like normal spleen)

50
Q

Whipple procedure (4)

A

Involves resection of pancreatic head, duodenum, gastric antrum and usually gallbladder.
Jejunal loop is brought up to RUQ for gastrojejunal, choledocojejunal or hepatojejunal and pancreatojejunal anastamosis.
Alternative method is to perform pancreatoduodenectomy to preserve pylorus when possible.
Here, stomach is left intact and proximal duodenum is used for duodenojejunal anastamosis.

51
Q

Complications of Whipple procedure (4)

A

Delayed gastric emptying (need for NG tube >1 day) and pancreatic fustula (amylase through surgical drain >50ml for longer than 7-10 days).
Both clinical diagnoses and most common complications of pancreatoduodenectomy.
Wound infection is 3rd commonest, occuring in 5-20%.

52
Q

Pancreatic transplant

A

Pancreatic (and renal) transplant is established therapy for severe T1DM.
Pancreas recieves arterial inflow from 2 sources (donor SMA, which supplies the head via inferior pancreatoduodenal artery, and donor splenic artery, which supplies body and tail).
Venous drainage is via both donor portal vein and recipient SMV.
Exocrine drainage is via bowel (in older transplant via bladder)

53
Q

Pancreatic transplant complications (7)

A

Commonest cause of graft failure is acute rejection.
Second is splenic vein thrombosis.
- Usually occurs within first 6 weeks.
- Venous thrombosis is much more common than arterial in pancreas, especially compared to other organs, because vessels are smaller and clot frequently forms and propagates from tied off stump vessels
Both venous thrombosis and acute rejection can appear as reversed diastolic flow.
Arterial thrombosis is less of a problem due to dual supply of pancreas (via Y graft).
Resistive indices are not of value in the pancreas, because the organ lacks a capsule.
Graft is also susceptible to pancreatitis, common <4 weeks after transplant, usually mild.
Increased rates of pancreatitis were seen with older bladder drained subtype.
Shrinking transplant is a buzzword for chronic rejection, where graft gets progressively smaller in size.

FRCR 2A (Crack The FRCR 2A) (55 decks)

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