7 - Pancreas And Spleen Flashcards by Samuel Halajian

Fun facts about the pancreas

Located in the epigastrium

Shares common channel with the liver and gall bladder

Common bile duct

Empties into the duodenum at the ampulla of Vater through the sphincter of Oddi

“Common channel”

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Endocrine functions of the pancreas

Islets of Langerhans

Insulin, glucagon, pancreatic polypeptide, somatostatin

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Exocrine function of the pancreas

Acinar cells

Bicarb and amylase/lipase

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MC patient age group for acute pancreatitis

40-70 yrs old

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Most acute pancreatitis is how severe?

Mild, self-limiting (90% of cases)

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MC cause of acute pancreatitis?

Gallstones

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Alcohol consumption leads to what kind of acute pancreatitis?

REALLY SEVERE

Increased secretion of pancreatic enzymes

Auto-digestion of pancreas

Necrosis

Hemorrhage

Outlet obstruction (Oddi)

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What impact does EtOH have on amylase?

It impairs production of amylase

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Presentation of acute pancreatitis

Med-epigastric, boring pain radiating to the back

N/V

Peritonitis

TTP

Guarding

Tachycardia

Cullen’s and/or Grey-Turner’s sign

Ileus pattern

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Workup for acute pancreatitis ?

Resuscitate
NPO
CBC (increased crit if dehydrated)
elevated BUN
Hypokalemia if N/V
T. Bili elevated if stone

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Imaging for acute pancreatitis

Plain films - calcifications or sentinel loop

US - gallstones, phlegmon, edema around pancreas

CT with contrast

MRI -> very diagnostic

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What criteria used for acute pancreatitis ?

Ransons

2/3 of:

Acute, severe, persistent epigastric pain
High serum amylase or lipase
CT or MRI findings

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What does mild acute pancreatitis look like?

No rebound tenderness

Normal HCT and creatinine

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Txt for acute pancreatitis

Resuscitate

Pain control

NPO (post-pyloric feeding)

ERCP is gallstone etiology

ABX against GNR’s if infection suspected (prophylaxis not recommended)

Surg for abscess or necrosis

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MC cause of chronic pancreatitis?

EtOH abuse

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Secondary causes of acute pancreatitis

Hyperproteinemia

Hypercalcuria

Cystic fibrosis

Autoimmune dz

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Clinical tetrad of chronic pancreatitis?

Abd pain
Weight loss
Diabetes
Steatorrhea

KNOW THIS FOR SURE

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Workup for chronic pancreatitis?

ERCP

Ductal dilation to 7mm
Clear stones from CBD
Dilation of stenosis

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Management of chronic pancreatitis

EtOH cessation

PPI / H2RA

Control blood sugars

Small, frequent low-fat meals

Lipase and fat-soluble vitamin supplements

Surgery (last-ditch) drainage, resection

How does pancreatic pseudocyst present?

Persistent elevation of amylase and early satiety

Acute vs chronic pseudocyst

Acute - resolves 4-6 weeks

Chronic > 6 weeks

Indications for surgery on pancreatic pseudocyst

Complications (hemorrhage, infection, leak)

Persistent sxs

PROCEDURE - percutaneous then tube drainage

Internal cyst gastronomy

Pancreatic trauma will present with:

Elevated serum amylase lipase

Epigastric pain

TTP

Txt of pancreatic trauma

Mild - no surgery, self limited, follow up CT to evaluate for pseudocyst

SEVERE - surgery

Risk factors for pancreatic CA

smoking, DM, genetic, chronic pancreatitis, high fat / low fiber diet

Presentation of pancreatic CA

Epigastric pain Jaundice Weight loss Palpable mass Mostly thin, jaundiced, older man with new onset DM Crappy survival rate

Workup for pancreatic CA

``` Liver enzymes US CT MRCP Bx ```

Txt for pancreatic CA

Neoadjuvant chemo/radiation Whipple procedure for adenocarcinoma of pancreatic head

When to to Whipple?

Last ditch effort Complications

What is the MC pancreatic endocrine tumor?

Insulinoma

What is Whipple’s triad?

Symptomatic, fasting hypoglycemia Serum glucose <50 Relief of sxs of glucose

Txt for insulinoma

Surgery with excellent long-term prognosis

How does gastrinoma present?

Persistent PUD refractory to aggressive PPI therapy

Workup for gastrinoma

Hold PPI’s and obtain serum gastrin level Localization of tumor

Where is gastinoma usually located?

Passaro’s triangle

Management of gastrinoma

Screening for MEN-1 and management of comorbidities Surgical resection once stabilized Prognosis dependent on liver mets Long-term (15yr) post-resection survival is 98% vs 74% for non-operative patients

Functions of spleen

Filter blood Host immune response Storage of blood and lymphocytes

How is the spleen well-visualized?

US CT MRI

Hypersplenism vs splenomegaly?

Hyper - overactive spleen Megaly - big spleen

Causes of hypersplenism or splenomegaly ?

``` Leukemias Lymphomas Portal HTN Thalassemia ITP/TTP Sickle cell Hereditary spherocytosis ```

What is the second MC site of aneurym?

Splenic artery

Management of splenic trauma

Try to txt nonoperativel if patient is hemodynamically stable Serial abd exams Surgery if they decomp

Post-op complications splenectomy

``` Bleeding Infection Colon / pancreatic injury DVT OPSI ```

What is OPSI

Overwhelming Post Splenectomy Infection Less than 1% of patients Higher in children, immunocompromised, and trauma Mitigated with vaccines STREP PNEUMO, H. FLU, MENINGOCOCCUS

What will most patients develop what after splenectomy?

Thrombocytosis (platelets under 700K) Resolves within weeks/months Mitigate with LMWH, SCDs and early post-op ambulation

I don’t find health-related puns funny anymore

since I started suffering from an irony deficiency