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ABSITE Review > ABSITE Review - Pancreas > Flashcards

ABSITE Review - Pancreas Flashcards

1
Q

What is the blood supply of the pancreas?

A

Head - superior (off GDA) and inferior (off SMA) pancreaticoduodenal arteries (anterior and posterior braches for each)
Body - great, inferior and caudal pancreatic artery (all off splenic artery)
Tail - splenic, gastroepiploic and dorsal pancreatic arteries

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2
Q

What is the only pancreatic enzyme secreted in active form?

A

Amylase

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3
Q

Which pancreatic cells receive preferential blood supply?

A

Islets cells receive majority of blood supply related to size, then blood goes to acinar cells.

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4
Q

What activates trypsinogen to trypsin? Where it is release?

A

Enterokinase released by the duodenum

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5
Q

How is the pancreas form embryologically?

A

Ventral pancreatic bud - connected to duct of Wirsung; migrates posteriorly, to the right, and clockwise to fuse with the dorsal bud - Forms uncinate and inferior portion of the head
Dorsal pancreatic bud - body, tail and superior aspect of the pancreatic head, has duct of Santorini

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6
Q

What is the name of the small pancreatic duct and where it drains?

A

Duct of Santorini that drains directly to the duodenum

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7
Q

What is the name of the major pancreatic duct and where it drains?

A

Duct of Wirsung that merges with CBD before entering duodenum

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8
Q

What is an annular pancreas? What is the treatment?

A

2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal x-ray
Tx - Duodenojejunostomy or Duodenoduodenostomy and sphinteroplasty

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9
Q

Which syndrome is associated with an annular pancreas?

A

Down Syndrome

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10
Q

What is a pancreas divisum?

A

Failed fusion of the pancreatic ducts; can result in pancreatitis from duct of Santorini (accessory duct) stenosis

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11
Q

How is the pancreas divisum diagnosed and treated?

A

Dx - ERCP - minor papilla will show long and large duct of Santorini; major papilla will show short duct of Wirsung
Tx - Sphincteroplasty and stent placement if symptomatic
If don’t work, may need longitudinal pancreatico jejunostomy

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12
Q

What the the two MCCs of pancreatitis in USA?

A

Gallstones and ETOH

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13
Q

What is the Grey Turner sign?

A

Flank Ecchymosis

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14
Q

What is Cullen’s sign?

A

Periumbilical ecchymosis

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15
Q

What is Fox’s sign?

A

Inguinal Ecchymosis

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16
Q

What is the treatment if you see gas in the pancreas on abdominal CT?

A

Need to remove infected material

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17
Q

What is the most important risk factor of necrotizing pancreatitis?

A

Obesity

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18
Q

What is the cause of ARDS, coagulopathy and pancreatic necrosis in pancreatitis?

A

ARDS - related to release of phospholipases
Coagulopathy - related to release of proteases
Pancreatic/fat necrosis - related to release of phospholipases

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19
Q

What other conditions can cause mild elevation in amylase and lipase?

A

Cholecystitis, perforated ulcer, sialodenitis, SBO and intestinal infarction

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20
Q

Which patients most commonly develop pseudocyst and where are they most commonly located?

A

MC in patients with chronic pancreatitis

Often occurs in the head of the pancreas, small cyst likely to resolve spontaneously (<5cm)

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21
Q

Which p psuedocyst need treatment?

A

Patients with continued symptoms or pseudocyst that are growing

22
Q

What is the treatment for pseudocysts?

A

1st - MRCP or ERCP to check for duct involvement
If duct involved, will need cystgastrostomy (endoscopic or open)
If duct not involved, may get away with percutaneous drainage of pseudocyst

23
Q

What is the treatment for incidental cyst?

A

Resection unless associated with pancreatitis or purely serous

24
Q

What is the treatment fo pancreatic fistulas?

A

Most close spontaneously (especially if low output <200cc/day)
Tx - allow drainage, TPN, octreotide
If failure to resolve with medical mgmt, can try ERCP, sphinterotomy and stent
If tha fails, distal lesions perform distal pancreatectomy; for proximal lesions may need Whipple

25
Q

What are the 2 MCCs of chronic pancreatitis?

A

1st - ETOH

2nd - Idiopathic

26
Q

What are the usual pathologic and radiologic findings of chronic pancreatitis?

A

Exocrine tissue gets calcified and fibrotic; islet cells usually preserved
Chain of lakes –> alternating segments of dilation and stenosis in pancreatic duct

27
Q

What are the surgical indications for chronic pancreatitis?

A

Pain that interferes with quality of life, nutrition abnormalities, addiction to narcotics, failure to rule out malignancy, biliary obstruction, abscess

28
Q

What are the surgical options for chronic pancreatitis?

A

Puestow procedure - pancreaticojejunostomy, for ducts >8mm (most patients improve –> open along main pancreatic duct and drain into jejunum
Distal pancreatic resection - for normal duct anatomy, failed puestow procedure or when only a small portion of the gland is affected
Whipple - may be needed in patients with pancreatic head disease

29
Q

What is the cause of patients with chronic pancreatitis that develop gastric varices?

A

Splenic vein thrombosis

30
Q

What is the diagnostic test and treatment for pancreatic insufficiency?

A

Dx - fecal fat testing

Tx - high-CHO, high-protein, low-fat diet with pancreatic enzyme replacement

31
Q

What is the #1 risk factor for pancreatic adenocarcinoma?

A

Tobacco

32
Q

What is the serum marker for pancreatic carcinoma?

A

CA 19-9

33
Q

What signs of unresectable pancreatic cancer?

A

Invasion of portal vein, SMV or retroperitoneum
Metastases to peritoneum, omentum and liver
Metastases to celiac or SMA nodal system (nodal system outside are of resection)

34
Q

What is the MC pancreatic cancer?

A

Pancreatic adenocarcinoma - 90%

35
Q

What are the MC complications of a Whipple procedure?

A 
#1 Delayed gastric emptying - reglan
Others - anastomotic breakdown, marginal ulceration, abscess or infection, pancreatitis, fistulas
36
Q

What is an alternative for painful unresectable cancer for pain control?

A

Celiac plexus block

37
Q

How much % of nonfunctional pancreatic tumors are malignant?

A

90%

38
Q

Which functional endocrine tumors respond to octreotide?

A

Insulinoma, glucagonoma, gastrinoma, VIPoma

39
Q

What is the MC islet cell tumor of the pancreas?

A

Insulinoma

40
Q

What is the Whipple’s triad?

A 
Seen in insulinoma
Fasting hypoglycemia ( papitations, increase HR and diaphoresis), relief with glucose
41
Q

How is an insulinoma diagnosed and treated?

A

Dx - Insulin to glucose ratio > 0.4 after fasting, increase C-peptide and proinsulin –> otherwise suspect Munchausen’s syndrome
Tx - enucleate if < 2cm; formal resection if > 2cm

42
Q

What is the MC islet cell tumor of the pancreas in MEN I syndrome?

A

Gastrinoma (ZES)

43
Q

Where are most gastrinomas found?

A

Gastrinoma triangle - CBD, neck of pancreas, 3rd portion of the duodenum

44
Q

What are the symptoms of gastrinoma?

A

Refractory ulcer disease (abdominal pain) and diarrhea (improved with H2 blocker)

45
Q

How are gastrinomas diagnosed and treatment?

A

Dx - Secretin stimulation test - increase gastrin (>200); normal patients; decrease gastrin
Tx - Enucleation if 2cm
Cannot find tumor –> perform duodenostomy and look inside duodenum for tumor (15% of microgastrinomas there)

46
Q

Diabetes, gallstones, steatorrhea and hypochlorhydria are classic symptoms of…

A

Somatostinoma

47
Q

Diabetes, stomatitis, dermatitis and weight loss are classic symptoms of…

A

Glucagonoma

48
Q

What is the name for the dermatitis in glucagonoma?

A

Necrolytic migratory erythema

49
Q

Watery diarrhes, hypokalemia and achlorhydia are classic symptoms of …

A

VIPoma (Verner-Morrison syndrome

50
Q

What is the difference in location and malignant potential between the functional pancreatic endocrine tumors?

A

Insulinoma - 85-95% benign; evenly distributes throughout pancreas
Gastrinoma - 50% malignant, 50% multiple
Somatostinoma - most malignant; most in head of pancreas
Glucagonoma - most malignant; most in distal pancreas
VIPoma - most malignant; most in distal pancreas

ABSITE Review (32 decks)

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