ABSITE Review - Pancreas Flashcards
What is the blood supply of the pancreas?
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
What is the only pancreatic enzyme secreted in active form?
Amylase
Which pancreatic cells receive preferential blood supply?
Islets cells receive majority of blood supply related to size, then blood goes to acinar cells.
What activates trypsinogen to trypsin? Where it is release?
Enterokinase released by the duodenum
How is the pancreas form embryologically?
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
What is the name of the small pancreatic duct and where it drains?
Duct of Santorini that drains directly to the duodenum
What is the name of the major pancreatic duct and where it drains?
Duct of Wirsung that merges with CBD before entering duodenum
What is an annular pancreas? What is the treatment?
2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal x-ray
Tx - Duodenojejunostomy or Duodenoduodenostomy and sphinteroplasty
Which syndrome is associated with an annular pancreas?
Down Syndrome
What is a pancreas divisum?
Failed fusion of the pancreatic ducts; can result in pancreatitis from duct of Santorini (accessory duct) stenosis
How is the pancreas divisum diagnosed and treated?
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
What the the two MCCs of pancreatitis in USA?
Gallstones and ETOH
What is the Grey Turner sign?
Flank Ecchymosis
What is Cullen’s sign?
Periumbilical ecchymosis
What is Fox’s sign?
Inguinal Ecchymosis
What is the treatment if you see gas in the pancreas on abdominal CT?
Need to remove infected material
What is the most important risk factor of necrotizing pancreatitis?
Obesity
What is the cause of ARDS, coagulopathy and pancreatic necrosis in pancreatitis?
ARDS - related to release of phospholipases
Coagulopathy - related to release of proteases
Pancreatic/fat necrosis - related to release of phospholipases
What other conditions can cause mild elevation in amylase and lipase?
Cholecystitis, perforated ulcer, sialodenitis, SBO and intestinal infarction
Which patients most commonly develop pseudocyst and where are they most commonly located?
MC in patients with chronic pancreatitis
Often occurs in the head of the pancreas, small cyst likely to resolve spontaneously (<5cm)
Which p psuedocyst need treatment?
Patients with continued symptoms or pseudocyst that are growing
What is the treatment for pseudocysts?
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
What is the treatment for incidental cyst?
Resection unless associated with pancreatitis or purely serous
What is the treatment fo pancreatic fistulas?
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
What are the 2 MCCs of chronic pancreatitis?
1st - ETOH
2nd - Idiopathic
What are the usual pathologic and radiologic findings of chronic pancreatitis?
Exocrine tissue gets calcified and fibrotic; islet cells usually preserved
Chain of lakes –> alternating segments of dilation and stenosis in pancreatic duct
What are the surgical indications for chronic pancreatitis?
Pain that interferes with quality of life, nutrition abnormalities, addiction to narcotics, failure to rule out malignancy, biliary obstruction, abscess
What are the surgical options for chronic pancreatitis?
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
What is the cause of patients with chronic pancreatitis that develop gastric varices?
Splenic vein thrombosis
What is the diagnostic test and treatment for pancreatic insufficiency?
Dx - fecal fat testing
Tx - high-CHO, high-protein, low-fat diet with pancreatic enzyme replacement
What is the #1 risk factor for pancreatic adenocarcinoma?
Tobacco
What is the serum marker for pancreatic carcinoma?
CA 19-9
What signs of unresectable pancreatic cancer?
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)
What is the MC pancreatic cancer?
Pancreatic adenocarcinoma - 90%
What are the MC complications of a Whipple procedure?
#1 Delayed gastric emptying - reglan Others - anastomotic breakdown, marginal ulceration, abscess or infection, pancreatitis, fistulas
What is an alternative for painful unresectable cancer for pain control?
Celiac plexus block
How much % of nonfunctional pancreatic tumors are malignant?
90%
Which functional endocrine tumors respond to octreotide?
Insulinoma, glucagonoma, gastrinoma, VIPoma
What is the MC islet cell tumor of the pancreas?
Insulinoma
What is the Whipple’s triad?
Seen in insulinoma Fasting hypoglycemia ( papitations, increase HR and diaphoresis), relief with glucose
How is an insulinoma diagnosed and treated?
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
What is the MC islet cell tumor of the pancreas in MEN I syndrome?
Gastrinoma (ZES)
Where are most gastrinomas found?
Gastrinoma triangle - CBD, neck of pancreas, 3rd portion of the duodenum
What are the symptoms of gastrinoma?
Refractory ulcer disease (abdominal pain) and diarrhea (improved with H2 blocker)
How are gastrinomas diagnosed and treatment?
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)
Diabetes, gallstones, steatorrhea and hypochlorhydria are classic symptoms of…
Somatostinoma
Diabetes, stomatitis, dermatitis and weight loss are classic symptoms of…
Glucagonoma
What is the name for the dermatitis in glucagonoma?
Necrolytic migratory erythema
Watery diarrhes, hypokalemia and achlorhydia are classic symptoms of …
VIPoma (Verner-Morrison syndrome
What is the difference in location and malignant potential between the functional pancreatic endocrine tumors?
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
