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
