Benign Pancreatic Diseases Flashcards
What are the relations of the pancreas?
POSTERIORLY
- IVC
- beginning of portal vein
- aorta
- superior mesenteric vessels
- suprarenal gland
ANTERIORLY
- stomach -> separated by lesser sac
- transverse colon
- mesocolon
UPPER BORDER
- splenic artery
What is the endocrine function of the pancreas?
- Type A -> glucagon
- Type B -> insulin
- Type D -> somatostatin
- Type F -> pancreatic polypeptide
What are the effects of insulin?
Within seconds
- increase entry of glucose into cells, muscles, fat, liver cells
- increases K entry into cells
Within minutes
- increase synthesis of glycogen
- inhibits gluconeogenesis
- activates lipoprotein lipase
- inhibits hormone sensitive lipase
Within hours
- increases mRNA for the enzyme involved in anabolism -> increased growth
What abnormalities does insulin cause?
- excess (insulinoma) -> hypoglycemia
- deficiency -> diabetes mellitus
What are the effects of glucagon?
- glycogenolysis
- gluconeogenesis
- lipolysis
- ketogenesis
- increased metabolic rate
- positive inotropic effect on heart
EXCESS -> hyperglycemia -> give somatostatin analogs (octreotide)
What are the effects of somatostatin?
act as inhibitory hormone to
- insulin
- glucagon
- pancreatic polypeptide
What controls the exocrine function of the pancreas?
- CHOLINERGIC NERVES -> stimulate secretion of pancreatic enzymes & aqueous component
- SYMPATHETIC -> inhibits its secretions
What is the classification of pancreatic lesions?
BENIGN
- autoimmune
- chronic pancreatitis
- pseudo-cyst
- pseudo-tumor
POTENTIALLY MALIGNANT
- serous/mucinous cystadenoma
- IPMN
MALIGNANT
- primary -> exocrine (adenocarcinoma) OR endocrine
- secondary (rare)
What’s the difference between serous & mucinous cystadenoma?
SEROUS MUCINOUS
- F > M - F > M
- 6-7th decade - 5th decade
- on the head - on body/tail
- benign - history of pancreatitis
- potentially malignant
What are intrapapillary mucinous neoplasms (IPMN)?
- cystic neoplasms derived from pancreatic ducts
- MD lesions have higher malignancy potential
- occurs at head of pancreas
How is IPMN diagnosed?
can present with pancreatitis or jaundice
- CT/MRI -> main duct disease = high risk of malignancy
- ERCP & aspiration -> mucin rich
observe low risk lesion
resect high risk or multiple worrisome features
How are potentially malignant pancreatic lesions managed?
Serous cystadenoma
- > 4cm or symptomatic -> surgical resection
- < 4cm & asymptomatic -> observe
Mucinous cystadenoma -> surgical resection
IPMN
- main duct -> surgical resection
- side branch -> < 3cm & no worrisome features -> observe
- > >3cm, symptomatic & has worrisome features -> surgical removal
What is the main difference between pancreatic cystadenomas & IPMN?
- IPMN communicates with ductal systems
- Cystadenomas has ovarian stroma
What is the main difference between pseudocysts & IPMN?
mucous production in IPMN
MEN mutations are present in which pancreatic tumor?
Pancreatic Neuroendocrine Tumor
- rare
- most are non functioning
graded based on
- differentiation
- mitotic index
- Ki-67 index
What is Whipple’s triad?
- fasting hypoglycemia
- serum glucose <50
- relief with glucose
in INSULINOMA
What are the symptoms of insulinoma?
- obtundation
- confusion
- diaphoresis
- palpitation
- high insulin
- high C-peptide
How is insulinoma diagnosed?
- 72h fasting -> measure C-peptide, proinsulin, insulin, & glucose levels are drawn every 6 hours until symptoms emerge
- CT -> localize
- intraoperative US
- angiograohy & venous sampling
Which pancreatic tumor is MEN1 associated & secretes gastrin?
GASTRINOMA
- solitary
- Zollinger-Ellison syndrome associated
Which pancreatic tumor causes watery diarrhea, hypokalemia, achlorhydria? (WDHA)
VIPoma (Verner Morrison syndrome)
- distal pancreas
- 70% malignant
- high serum VIP > 200
how is VIPoma diagnosed & treated?
CT & octreoscan
EUS -> localize
treatment
- IV fluids
- electrolyte correction
- somatostatin
- debulking
- hepatic artery embolization for liver metastasis
a patients present with serum glucagon >500 & mass in body & tail of pancreas, biopsy of skin shows vacuolated keratinocytes, what is your diagnosis?
Glucagonoma
treatment
- control BS
- TPN
- octreotide
- debulking
What diseases is PNET associated with?
- MEN1
- Hippel-Lindau disease
- Von Recklinghausen disease
What are the signs & symptoms of PNET?
- abdominal pain
- weight loss
- anorexia & nausea
- obstructive jaundice
- intra-abdominal hemorrhage
- palpable mass
How is PNET diagnosed?
1- history of symptoms of functioning tumors
2- Chromogranin A biochemical confirmatory test
3- imaging for localization -> CT -> MRI -> EUS -> SRCS -> angio -> surgical exploration
4- evaluate for metastatic disease
How is nonmetastatic PNET management?
SURGICAL treatment
- if not well localized -> surgical exploration with US -> full pancreatic mobilization
- asymptomatic nonfunctional -> elective surgery
How is metastatic PNET managed?
MEDICAL therapy, liver directed therapy. & SURGERY
- surgical resection if all visible tumor can be removed
- if not -> debulking -> symptom control -> liver only disease
