Ch 33 Pancreas Flashcards
Vascular anatomy of superior abdominal aorta
Celiac trunk - L gastric, splenic, common hepatic
Splenic - short gastrics, L gastroepiploic, splenic, pancreatic (great, dorsal, caudal)
Common hepatic - proper hepatic, gastroduodenal (GDA)
Proper hepatic - R gastric, L/R hepatic
GDA - R gastroepiploic, antero/posterosuperior pancreaticoduodenal
SMA - postero/anteroinferior pancreaticoduodenal artery, jejunal arteries
Pancreas components
head (incl. uncinate), body, tail
Location of uncinate relative to vessels
rests on aorta, behind SMV
Relation of SMV/SMA/pancreas
SMV anterior and to the right –> both lie behind neck of pancreas
Relation of IVC/Aorta
IVC anterior and to the right/ L renal vein crosses over aorta
Relation of portal vein/pancreas
Formation of SMV/splenic vein occurs behind neck of pancreas
Pancreas Blood Supply: head
superior (GDA) and inferior pancreaticoduodenal (SMA) arteries (both have anterior/posterior branches)
Pancreas Blood Supply: body
great, dorsal, and caudal pancreatic arteries (Splenic) come together to form inferior pancreatic artery which anastomoses with superior pancreaticoduodenal artery
Pancreas Blood Supply: tail
splenic, gastroepiploic, dorsal pancreatic artery
Venous drainage of the pancreas enters the _____
portal system
Lymphatic drainage of the pancreas include _____ nodes (2)
celiac and SMA
_____cells secrete HCO3-
ductal
_____cells secrete digestive enzymes
acinar
6 exocrine products of the pancreas
hco3-, amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase
____ is the only pancreatic enzyme secreted in active form and its function is to ______
amylase; hydrolyze alpha 1-4 linkages of glucose chains
6 endocrine functions of the pancreas and cells of origin
alpha- glucagon beta - insulin (at center of islets) delta - somatostatin pp/f - pancreatic polypeptide islet cells - VIP, serotonin
_____ cells receive the majority of pancreatic blood supply on a size basis
islet cells (followed by acinar cells)
____ from ____ structure activates trypsinogen to ____ which does _____ function
enterokinase; duodenum; trypsin; activates enzymes including trypsinogen (but not amylase)
Secretin inc/dec ____ primarily
increase HCO3
CCK inc/dec ____ primarily
increase pancreatic enzymes
ACh inc/dec ____ primarily
increases HCO3 and enzymes
Somatostatin and glucagons inc/dec ____ primarily
decrease exocrine function
CCK and secretin are primarily released by the _____
duodenum
Embryology of pancreas
ventral pancreatic bud migrates posteriorly to the right and clockwise to fuse with the dorsal bud; forms the uncinate and inferior portion of the head
dorsal pancreatc bud composes body, tail, and superior aspect of pancreatic head
the duct of _____ is in the ventral pancreatic bud and the duct of _____ is in the dorsal pancreatic bud. Which is the major duct?
wirsung, santorini; wirsung
The duct of wirsung drains into the _____ and the duct of santorini drains into the ____
merges with CBD and then enters duodenum; directly into duodenum
Failure of clockwise rotation of the pancreas leads to _____ which is associated with ____ disease which can lead to ____ on xray and can lead to ____ clinical syndrome
annular pancreas; down’s syndrome; double bubble; dudodenal obstruction from pancreas “strangling duodenum”/preventing passage of bolus through duodenum
Tx of annular pancreas
duodenojejunostomy or duodenoduodenostomy with possible sphincteroplasty
*pancreas not resected
Failed fusion of the pancreatic ducts known as ______ can lead to ____ clinical syndrome from ____ stenosis
pancreas divisum; pancreatitis; duct of santorini
Dx of pancreas divisum
ERCP - minor papilla will show long and large duct of santorini; major papilla will show short duct of wirsung
Tx of pancreas divisum
ERCP with sphincteroplasty; open sphincteroplasty if that fails
Heterotopic pancreas are most commonly found in the ______ and are a/symptomatic and are treated with ____
duodenum; asymptomatic; surgical resection if symptomatic
Most common etiologies of acute pancreatitis (and others)
gallstone and etoh
others = ercp, trauma (children most common), hyperlipidemia, hypercalcemia, viral infection, medications (aza, furosemide, steroids, cimetidine)
Pathophysiology of gallstone pancreatitis
gallstone blocks ampulla of vater leading to impaired extrusion of zymogen granules and activation of degradation enzymes –> pancreatic autodigestion
Pathophysiology of etoh pancreatitis
leads to autoactivation of pancreatic enzymes
General and specific findings in acute pancreatitis
General: abd pain, n/v, anorexia
Specific: jaundice, L pleural effusion, ascites, sentinal loop –> dilated small bowel near the pancreas as a result of inflammation
Mortality rate of acute pancreatitis
10% (50% with hemorrhagic)
What do we think if a patient has pancreatitis without obvious cause
malignancy!
Ranson’s criteria - how many are there, what are they, what is the mortality rate if they are all hit
8,
on admission: age>55, wbc>16, gluc>200, AST>250, LDH >350
after 48 hours: hct down 10%, bun up 5, ca4, fluid sequestration >6L
100% if 8 are hit
GALAW and CHOBBS glucose ast ldh age wbc
calcium hct o2 base bun sequestration
Labs in pancreatitis
increased amylase, lipase, wbc
DX pancreatitis
ultrasound - gallstones and CBD dilation
CT - complications(e.g abscess); necrotic pancreas does not uptake contrast
_____ pancreas does not uptake contrast
necrotic
Tx acute pancreatitis
NPO, aggressive fluid resuscitation
ERCP for gallstones/CBD stones = sphincterotomy and extraction
ABx for stones, failure to improve, suspected infection
TPN for recovery
Chole after recovered (same admission)
avoid morphine
Role of morphine in acute pancreatitis
avoid –> can contract sphincter of oddi and worsen attack
3x bleeding signs in pancreatitis
grey turner - flank ecchymosis
cullen - periumbilical ecchymosis
fox - inguinal ecchymosis
What % of acute pancreatitis gets necrosis? What to do about it?
15%
- leave sterile necrosis alone
- if infected (wbc, fever, sepsis, blood cultures, ct aspiration of fluid) –> surgical debridement
Tx of pancreatic abscess
surgical debridement
Role of CT guided drainage for pancreatic necrosis/abscess
Not effective
What to do about gas in pancreatic necrosis
need open debridement
Leading cause of death in pancreatitis
infection with GNRs
Indications for surgery in acute pancreatitis
infected, abscess or post-pancreatitis for chole
What is the link between acute pancreatitis and ARDS?
release of phospholipases leads to ARDS
What is the link between acute pancreatitis and coagulopathy?
related to release of proteases
What causes pancreatic fat necrosis in pancreatitis?
release of phospholipases
In what conditions do amylase and lipase increase?
pancreatitis, sbo, intestinal infarct, cholecystitis, perforated ulcer, sialoadenitis
Pancreatic pseudocysts are most common in patients with _____
chronic pancreatitis
Concern for pseudocysts not related to pancreatitis
rule out cancer (mucinous cystadenocarcinoma)
symptoms of pancreatic pseudocyst
pain, fever, weight loss, bowel obstruction from compression
Where do pseudocysts happen?
head of pancreas (non epithelialized sac)
Tx of pancreatic pseudocyst
- most resolve spontaneously (esp if
Pseudocyst grows for 3 months–> tx?
resection to r/o ca
Pseudocyst persists after 3 months > tx?
perc or open cystogastrostomy
Complications of pseudocyst
infection, portal or splenic vein thrombosis
What cancers are of concern in pseudocysts not related to pancreatitis?
mucinous cystadenocarcinoma
intraductal papillary-mucinous neoplasms (IPMN)
UNLESS serous and non-complex
Malignancy risk of non-complex serous cystadenomas and mgmt
follow
Mgmt of pancreatic fistulae
most close spontaneously (esp if low output ERCP/sphincterotomy/stent –> remove stent after closure
Pathophysiology of pleural effusion in pancreatitis
retroperitoneal leakage of pancreatic fluid from duct or cyst/not a fistula!
Tx pleural effusion in pancreatitis
- majority close on own
- thoracentesis followed by conservative Tx (NPO,TPN,octreotide) and then follow fistula pathway
- amylase will be elevated in fluid
chronic pancreatitis correlates with irreversible _____
parenchymal fibrosis
MCC chronic pancreatitis
etoh, idiopathic 2nd most common
MC presentation of chronic pancreatitis
mc pain
-anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis
Exocrine/endocrine function in chronic pancreatitis
endocrine function preserved; exocrine decreased
-malabsorption of fat soluble vitamins
Tx malabsorption in chronic pancreatitis
pancrelipase
Dx chronic pancreatitis
abdominal CT - shrunken pancreas with calcifications
US -shows pancreatic ducts >4mm, cysts, atrophy
ERCP - sensitive at dx
Term for alternating dilation and stenosis in pancreatic duct –> what is this?
chain of lakes, sign of advanced disease in chronic pancreatitis
Tx chronic pancreatitis
pancrelipase, pain control, nutritional support, surgery for specific indications
indications for surgery in chronic pancreatitis
- pain that interferes with qol
- nutrition abnormalities
- addiction to narcotics
- failure to rule out ca
- biliary obstruction
6 surgical options for chronic pancreatitis and their indications
- puestow procedure (pancreaticojejunostomy for enlarged ducts>8mm)
- distal pancreatic resection (for normal/small ducts and only distal involvement)
- Whipple (for normal/small ducts with isolated head disease)
- Beger-Frey- duodenal preserving head coreout for normal/small ducts with isolated pancreatic head enlargement
- Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy- pain control
- hepaticojejunostomy or choledochojejunostomy for CBD dilation for pain, jaundice, cirrhosis, cholangitis after r/o not CA
Puestow procedure
chronic pancreatitis - pancreaticojejunostomy for enlarged ducts>8mm –> most improve
open along main duct and drain into jejunum
MCC splenic vein thrombosis
chronic pancreatitis
Tx splenic vein thrombosis
splenectomy for isolated bleeding gastric varices
Problem with splenic vein thrombosis
bleeding from isolated gastric varices that form collaterals
MCC pancreatic insufficiency
long-standing pancreatitis or after total pancreatectomy (over 90% function must be lost)
Symptoms of pancreatic insufficiency
generally refers to exocrine function –> malabsoprtion, steatorrhea
Dx pancreatic insufficiency
fecal fat testing
Tx pancreatic insufficiency
high carb, high protein, low fat diet, pancrease (pancreatic enzymes)
Jaundice workup
- US
- positive CBD stones, no mass –> ERCP
- no cbd stones, no mass –> MRCP
- positive mass –> MRCP
Epidemiology of pancreatic adenocarcinoma
males 6th and 7th decades
symptoms pancreatic adenocarcinoma
weight loss (MC), jaundice, pain
survival rate pancreatic adenocarcinoma
20% 5 year survival with resection
MC risk factor pancreatic adenocarcinoma
tobacco
marker pancreatic adenocarcinoma
CA 19-9
MC mutation pancreatic adenocarcinoma
95% p16 mutation (tumor suppressor, binds cyclin complexes)
initial spread of pancreatic adenocarcinoma
lymphatic
location and invasion pancreatic adenocarcinoma
70% head
- 50% invade portal vein, smv, or retroperitoneum at time of diagnosis –> unresectable
- mets to peritoneum, omentum, liver –> unresectable
- mets to celiac/sma nodes –> unresectable
- head masses are most curable
Which location of pancreatic cancer is most curable?
head masses
What’s the story on resectability for pancreatic adenocarcinoma?
If there is any invasion to other structures or plexus nodes, it is unresectable
MC subtype pancreatic adenocarcinoma
ductal adenocarcinoma
favorable subtypes pancreatic adenocarcinoma
papillary or mucinous cystadenocarcinoma
labs in pancreatic adenocarcinoma
increased bilirubin and alkphos
when to biopsy pancreatic adenocarcinoma
if resectable –> no biopsy, resect
if mets –> biopsy to direct therapy
imaging to differentiate chronic pancreatitis from CA
mrcp
mrcp findings in ca (3)
duct with irregular narrowing displacement destruction -also can detect vessel involvement 3Ds
ct signs for pancreatic head tumors (2)
- double duct sign (dilation of pancreatic and CBD)
- lesion
Tx of unresectable pancreatic adenocarcinoma
palliation - biliary stents, hepaticojejunostomy (for biliary obstruction), gastrojejunostomy (for duodenal obstruction), and celiac plexus ablation (for pain)
Whipple complications
- delayed gastric emptying (MC)
- fistula
- leak
- marginal ulceration
- bleeding
tx of delayed gastric emptying
metoclopramide
tx of post-whipple fistula
conservative
tx of post-whipple leak
place drains and tx like fistula
tx of marginal ulceration post-whipple
ppi
tx of bleeding post whipple or pancreatic surgery
angio for embolization (tissue planes are friable after surgery so operative control of bleeding is difficult)
chemo for pancreatic adenocarcinoma
gemcitabine post op
What are the predictors of prognosis for non-metastatic pancreatic adenocarcinoma?
nodal invasion, ability to get a clear margin
what proportion of pancreatic endocrine neoplasms are non-functional?
1/3
what percent of pancreatic nonfunctional endocrine neoplasms malignant?
90
how does the course of nonfunctional endocine neoplasms compare to that of pancreatic adenocarcinoma
indolent and protracted course
Tx of nonfunctional endocrine neoplasms
- resect; metastatic disease precludes resection
- 5fu, streptozocin
most common metastasis in nonfunctional endocrine neoplasms
liver
what proportion of pancreatic endocrine neoplasms are functional tumors?
2/3
Most common endocrine pancreatic tumors in head
gastrinoma, somatostatinoma
Tx of functional endocrine neoplasm of pancreas
octreotide or debulking - insulinoma, glucagonoma, gastrinoma, VIPoma
first metastatic location for functional endocrine neoplasm of pancreas
liver
MC functional endocrine neoplasm of pancreas
insulinoma - most common islet cell tumor
malignant potential of insulinomas
10%
90% are benign and evenly distributed throughout pancreas
Dx insulinoma
insulin to glucose ratio > 0.4 after fasting, elevated C peptide and proinsulin –> if not elevated, suspect munchausen
Tx insulinoma
- enucleate if 2cm
- tx metastatic with 5fu, streptozocin and octreotide
Most common pancreatic islet cell tumor in MEN1 patients
gastrinoma/zes
malignancy of gastrinoma/zes
50%
single/multiple gastrinoma/zes frequency
50% multiple
spontaneity frequency gastrinoma/zes
75% spontaneous
25% MEN1
location of gastrinoma/zes
gastrinoma triangle - cbd, neck of pancreas, third portion of duodenum
symptoms of gastrinoma/zes
refractory or complicated ulcer disease and diarrhea (improved with ppi)
dx gastrinoma/zes
- serum gastrin usually >200, 1000s is diagnostic
- secretin stimulation test - ZES patients: elevate gastrin >200; normal patients reduce gastrin
Tx gastrinoma/zes
enucleate 2cm
- malignant disease –> excise suspicious nodes
- cannot find tumor –> perform duodenostomy and look inside duodenum
- duodenonal tumor –> resection with primary closure/whipple if extensive (check pancreas)
- debulking –> can improve symptoms
what % of microgastrinomas are present inside the duodenum
15
Best study for localizing gastrinoma
octreotide scan
Symptoms of glucagonoma
diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema)
rash in glucagonoma
necrolytic migratory erythema
dx glucagonoma
fasting glucagon level
location of glucagonoma
distal pancreas
what proportion of glucagonomas are malignant
most of them
Tx of necrolytic migratory erythema
zinc, amino acids, fatty acids
VIPoma AKA _____ has ___ symptoms
verner-morrison
watery diarrhea, hypokalemia, achlorhydria (WDHA)
Dx VIPoma
rule out other causes of diarrhea, elevated VIP levels
what proportion of vipomas are malignant
most of them
location of vipoma
distal pancreas MC, 10% extrapancreatic (RP, thoracic)
Frequency of somatostatinoma
very rare
Symptoms of somatostatinoma
diabetes, gallstones, steatorrhea, hypochlorhydria
Dx somatostatinoma
fasting somatostatin level
location of somatostatinoma
head of pancreas
malignancy of somatostatinoma
most malignant
tx somatostatinoma
chole with resection
Symptoms of insulinoma AKA _____
hypoglycemia (
