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ABSITE > Ch 33 Pancreas > Flashcards

Ch 33 Pancreas Flashcards

1
Q

Vascular anatomy of superior abdominal aorta

A

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

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2
Q

Pancreas components

A

head (incl. uncinate), body, tail

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3
Q

Location of uncinate relative to vessels

A

rests on aorta, behind SMV

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4
Q

Relation of SMV/SMA/pancreas

A

SMV anterior and to the right –> both lie behind neck of pancreas

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5
Q

Relation of IVC/Aorta

A

IVC anterior and to the right/ L renal vein crosses over aorta

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6
Q

Relation of portal vein/pancreas

A

Formation of SMV/splenic vein occurs behind neck of pancreas

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7
Q

Pancreas Blood Supply: head

A

superior (GDA) and inferior pancreaticoduodenal (SMA) arteries (both have anterior/posterior branches)

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8
Q

Pancreas Blood Supply: body

A

great, dorsal, and caudal pancreatic arteries (Splenic) come together to form inferior pancreatic artery which anastomoses with superior pancreaticoduodenal artery

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9
Q

Pancreas Blood Supply: tail

A

splenic, gastroepiploic, dorsal pancreatic artery

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10
Q

Venous drainage of the pancreas enters the _____

A

portal system

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11
Q

Lymphatic drainage of the pancreas include _____ nodes (2)

A

celiac and SMA

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12
Q

_____cells secrete HCO3-

A

ductal

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13
Q

_____cells secrete digestive enzymes

A

acinar

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14
Q

6 exocrine products of the pancreas

A

hco3-, amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase

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15
Q

____ is the only pancreatic enzyme secreted in active form and its function is to ______

A

amylase; hydrolyze alpha 1-4 linkages of glucose chains

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16
Q

6 endocrine functions of the pancreas and cells of origin

A 
alpha- glucagon
beta - insulin (at center of islets)
delta - somatostatin
pp/f - pancreatic polypeptide
islet cells - VIP, serotonin
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17
Q

_____ cells receive the majority of pancreatic blood supply on a size basis

A

islet cells (followed by acinar cells)

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18
Q

____ from ____ structure activates trypsinogen to ____ which does _____ function

A

enterokinase; duodenum; trypsin; activates enzymes including trypsinogen (but not amylase)

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19
Q

Secretin inc/dec ____ primarily

A

increase HCO3

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20
Q

CCK inc/dec ____ primarily

A

increase pancreatic enzymes

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21
Q

ACh inc/dec ____ primarily

A

increases HCO3 and enzymes

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22
Q

Somatostatin and glucagons inc/dec ____ primarily

A

decrease exocrine function

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23
Q

CCK and secretin are primarily released by the _____

A

duodenum

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24
Q

Embryology of pancreas

A

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

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25
Q

the duct of _____ is in the ventral pancreatic bud and the duct of _____ is in the dorsal pancreatic bud. Which is the major duct?

A

wirsung, santorini; wirsung

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26
Q

The duct of wirsung drains into the _____ and the duct of santorini drains into the ____

A

merges with CBD and then enters duodenum; directly into duodenum

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27
Q

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

A

annular pancreas; down’s syndrome; double bubble; dudodenal obstruction from pancreas “strangling duodenum”/preventing passage of bolus through duodenum

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28
Q

Tx of annular pancreas

A

duodenojejunostomy or duodenoduodenostomy with possible sphincteroplasty

*pancreas not resected

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29
Q

Failed fusion of the pancreatic ducts known as ______ can lead to ____ clinical syndrome from ____ stenosis

A

pancreas divisum; pancreatitis; duct of santorini

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30
Q

Dx of pancreas divisum

A

ERCP - minor papilla will show long and large duct of santorini; major papilla will show short duct of wirsung

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31
Q

Tx of pancreas divisum

A

ERCP with sphincteroplasty; open sphincteroplasty if that fails

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32
Q

Heterotopic pancreas are most commonly found in the ______ and are a/symptomatic and are treated with ____

A

duodenum; asymptomatic; surgical resection if symptomatic

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33
Q

Most common etiologies of acute pancreatitis (and others)

A

gallstone and etoh

others = ercp, trauma (children most common), hyperlipidemia, hypercalcemia, viral infection, medications (aza, furosemide, steroids, cimetidine)

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34
Q

Pathophysiology of gallstone pancreatitis

A

gallstone blocks ampulla of vater leading to impaired extrusion of zymogen granules and activation of degradation enzymes –> pancreatic autodigestion

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35
Q

Pathophysiology of etoh pancreatitis

A

leads to autoactivation of pancreatic enzymes

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36
Q

General and specific findings in acute pancreatitis

A

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

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37
Q

Mortality rate of acute pancreatitis

A

10% (50% with hemorrhagic)

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38
Q

What do we think if a patient has pancreatitis without obvious cause

A

malignancy!

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39
Q

Ranson’s criteria - how many are there, what are they, what is the mortality rate if they are all hit

A

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
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40
Q

Labs in pancreatitis

A

increased amylase, lipase, wbc

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41
Q

DX pancreatitis

A

ultrasound - gallstones and CBD dilation

CT - complications(e.g abscess); necrotic pancreas does not uptake contrast

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42
Q

_____ pancreas does not uptake contrast

A

necrotic

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43
Q

Tx acute pancreatitis

A

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

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44
Q

Role of morphine in acute pancreatitis

A

avoid –> can contract sphincter of oddi and worsen attack

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45
Q

3x bleeding signs in pancreatitis

A

grey turner - flank ecchymosis
cullen - periumbilical ecchymosis
fox - inguinal ecchymosis

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46
Q

What % of acute pancreatitis gets necrosis? What to do about it?

A

15%

  • leave sterile necrosis alone
  • if infected (wbc, fever, sepsis, blood cultures, ct aspiration of fluid) –> surgical debridement
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47
Q

Tx of pancreatic abscess

A

surgical debridement

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48
Q

Role of CT guided drainage for pancreatic necrosis/abscess

A

Not effective

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49
Q

What to do about gas in pancreatic necrosis

A

need open debridement

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50
Q

Leading cause of death in pancreatitis

A

infection with GNRs

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51
Q

Indications for surgery in acute pancreatitis

A

infected, abscess or post-pancreatitis for chole

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52
Q

What is the link between acute pancreatitis and ARDS?

A

release of phospholipases leads to ARDS

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53
Q

What is the link between acute pancreatitis and coagulopathy?

A

related to release of proteases

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54
Q

What causes pancreatic fat necrosis in pancreatitis?

A

release of phospholipases

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55
Q

In what conditions do amylase and lipase increase?

A

pancreatitis, sbo, intestinal infarct, cholecystitis, perforated ulcer, sialoadenitis

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56
Q

Pancreatic pseudocysts are most common in patients with _____

A

chronic pancreatitis

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57
Q

Concern for pseudocysts not related to pancreatitis

A

rule out cancer (mucinous cystadenocarcinoma)

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58
Q

symptoms of pancreatic pseudocyst

A

pain, fever, weight loss, bowel obstruction from compression

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59
Q

Where do pseudocysts happen?

A

head of pancreas (non epithelialized sac)

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60
Q

Tx of pancreatic pseudocyst

A
  • most resolve spontaneously (esp if
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61
Q

Pseudocyst grows for 3 months–> tx?

A

resection to r/o ca

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62
Q

Pseudocyst persists after 3 months > tx?

A

perc or open cystogastrostomy

63
Q

Complications of pseudocyst

A

infection, portal or splenic vein thrombosis

64
Q

What cancers are of concern in pseudocysts not related to pancreatitis?

A

mucinous cystadenocarcinoma
intraductal papillary-mucinous neoplasms (IPMN)

UNLESS serous and non-complex

65
Q

Malignancy risk of non-complex serous cystadenomas and mgmt

A

follow

66
Q

Mgmt of pancreatic fistulae

A

most close spontaneously (esp if low output ERCP/sphincterotomy/stent –> remove stent after closure

67
Q

Pathophysiology of pleural effusion in pancreatitis

A

retroperitoneal leakage of pancreatic fluid from duct or cyst/not a fistula!

68
Q

Tx pleural effusion in pancreatitis

A
  • majority close on own
  • thoracentesis followed by conservative Tx (NPO,TPN,octreotide) and then follow fistula pathway
  • amylase will be elevated in fluid
69
Q

chronic pancreatitis correlates with irreversible _____

A

parenchymal fibrosis

70
Q

MCC chronic pancreatitis

A

etoh, idiopathic 2nd most common

71
Q

MC presentation of chronic pancreatitis

A

mc pain

-anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis

72
Q

Exocrine/endocrine function in chronic pancreatitis

A

endocrine function preserved; exocrine decreased

-malabsorption of fat soluble vitamins

73
Q

Tx malabsorption in chronic pancreatitis

A

pancrelipase

74
Q

Dx chronic pancreatitis

A

abdominal CT - shrunken pancreas with calcifications
US -shows pancreatic ducts >4mm, cysts, atrophy
ERCP - sensitive at dx

75
Q

Term for alternating dilation and stenosis in pancreatic duct –> what is this?

A

chain of lakes, sign of advanced disease in chronic pancreatitis

76
Q

Tx chronic pancreatitis

A

pancrelipase, pain control, nutritional support, surgery for specific indications

77
Q

indications for surgery in chronic pancreatitis

A
  • pain that interferes with qol
  • nutrition abnormalities
  • addiction to narcotics
  • failure to rule out ca
  • biliary obstruction
78
Q

6 surgical options for chronic pancreatitis and their indications

A
  1. puestow procedure (pancreaticojejunostomy for enlarged ducts>8mm)
  2. distal pancreatic resection (for normal/small ducts and only distal involvement)
  3. Whipple (for normal/small ducts with isolated head disease)
  4. Beger-Frey- duodenal preserving head coreout for normal/small ducts with isolated pancreatic head enlargement
  5. Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy- pain control
  6. hepaticojejunostomy or choledochojejunostomy for CBD dilation for pain, jaundice, cirrhosis, cholangitis after r/o not CA
79
Q

Puestow procedure

A

chronic pancreatitis - pancreaticojejunostomy for enlarged ducts>8mm –> most improve

open along main duct and drain into jejunum

80
Q

MCC splenic vein thrombosis

A

chronic pancreatitis

81
Q

Tx splenic vein thrombosis

A

splenectomy for isolated bleeding gastric varices

82
Q

Problem with splenic vein thrombosis

A

bleeding from isolated gastric varices that form collaterals

83
Q

MCC pancreatic insufficiency

A

long-standing pancreatitis or after total pancreatectomy (over 90% function must be lost)

84
Q

Symptoms of pancreatic insufficiency

A

generally refers to exocrine function –> malabsoprtion, steatorrhea

85
Q

Dx pancreatic insufficiency

A

fecal fat testing

86
Q

Tx pancreatic insufficiency

A

high carb, high protein, low fat diet, pancrease (pancreatic enzymes)

87
Q

Jaundice workup

A
  1. US
    - positive CBD stones, no mass –> ERCP
    - no cbd stones, no mass –> MRCP
    - positive mass –> MRCP
88
Q

Epidemiology of pancreatic adenocarcinoma

A

males 6th and 7th decades

89
Q

symptoms pancreatic adenocarcinoma

A

weight loss (MC), jaundice, pain

90
Q

survival rate pancreatic adenocarcinoma

A

20% 5 year survival with resection

91
Q

MC risk factor pancreatic adenocarcinoma

A

tobacco

92
Q

marker pancreatic adenocarcinoma

A

CA 19-9

93
Q

MC mutation pancreatic adenocarcinoma

A

95% p16 mutation (tumor suppressor, binds cyclin complexes)

94
Q

initial spread of pancreatic adenocarcinoma

A

lymphatic

95
Q

location and invasion pancreatic adenocarcinoma

A

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
96
Q

Which location of pancreatic cancer is most curable?

A

head masses

97
Q

What’s the story on resectability for pancreatic adenocarcinoma?

A

If there is any invasion to other structures or plexus nodes, it is unresectable

98
Q

MC subtype pancreatic adenocarcinoma

A

ductal adenocarcinoma

99
Q

favorable subtypes pancreatic adenocarcinoma

A

papillary or mucinous cystadenocarcinoma

100
Q

labs in pancreatic adenocarcinoma

A

increased bilirubin and alkphos

101
Q

when to biopsy pancreatic adenocarcinoma

A

if resectable –> no biopsy, resect

if mets –> biopsy to direct therapy

102
Q

imaging to differentiate chronic pancreatitis from CA

A

mrcp

103
Q

mrcp findings in ca (3)

A 
duct with irregular narrowing
displacement
destruction
-also can detect vessel involvement
3Ds
104
Q

ct signs for pancreatic head tumors (2)

A
  • double duct sign (dilation of pancreatic and CBD)

- lesion

105
Q

Tx of unresectable pancreatic adenocarcinoma

A

palliation - biliary stents, hepaticojejunostomy (for biliary obstruction), gastrojejunostomy (for duodenal obstruction), and celiac plexus ablation (for pain)

106
Q

Whipple complications

A
  1. delayed gastric emptying (MC)
  2. fistula
  3. leak
  4. marginal ulceration
  5. bleeding
107
Q

tx of delayed gastric emptying

A

metoclopramide

108
Q

tx of post-whipple fistula

A

conservative

109
Q

tx of post-whipple leak

A

place drains and tx like fistula

110
Q

tx of marginal ulceration post-whipple

A

ppi

111
Q

tx of bleeding post whipple or pancreatic surgery

A

angio for embolization (tissue planes are friable after surgery so operative control of bleeding is difficult)

112
Q

chemo for pancreatic adenocarcinoma

A

gemcitabine post op

113
Q

What are the predictors of prognosis for non-metastatic pancreatic adenocarcinoma?

A

nodal invasion, ability to get a clear margin

114
Q

what proportion of pancreatic endocrine neoplasms are non-functional?

A

1/3

115
Q

what percent of pancreatic nonfunctional endocrine neoplasms malignant?

A

90

116
Q

how does the course of nonfunctional endocine neoplasms compare to that of pancreatic adenocarcinoma

A

indolent and protracted course

117
Q

Tx of nonfunctional endocrine neoplasms

A
  • resect; metastatic disease precludes resection

- 5fu, streptozocin

118
Q

most common metastasis in nonfunctional endocrine neoplasms

A

liver

119
Q

what proportion of pancreatic endocrine neoplasms are functional tumors?

A

2/3

120
Q

Most common endocrine pancreatic tumors in head

A

gastrinoma, somatostatinoma

121
Q

Tx of functional endocrine neoplasm of pancreas

A

octreotide or debulking - insulinoma, glucagonoma, gastrinoma, VIPoma

122
Q

first metastatic location for functional endocrine neoplasm of pancreas

A

liver

123
Q

MC functional endocrine neoplasm of pancreas

A

insulinoma - most common islet cell tumor

124
Q

malignant potential of insulinomas

A

10%

90% are benign and evenly distributed throughout pancreas

125
Q

Dx insulinoma

A

insulin to glucose ratio > 0.4 after fasting, elevated C peptide and proinsulin –> if not elevated, suspect munchausen

126
Q

Tx insulinoma

A
  • enucleate if 2cm

- tx metastatic with 5fu, streptozocin and octreotide

127
Q

Most common pancreatic islet cell tumor in MEN1 patients

A

gastrinoma/zes

128
Q

malignancy of gastrinoma/zes

A

50%

129
Q

single/multiple gastrinoma/zes frequency

A

50% multiple

130
Q

spontaneity frequency gastrinoma/zes

A

75% spontaneous

25% MEN1

131
Q

location of gastrinoma/zes

A

gastrinoma triangle - cbd, neck of pancreas, third portion of duodenum

132
Q

symptoms of gastrinoma/zes

A

refractory or complicated ulcer disease and diarrhea (improved with ppi)

133
Q

dx gastrinoma/zes

A
  • serum gastrin usually >200, 1000s is diagnostic

- secretin stimulation test - ZES patients: elevate gastrin >200; normal patients reduce gastrin

134
Q

Tx gastrinoma/zes

A

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
135
Q

what % of microgastrinomas are present inside the duodenum

A

15

136
Q

Best study for localizing gastrinoma

A

octreotide scan

137
Q

Symptoms of glucagonoma

A

diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema)

138
Q

rash in glucagonoma

A

necrolytic migratory erythema

139
Q

dx glucagonoma

A

fasting glucagon level

140
Q

location of glucagonoma

A

distal pancreas

141
Q

what proportion of glucagonomas are malignant

A

most of them

142
Q

Tx of necrolytic migratory erythema

A

zinc, amino acids, fatty acids

143
Q

VIPoma AKA _____ has ___ symptoms

A

verner-morrison

watery diarrhea, hypokalemia, achlorhydria (WDHA)

144
Q

Dx VIPoma

A

rule out other causes of diarrhea, elevated VIP levels

145
Q

what proportion of vipomas are malignant

A

most of them

146
Q

location of vipoma

A

distal pancreas MC, 10% extrapancreatic (RP, thoracic)

147
Q

Frequency of somatostatinoma

A

very rare

148
Q

Symptoms of somatostatinoma

A

diabetes, gallstones, steatorrhea, hypochlorhydria

149
Q

Dx somatostatinoma

A

fasting somatostatin level

150
Q

location of somatostatinoma

A

head of pancreas

151
Q

malignancy of somatostatinoma

A

most malignant

152
Q

tx somatostatinoma

A

chole with resection

153
Q

Symptoms of insulinoma AKA _____

A

hypoglycemia (

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