Chapter 33 - Pancreas++ Flashcards
1
Q
Pancreas alpha cells secrete what?
A
Glucagon - catabolic, fasting state; mobilizes glucose (liver glycogen, then protein and fat), fatty acids (most nutrient needs), amino acids
2
Q
Pancreas beta cells secrete what?
A
Insulin - anabolic, fed state; stores glucose, fatty acids, amino acids; through Na/K/ATPase decreases plasma glucose, K
3
Q
Pancreas delta cells secrete what?
A
Somatostatin - decreases gastrin, glucagon, VIP, insulin
4
Q
PP cells (F cells) secrete what?
A
Pancreatic polypeptide - regulation of HCO3 secretion
6
Q
Secretin causes excretion of what in the pancreas? Decreases what?
A
HCO3- increases, gastrin decreases (can be used to test for gastrinoma - gastrin will paradoxically increase)
7
Q
Which pancreas cells receive the majority of blood supply relative to size?
A
Islet cells
8
Q
CCK causes excretion of what in the pancreas?
A
Enzymes (as opposed to secretin)
9
Q
Pancreas islet cells secrete what?
A
VIP, serotonin, neuropeptide Y, gastrin-releasing peptide
10
Q
ACh causes excretion of what in the pancreas?
A
Enzymes and HCO3-
11
Q
Somatostatin causes what in the pancreas?
A
Decreased exocrine function of pancreas
12
Q
Pancreas ventral bud forms what?
A
Uncinate and inferior portion of the head, Duct of Wirsung (main drainage)
13
Q
Dorsal pancreatic bud forms what?
A
Body, tail, superior aspect of pancreatic head (main functional component); Duct of Santorini
14
Q
What is the only pancreatic enzyme secreted in active form?
A
Amylase - hydrolyzes alpha 1-4 glucose chains
15
Q
Migration of ventral pancreatic bud?
A
Migrates posteriorly, to the right, and clockwise to fuse with dorsal bud
16
Q
Genetic syndrome associated with annular pancreas?
A
Down Syndrome
17
Q
Ranson’s criteria: on admission
A
Use to assess pancreatitis severity Age >55 WBC >16 Glucose >200 AST >250 LDH >300
18
Q
Radiographic findings of annular pancreas?
A
Double bubble on x ray
19
Q
Ranson’s criteria: after 48h
A
Hct decrease by 10% BUN increase by 5 Ca <8 mg pO2 <60 Base deficit >4 Fluid sequestration >6000
20
Q
Most common site of heterotopic pancreas? How is it treated?
A
Duodenum; surgical resection only if symptomatic
21
Q
Treatment for annular pancreas?
A
Duodenojejunostomy or duodenoduodenostomy and sphincteroplasty; pancreas NOT resected
22
Q
% of time surgery required for pancreatic necrosis?
A
10% (due to infection)
23
Q
Management of postoperative pancreatic fistulas?
A
Dx: fluid amylase >3x serum amylase.
Tx: drains (retention or placement), maintain fluid/lyte balance, nutritional support
- Allow to close if <200ml/d: 50-80% success in 4-6 wks.
- Follow up w/ CT or MRI after 6-8 wks.
- If persistent/expansion on f/u: ERCP w/ stent
- If still persists or can’t do ERCP: anastomose vs resect.
Of note, ERCP is often the best first step in nonoperative pancreatic fistulas.
24
Q
% of time pancreatic necrosis occurs following pancreatitis?
A
15%
25
Q
Expectant management of pancreatic pseudocyst for how long?
A
6 wks to 3 mo, then do enterostomy (perc drainage has high recurrence rate and high fistula complication rate)
26
Complications following pancreatic necrosis?
ARDS, coagulopathy (protease-related)
27
Etiology of chronic pancreatitis?
```
#1 EtOH
#2 idiopathic
```
28
Surgical options for chronic pancreatitis?
Need to know if panc head involvement and duct size.
Puestow procedure for ducts >8mm (side-side panc-J).
- Anastomosis length should be >6cm.
Distal panc for normal duct/failed Puestow.
Whipple.
29
Treatment for chronic pancreatitis?
Initial tx: Supportive care, pain control, nutritional support; surgery for pain interfering with QOL, to r/o malignancy.
30
Radiographic findings of chronic pancreatitis?
CT: shrunken gland with calcifications
US: >4mm pancreatic duct
ERCP: chain of lakes (very sensitive)
31
Treatment for bleeding gastric varices. What is this most often caused by?
Often due to splenic v. thrombosis from chronic pancreatitis.
Splenectomy is tx.
32
Complications of Whipple?
#1 is delayed gastric emptying (tx reglan), anastamotic breakdown, marginal ulceration, abscess/infection, pancreatitis, fistulas, bleeding
33
% of nonfunctional endocrine tumors that are malignant?
90%. All get resected:
- <2 cm: enucleation
- otherwise: formal resection w/ LADx + splenx
34
Pathophysiology of chronic pancreatitis?
Irreversible parenchymal fibrosis, islet cells usually preserved
35
Most common cause of splenic v. thrombosis?
Chronic pancreatitis
36
Fraction of pancreatic neoplasms that are nonfunctional endocrine tumors?
1/3 (most common)
37
Chemo used for nonfunctional endocrine tumors?
5FU, streptozocin
38
Most common islet cell tumor?
Insulinoma. Can be found anywhere in pancreas, unlikely to be malignant. Cannot be localized w/ somatostatin scan. Large biochemical workup required for diagnosis.
39
What is Whipple's triad?
Symptomatic hypoglycemia, fasting hypoglycemia (<50), relief with glucose. Psx of insulinoma.
40
Treatment for insulinoma?
Glucose management. Somatostatin analogue and diazoxide help.
Enucleation if <3cm.
Streptozocin, octreotide, 5FU for mets.
Suspicion for malignancy requires formal resection.
41
Treatment for insulinoma?
Enucleation if <3cm.
Streptozocin, octreotide, 5FU for mets.
Suspicion for malignancy requires formal resection.
42
Most common pancreatic islet cell tumor associated with MEN1?
Gastrinoma - 25% associated with MEN1
43
Nonfunctional endocrine tumors most common site of metastasis?
Liver
44
Treatment of gastrinoma?
Preoperative optimization with PPIs (can ctrl sx alone).
If MEN1, screen for hypercalcemia and hyperparathyroidism. Treat hyperparathyroidism before gastrinoma.
Enucleation if <2cm.
Otherwise formal resection (Whipple vs distal pancreatectomy). All require lymph node dissection.
45
How is diagnosis of gastrinoma made?
Fasting serum gastrin >200 (1000s diagnostic). Secretin stim test (gastrin remains high) if b/w 200 and 1000.
46
Symptoms of gastrinoma?
Refractory ulcer disease (parietal cells activated), abdominal pain, weight loss, diarrhea improved with H2 blockers.
47
Symptoms of somatostatinoma?
Diabetes, gallstones, steatorrhea, malabsoprtion
48
What do you do if you can't find the gastrinoma?
Triphasic CT or MRI, somatostatin receptor scintigraphy (works for all PNETs except insulinoma), EUS. Consider intra-arterial Ca injection w/ hepatic vein sampling for gastrin.
Last line: OR - intraoperative US, transduodenal palpation, intraop endoscopy, duodenotomy and palpate gastrinoma triangle.
49
Diagnosis of somatostatinoma?
Fasting somatostatin level. Usually malignant. Found in head of pancreas and in 2nd part of duodenum.
50
Treatment of glucagonoma?
Preop optimization: tight glucose control, somatostatin, nutrition (amino acids resolves rash), zinc replacement. Consider anticoagulation.
No role for enucleation - high risk of malignancy. Will require formal resection (usually distal pancreatectomy). Always add cholecystectomy d/t requirement of postop somatostatin.
Postop: supportive care, octreotide.
51
Boundaries of the gastrinoma triangle?
CBD and cystic duct, neck of pancreas, 3rd portion of the duodenum
52
Symptoms of VIPoma (Verner-Morrison syndrome)?
Watery diarrhea, hypokalemia, achlorydia (WDHA). Usually malignant.
53
Treatment of somatostatinoma?
Resection with lymphadenectomy and cholecystectomy
54
Diagnosis of VIPoma?
Fasting VIP levels (elevated when having diarrhea), confirmed by repeat.
CT/MRI locate and stage.
Somatostatin receptor scintigraphy if uncertain or mets.
EUS.
55
Most common location of VIPoma?
Distal pancreas.
Preop w/ octreotide and fix lytes.
Do formal anatomic resection w/ negative margins and lymphadenectomy and cholecystectomy.
56
Most common location of glucagonoma?
Distal pancreas
57
5 yr survival with pancreatic adenocarcinoma?
30% with resection R0 node negative resx. 4th leading cause of cancer death in US. Surgery is only possible cure.
58
Symptoms of pancreatic adenocarcinoma?
Weight loss (most common), painless jaundice. Usually presents late, so only 15-20% of pts are candidates for resection.
59
#1 risk factor for pancreatic adenocarcinoma?
Smoking
60
Treatment for pancreatic insufficiency?
High carb, high protein, low fat diet with enzyme replacement
61
% of pancreatic adenocarcinoma found in the head of the pancreas?
70%
62
% of exocrine pancreas tumors that are ductal adenocarcinomas?
90%
63
Which tumor of the exocrine pancreas is considered premalignant?
Mucinous cystadenoma
64
Chemotherapy for pancreatic adenocarcinoma?
Gemcitabine (with XRT)
65
Treat VIPoma
Replace fluids and lytes.
Octreotide.
Distal pancreatectomy (no enucleation) w/ lymphadenectomy. Add cholecystectomy.
F/u 12 mo w/ VIP level, CT/MRI.
66
What margin of the pancreas is often the limiting step in surgery and requires special radiology attention when staging?
uncinate - near SMA and SMV
67
Branches of what arteries supply the pancreas?
common hepatic artery - GDA - ant/post superior PDAs
splenic artery - dorsal pancreatic artery
SMA - ant/post inferior PDAs
68
What is the nerve supply of the pancreas?
Splanchnic
Vagus
Celiac plexus
69
What hormones control exocrine function of the pancreas?
Gastrin
CCK - phospholipase C, increases enzyme secretion
secretin - cAMP, increases alkaline juice secretion
Secretion is alkaline fluid w/ high bicarb.
70
Pancreatic development
Arises from endoderm as a dorsal and ventral bud.
71
How do you workup acute pancreatitis?
Lipase, imaging to exclude other diagnoses. Severity scores (APACHE, SOFA).
72
Discuss pancreatic divisum.
Failure to fuse dorsal and ventral buds. Secretion from the dorsal pancreas (most of pancreatic tissue) drains through the minor papilla.
73
How do you manage acute pancreatitis?
Fluids (large volume resuscitation for severe). NGT decompression, pain control, oxygen, identify origin.
Gallstones require lap chole w/ IOC after lab values and sx improve, during same hospital stay.
Cholangitis or choledocholithiasis will require ERCP w/ subsequent cholecystectomy.
74
How do you manage acute fluid collections associated with pancreatitis?
Not septic: acute peripancreatic fluid collection, acute postnecrotic fluid collection - observe first w/ f/u CT or MRI; do not touch until wall is mature
Septic: ICU/IVF/abx, perc drain if mature wall, step up (wider drainage, VARD).
Pseudoaneurysm: angiographic embo
Symptomatic: ERCP w/ transpapillary stenting
75
In a patient with severe necrotizing pancreatitis and a bacterial source of infection, what abx do you use?
Abx are not routine, only given when infection suspected. Find source.
Cipro/flagyl or imipenem.
In a septic patient where routine workup cannot ID a source, get CT w/ FNA gram stain/culture of necrotic material/fluid.
76
When can patients with pancreatitis be given an oral diet?
As soon as they can tolerate it. Otherwise attempt jejunal feeding until PO can be tolerated (radiology should confirm placement before feeds started, elemental feeds). If enteral feeding not tolerated, then give TPN. Enteral nutrition maintains intestinal barrier and prevents bacterial translocation from the gut, avoids central line complications.
77
How do you define chronic pancreatic fluid collections? How do you manage them?
>4 weeks.
Pseudocyst - 6 wks expectant mgmt; if contd sx (low-grade fever, mild leukocytosis, inability to eat, nausea), >6 cm. Need ERCP/MRCP to assess duct, cystgastrostomy w/ biopsy of lining (make sure no epithelium to confirm dx). If pseudoaneurysm suspected, do not attempt endoscopic drainage (10% occurrence, need arterial embo first).
Walled off necrosis - same as pseudocyst except will need VARD.
78
How do you workup chronic pancreatitis?
History: abdominal pain assd w/ food, steatorrhea, diabetes, malabsoprtion; hx of alcoholism, hx of previous pancreatitis.
Labs may be normal. HbA1c can check endocrine function. Fecal elastase can check exocrine function.
MRCP or ERCP for duct analysis - beading, shrunken, dilated.
CT or EUS (most sensitive) for morphology - calcifications, head vs tail involvement.
79
What procedure is needed for chronic pancreatitis with large duct (>1cm) disease without pancreatic head involvement?
Puestow. Anastomosis length should be >6cm.
80
What is chronic pancreatitis?
inflammatory disorder of the pancreas characterized by glandular fibrosis resulting in permanent structural and functional changes in the organ, ultimately leading to pancreatic endocrine and exocrine insufficiency
81
What procedure is needed for chronic pancreatitis with small/normal duct disease with pancreatic head involvement?
Whipple (easier than the other two), Beger (if mainly head involvement), or Frey (if normal or large duct).
82
What procedure is needed for chronic pancreatitis with large duct (>1cm) disease with pancreatic head involvement?
Frey
83
What procedure is needed for chronic pancreatitis with small duct disease with pancreatic head involvement?
Whipple, Beger, or Frey
84
How do you manage a pancreatic pseudoaneurysm? What is it?
Bleeding into pseudocyst resulting from chronic inflammation.
Sx: Acute exacerbation of abdominal pain.
Dx: CT shows increasing size and density of pseudocyst content (blood).
Tx: angio embolization, then formal resection w/ direct ligation of the involved artery (GDA, PDA, splenic). Do not attempt endoscopic drainage.
85
How are most pancreatic cysts found?
incidentally; GI will often then do ERCP w/ EUS and bx and refer to surgery once dx is made
86
What procedure is needed for chronic pancreatitis with minimal change?
denervation - thoracoscopic splanchnicectomy
87
How do you workup a pancreatic cyst?
Triple phase CT or MRCP.
EUS to FNA bx and fluid analysis - CEA and amylase
ERCP - look for "fish-mouth" papilla w/ mucin flowing
88
What are the two major divisions of pancreatic cysts?
mucinous, serous
89
What is pancreatic cyst CEA >192 consistent with?
Mucinous cyst (high malignant potential) - warrant resection
90
What if there is low amylase and low CEA seen in pancreatic cyst?
Serous cyst
91
What does an elevated amylase from pancreatic cyst mean?
communication with the pancreatic ductal system - pseudocyst or IPMN
92
Which cyst diagnoses warrant an operation?
Most of them except asymptomatic serous cyst and branch duct IPMN
- Main duct IPMN
- Mucinous cyst
- Serous cyst with sx
- branch duct IPMN w/ high risk or worrisome features
93
Which branch-duct IPMNs need resection?
```
>3 cm
mural nodule
main duct involvement (60% malignant)
cytology suspicious
thickened cyst wall
main duct >1 cm
```
94
Who gets serous cystadenomas?
Old women.
CT shows central "stellate" scar (like FNH in liver).
EUS fluid analysis shows low CEA and amylase (can be high).
Operate only if symptomatic or >5-6 cm.
95
Which branch-duct IPMNs need resection?
```
>3 cm
mural nodule
main duct involvement
cytology suspicious
thickened cyst wall
main duct >1 cm
```
96
Do IPMNs have malignant potential?
The highest of all cystic
97
How do you manage mixed duct IPMNs?
Same as main duct - resect
98
What other diagnostic study should one perform in a Western country with a patient with new IPMN?
Colonoscopy, especially those with microcytic anemia and older than 50. High incidence of adenocarcinoma in IPMN patients.
99
If a young female (22 yrs) presents with a 10 cm pancreatic cyst w/ solid components, what is the likely dx?
Solid pseudopapillary neoplasm.
Sx of mass effect.
Resect these,
100
Insulinoma lab dx
Low fasting glucose, high fasting insulin, high C-peptide, negative oral hypoglycemic drugs
101
Nonfunctional PNET lab dx
chromogranin A, neurotensin, pancreatic polypeptide; usually in pancreatic head
102
Most PNETs require what surgery?
Formal resection.
Insulinoma - enucleation ok for small.
Gastrinoma - enucleation ok for small size, but still require lymphadenectomy.
103
In patients with lab findings of PNET, but in whom CT scan and somatostatin receptor scintigraphy is negative, what can be done as a next localization step?
calcium-stimulated angiography
104
What vitamin deficiency is common in glucagonoma?
zinc, correct this
105
What is borderline resectable pancreatic adenocarcinoma? What should be done?
- No distant mets
- Tumor abuts <180 degrees of SMA
- Short segment abutment of hepatic artery
- Majority of portal/SMV abutment
- Short segment occlusion of portal/SMV
Preop chemo +/- radiation.
106
Symptoms of glucagonoma
diabetes, necrolytic migratory erythema, DVT (factor X-like mediator), weight loss and malnutrition 2/2 catabolic effect, depression, anemia (bone marrow suppression)
107
How do you treat periampullary duodenal adenocarcinoma?
Pancreaticoduodenectomy.
5-FU-based regimens are employed for cases that warrant systemic chemotherapy, including node-positive disease following resection or unresectable disease.
Advanced tumors in the duodenum may be prone to forms of local invasion not commonly seen with other periampullary adenocarcinoma, such as invasion into the inferior vena cava or right kidney. In these circumstances, preoperative chemotherapy or chemoradiation may be employed as a means of enhancing the likelihood of a margin-positive resection.
108
How do you treat distal cholangiocarcinoma (intra-pancreatic portion of CBD)?
Pancreaticoduodenectomy.
Gemcitabine-based chemotherapy is typically offered as adjuvant therapy for patients with node-positive disease or as definitive therapy for patients with unresectable or metastatic disease. As with pancreatic adenocarcinoma, radiation therapy is typically reserved for adjuvant therapy following resection with close or positive resection margins or for palliation of tumor-related symptoms in cases of unresectable disease.
109
How do you manage postop DGE after pancreaticoduodenectomy?
| A complication seen in 35-70% of pancreaticoduodenectomies.
Risk: fistulas, DM, and malnutrition.
Causes: abscess, obsx, edema, pancreatitis.
Dx: swallow study shows slow passage.
Mgmt: Resolves in 6 wks in most.
- Prolonged NGT decompression.
- IVF and distal tube feeding.
- Liberal use of erythromycin (binds motilin to stim smooth muscle contraction) and metoclopramide.
Consider jejunal feeding tube (placed at time of initial operation) to allow continued feeding while waiting for gastric function.
110
What are the three general phases for carrying out operative management of pancreatic head cancer?
1. Assess resectability.
2. Pancreaticoduodenectomy. Classic resection indicated if the tumor encroaches D1.
3. Restore GI continuity.
111
How do you manage postop DGE after pancreaticoduodenectomy?
| A complication seen in 35-70% of pancreaticoduodenectomies.
Risk: fistulas, DM, and malnutrition.
Causes: abscess, obsx, edema, pancreatitis.
Dx: swallow study shows slow passage.
Mgmt: Resolves in 6 wks in most.
- Prolonged NGT decompression.
- IVF and distal tube feeding.
- Liberal use of erythromycin (binds motilin to stim smooth muscle contraction) and metoclopramide.
Consider jejunal feeding tube (placed at time of initial operation) to allow continued feeding while waiting for gastric function.
112
After pancreaticoduodenectomy, what is a potentially fatal complication? How do you prevent? How do you treat?
Delayed postop bleeds: pseudoaneurysm from GDA stump bleed.
- leave long stump
- tx w/ angiography and embolization
113
What is the role of staging laparoscopy in pancreatic cancer?
Should be considered in patients with potentially resectable disease on CT but with other features metastasis - significant weight loss, large tumor size, hypoalbuminemia.
114
How do you determine the cause of steatorrhea as intestinal or pancreatic in origin (eg pt w/ hx of chronic pancreatitis and multiple small bowel resections)?
24-hour fecal fat test:
- >20 g - pancreatic insufficiency
- secretin stim abnormal
- PP levels low
115
Spleen preservation for distal pancreatectomy?
Only if disease is benign. Formal resections for possible malignant disease require splenectomy.
