Chapter 33 - Pancreas Flashcards
What is the only pancreatic enzyme secreted in active form?
Amylase - hydrolyzes alpha 1-4 glucose chains
Alpha cells secrete what?
Glucagon
Beta cells secrete what?
Insulin
Delta cells secrete what?
Somatostatin
PP cell secrete what?
Pancreatic polypeptide
Islet cells secrete what?
VIP, serotonin, neuropeptide Y, gastrin-releasing peptide
Which cells receive the majority of blood supply relative to size?
Islet cells
Secretin causes excretion of what?
HCO3-
CCK causes excretion of what?
Enzymes
ACh causes excretion of what?
Enzymes and HCO3-
Somatostatin leads to what?
Decreased exocrine function of pancreas
Migration of ventral pancreatic bud?
Migrates posteriorly, to the right, and clockwise to fuse with dorsal bud
Ventral bud forms what?
Uncinate and inferior portion of the head, Duct of Wirsung
Dorsal pancreatic bud forms what?
Body, tail, superior aspect of pancreatic head; Duct of Santorini
What is an annular pancreas?
2nd portion of duodenum trapped in pancreatic band; due to failure of rotation of ventral bud
Radiographic findings of annular pancreas?
Double bubble on x ray
Syndrome associated with annular pancreas?
Down Syndrome
Treatment for annular pancreas?
Duodenojejunostomy or duodenoduodenostomy and sphincteroplasty; pancreas NOT resected
Most common site of heterotopic pancreas?
Duodenum; surgical resection only if symptomatic
Ranson’s criteria: on admission
Age >55, WBC >16, glucose >200, AST >250, LDH >300
Ranson’s criteria: after 48h
Hct decrease by 10%, BUN increase by 5, Ca 4, pa02 6L
% of time pancreatic necrosis occurs following pancreatitis?
15%
% of time surgery required for necrosis?
10% (due to infection)
Risk factor for pancreatic necrosis?
Obesity
Complications following pancreatic necrosis?
ARDS, coagulopathy (protease-related)
Expectant management of pancreatic pseudocyst for how long?
3mo
Treatment of pancreatic fistulas?
Allow to close spontaneously if <200ml/d; drainage via ERCP or distal pancreatectomy, TPN, octreotide
Etiology of chronic pancreatitis?
1 EtOH, #2 idiopathic
Pathophysiology of chronic pancreatitis?
Irreversible parenchymal fibrosis, islet cells usually preserved
Radiographic findings of chronic pancreatitis?
CT: shrunken gland with calcs; US: >4mm pancreatic duct; ERCP: chain of lakes (very sensitive)
Treatment for chronic pancreatitis?
Supportive care, pain control, nutritional support; surgery for pain interfering with QOL, to r/o malignancy
Surgical options for chronic pancreatitis?
Puestow procedure for ducts >8mm, distal panc for normal duct/failed Puestow, Whipple
Most common cause of splenic v. thrombosis?
Chronic pancreatitis
Treatment for bleeding gastric varices due to splenic v. thrombosis?
Splenectomy
Complications of Whipple?
1 delayed gastric emptying (reglan), anastamotic breakdown, marginal ulceration, abscess/infection, pancreatitis, fistulas, bleeding
Fraction of pancreatic neoplasms that are nonfunctional endocrine tumors?
1/3
% of nonfunctional endocrine tumors that are malignant?
90%
Chemo used for nonfunctional endocrine tumors?
5FU, streptozocin
Nonfunctional endocrine tumors most common site of metastasis?
Liver
Most common islet cell tumor?
Insulinoma
What is Whipple’s triad?
Symptomatic hypoglycemia, fasting hypoglycemia (<50), relief with glucose
% of insulinomas that are benign?
85-95%
Treatment for insulinoma?
Enucleation (2cm), streptozocin, octreotide, 5FU for mets
Most common pancreatic islet cell tumor associated with MEN1
Gastrinoma - 25% associated with MEN1
Boundaries of the gastrinoma triangle?
CBD and cystic duct, neck of pancreas, 3rd portion of the duodenum
Symptoms of gastrinoma?
Refractory ulcer disease, diarrhea improved with H2 blockers
How is diagnosis of gastrinoma made?
Serum gastrin >200 (1000s diagnostic), secretin stim test (gastrin remains high)
Treatment of gastrinoma?
Enucleation (2cm)
What do you do if you can’t find the gastrinoma?
Open the duodenum, somatostatin receptor scintigraphy
Symptoms of somatostatinoma?
Diabetes, gallstones, steatorrhea, hypochlorydia
Diagnosis of somatostatinoma?
Fasting somatostatin level
Treatment of somatostatinoma?
Resection with cholecystectomy
Symptoms of glucagonoma?
Diabetes, stomatitis, dermatitis, weight loss
Most common location of glucagonoma?
Distal pancreas
Treatment of glucagonoma?
Zinc, amino acids for rash
Symptoms of VIPoma (Verner-Morrison syndrome)?
Watery diarrhea, hypokalemia, achlorydia (WDHA)
Diagnosis of VIPoma?
Increased VIP levels
Most common location of VIPoma?
Distal pancreas
% of function that must be lost before pancreatic insufficiency develops?
90%
Treatment for pancreatic insufficiency?
High carb, high protein, low fat diet iwth enzyme replacement
Symptoms of pancreatic adenoca?
Weight loss (most common), jaundice, pain
5 yr survival with pancreatic adenoca?
20% with resection
1 risk factor for pancreatic adenoca?
Smoking
What makes pancreatic adenoca unresectable at time of diagnosis?
Invasion of portal vein, SMV, or retroperitoneum; mets to peritoneum, omentum, liver, celiac or SMA nodal system (50% of patients unresectable)
% of pancreatic adenoca found in the head of the pancreas?
70%
% of exocrine pancreas tumors that are ductal adenocarcinomas?
90%
Which tumor of the exocrine pancreas is considered premalignant?
Mucinous cystadenoma
Chemotherapy for pancreatic adenocarcinoma?
Gemcitabine (with XRT)
Signs of carcinoma on ERCP?
Duct with irregular narrowing, displacement, destruction
