Chapter 33 - Pancreas Flashcards
Pancreas alpha cells secrete what?
Glucagon
Pancreas beta cells secrete what?
Insulin
Pancreas delta cells secrete what?
Somatostatin
PP cells secrete what?
Pancreatic polypeptide
Which pancreas cells receive the majority of blood supply relative to size?
Islet cells
Pancreas islet cells secrete what?
VIP, serotonin, neuropeptide Y, gastrin-releasing peptide
Secretin causes excretion of what in the pancreas?
HCO3-
CCK causes excretion of what in the pancreas?
Enzymes
ACh causes excretion of what in the pancreas?
Enzymes and HCO3-
Somatostatin causes what in the pancreas?
Decreased exocrine function of pancreas
What is the only pancreatic enzyme secreted in active form?
Amylase - hydrolyzes alpha 1-4 glucose chains
Pancreas 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? What causes it?
2nd portion of duodenum trapped in pancreatic band, can lead to early obstruction; due to failure of rotation of ventral bud
Migration of ventral pancreatic bud?
Migrates posteriorly, to the right, and clockwise to fuse with dorsal bud
Genetic syndrome associated with annular pancreas?
Down Syndrome
Radiographic findings of annular pancreas?
Double bubble on x ray
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 <8 mg pO2 <60 Base deficit >4 Fluid sequestration >6000
Most common site of heterotopic pancreas? How is it treated?
Duodenum; surgical resection only if symptomatic
Treatment for annular pancreas?
Duodenojejunostomy or duodenoduodenostomy and sphincteroplasty; pancreas NOT resected
% of time surgery required for pancreatic necrosis?
10% (due to infection)
Major risk factor for pancreatic necrosis?
Obesity
% of time pancreatic necrosis occurs following pancreatitis?
15%
Complications following pancreatic necrosis?
ARDS, coagulopathy (protease-related)
Treatment of pancreatic fistulas?
Allow to close if <200ml/d: 50-80% success in 4-6 wks
Follow up w/ CT or MRI after 6-8 wks
Stent via ERCP if psx sx or expansion on f/u CT/MRI
If still persists or can’t do ERCP: anastomose vs resect
Etiology of chronic pancreatitis?
#1 EtOH #2 idiopathic
Expectant management of pancreatic pseudocyst for how long?
3mo
Radiographic findings of chronic pancreatitis?
CT: shrunken gland with calcifications
US: >4mm pancreatic duct
ERCP: chain of lakes (very sensitive)
Pathophysiology of chronic pancreatitis?
Irreversible parenchymal fibrosis, islet cells usually preserved
Surgical options for chronic pancreatitis?
Puestow procedure for ducts >8mm (side-side panc-J)
Distal panc for normal duct/failed Puestow
Whipple
Treatment for chronic pancreatitis?
Supportive care, pain control, nutritional support; surgery for pain interfering with QOL, to r/o malignancy
Treatment for bleeding gastric varices due to splenic v. thrombosis?
Splenectomy
Complications of Whipple?
1 is delayed gastric emptying (reglan), anastamotic breakdown, marginal ulceration, abscess/infection, pancreatitis, fistulas, bleeding
Most common cause of splenic v. thrombosis?
Chronic pancreatitis
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
Treatment of gastrinoma?
Enucleation if >2 cm
How is diagnosis of gastrinoma made?
Serum gastrin >200 (1000s diagnostic), secretin stim test (gastrin remains high)
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
Treatment of glucagonoma?
Supportive care, glucose control, octreotide
Resection if amenable
Symptoms of VIPoma (Verner-Morrison syndrome)?
Watery diarrhea, hypokalemia, achlorydia (WDHA)
Diagnosis of VIPoma?
Increased VIP levels, confirmed by repeat
CT/MRI locate and stage
Somatostatin receptor scintigraphy if uncertain or mets
Most common location of glucagonoma?
Distal pancreas
% of function that must be lost before pancreatic insufficiency develops?
90%
Most common location of VIPoma?
Distal pancreas
Symptoms of pancreatic adenocarcinoma?
Weight loss (most common), jaundice, painless
5 yr survival with pancreatic adenocarcinoma?
20% with resection
1 risk factor for pancreatic adenocarcinoma?
Smoking
What makes pancreatic adenocarcinoma unresectable at time of diagnosis?
Invasion of portal vein, SMV, or retro-peritoneum
Mets to peritoneum, omentum, liver, celiac or SMA nodal system
50% of patients unresectable
Treatment for pancreatic insufficiency?
High carb, high protein, low fat diet with enzyme replacement
% of pancreatic adenocarcinoma 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
Treat VIPoma
Replace fluids and lytes
Octreotide
Distal pancreatectomy
F/u 12 mo w/ VIP level, CT/MRI
