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My Absite > Chapter 33: Pancreas > Flashcards

Chapter 33: Pancreas Flashcards

1
Q

Rests on aorta, behind SMV

A

Uncinate process

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2
Q

Lays behind neck of pancreas

A

SMV and SMA

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3
Q

Forms behind the neck (SMV and splenic vein)

A

Portal vein

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4
Q

Blood supply to head of pancreas

A

Superior (off GDA) and inferior (off SMA), pancreaticoduoenal arteries (anterior and posterior branches for each)

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5
Q

Blood supply to body of pancreas

A

great, inferior, and caudal pancreatic arteries (all off splenic artery)

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6
Q

Blood supply to tail of pancreas

A

Splenic, gastroepiploic and dorsal pancreatic arteries

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7
Q

Venous drainage of the pancreas

A

Portal system

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8
Q

Lymphatics for pancreas

A

Celiac and SMA nodes

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9
Q

Pancreas: cells secrete HCO3- solution (have carbonic anhydrase)

A

Ductal cells

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10
Q

Pancreas: cells secrete digestive enzymes

A

Acinar cells

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11
Q

Exocrine function of the pancreas

A

Amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase, HCO3-

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12
Q

Only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains

A

Amylase

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13
Q

Endocrine function of the pancreas:

  • Alpha
  • Beta
  • Delta
  • PP or F cells
  • Islet cells
A
  • Alpha: glucagon
  • Beta: (center of islets): insulin
  • Delta: somatostatin
  • PP or F cells: pancreatic polypeptide
  • Islet cells: also produce VIP, serotonin
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14
Q

Endocrine: receive majority of blood supply related to size

A

Islets cells

- after islets, blood goes to acinar cells

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15
Q

Released by the duodenum, activates trypsinogen to trypsin

A

Enterokinase

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16
Q

After being activated by enterokinase, Activates pancreatic enzymes, including trypsinogen

A

Trypsin

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17
Q

Hormonal control of pancreatic excretion

A

Secretin, CCK, Acetylcholine, somatostatin, glucagon, CCK and secretin

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18
Q

Increases HCO3- mostly

A

Secretin

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19
Q

Increases pancreatic enzymes mostly

A

CCK

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20
Q

Increases HCO- and enzymes

A

Acetylcholine

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21
Q

Decreases exocrine function

A

Somatostatin and glucagons

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22
Q

Mostly released by cells in the duodenum

A

CCK and secretin

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23
Q

Connected to duct of Wirsung; migrates posteriorly, to the right, and clockwise to fuse with the dorsal bud
- Forms uncinate and inferior portion of the head

A

Ventral pancreatic bud

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24
Q

Body, tail, and superior aspect of the pancreatic head; has duct of Santorini

A

Dorsal pancreatic bud

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25
Q

Major pancreatic duct that merges with CBD before entering duodenum

A

Duct of Wirsung

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26
Q

Small accessory pancreatic duct that drains directly into duodenum

A

Duct of Santorini

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27
Q

2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal XR; get duodenal obstruction (N/V, abdominal pain)

A

Annular pancreas

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28
Q

What is annular pancreas associated with?

A

Down syndrome; forms the ventral pancreatic bud from failure of clockwise rotation

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29
Q

Tx: annular pancreas

A

Duodenojejunostomy and duodenoduodenostomy; possible sphincteroplasty
- pancreas not resected

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30
Q

Failed fusion of the pancreatic ducts; can result in pancreatitis from duct of Santorini (accessory duct) stenosis
- Most are asymptomatic; some get pancreatitis

A

Pancreas divisum

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31
Q

Dx: 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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32
Q

Tx: pancreas divisum

A

ERCP with sphincteroplasty; open sphincteroplasty if that fails

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33
Q
  • Most commonly found in duodenum
  • usually asymptomatic
  • surgical resection if symptomatic
A

heterotopic pancreas

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34
Q

Acute pancreatitis: Most common etiologies in the US

A

Gallstones and ETOG

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35
Q

Etiologies of acute pancreatitis

A

Gallstones, ETOH, ERCP trauma, HLD, Hyper-Ca, viral infection, medications (azathioprine, furosemide, steroids, cimetidine)

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36
Q

How do gallstones cause acute pancreatitis?

A

Can obstruct the ampulla of Vater, causing impaired extrusion of zymogen granules and activation of degradation enzymes -> leads to pancreatic auto-digestion

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37
Q

How does alcohol cause acute pancreatitis?

A

Can cause auto-activation of the pancreatic enzymes while still in the pancreas

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38
Q

Symptoms: abdominal pain radiating to the back, nausea, vomiting, anorexia
- can also get jaundice, left pleural effusion, ascites or sentinel loop (dilated small bowel near the pancreas as a result of the inflammation)

A

Acute pancreatitis

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39
Q

Mortality rate of acute pancreatitis

A

Mortality rate 10%; hemorrhagic pancreatitis mortality 50%

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40
Q

What do you need to worry about in pancreatitis without an obvious cause?

A

Need to worry about malignancy

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41
Q

Ranson’s criteria on admission

A 
Age > 55
WBC > 16
Glucose > 200
AST > 250
LDH > 350
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42
Q

Ranson’s criteria after 48 hours

A

Hct decrease 10%
BUN increase of 5
Ca 4
Fluid sequestration > 6L

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43
Q

What is a patient has 8 components of the Ranson’s criteria?

A

Mortality rate near 100%

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44
Q

Labs: acute pancreatitis

A

Increased amylase, lipase, and WBCs

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45
Q

Ultrasound: acute pancreatitis

A

Needed to check for gallstones and possible CBD dilatation

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46
Q

Abdominal CT: acute pancreatitis

A

To check for complications (necrotic pancreas will not uptake contrast)

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47
Q

Tx: acute pancreatitis

A

NPO, aggressive fluid resuscitation

  • ERCP (gallstone pancreatitis and retained CBD stones)
  • Antibiotics (stones, severe pancreatitis, failure to improve, or suspected infection)
  • TPN (recovery period)
  • Cholecystectomy (gall stones)
  • No morphine
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48
Q

When is ERCP needed in acute pancreatitis?

A

Gallstone pancreatitis and retained CBD stones -> perform sphincterotomy and stone extraction

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49
Q

When are antibiotics needed for acute pancreatitis?

A

Stones, severe pancreatitis, failure to improve, or suspected infection

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50
Q

What is the role of cholecystectomy with acute pancreatitis?

A

Patients with gallstone pancreatitis should undergo cholecystectomy when recovered from pancreatitis (same hospital admission)

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51
Q

Why is morphine avoided in acute pancreatitis?

A

Should be avoided as it can contract the sphincter of Oddi and worsen attack

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52
Q

Sign: flank ecchymosis

A

Grey Turner sign (bleeding)

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53
Q

Sign: periumbilical ecchymosis

A

Cullen’s sign (bleeding)

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54
Q

Sign: inguinal ecchymosis

A

Fox’s sign (bleeding)

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55
Q

What are three physical exam signs of bleeding?

A
  • Grey turner (flank)
  • Cullen’s (periumbilical)
  • Fox’s (inguinal)
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56
Q

Rate of pancreatic necrosis

A

15% get pancreatic necrosis; leave sterile necrosis alone

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57
Q

Management: infected pancreatic necrosis

A
  • May need to sample necrotic pancreatic fluid with CT-guided aspiration to get diagnosis
  • Surgical debridement
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58
Q

Fever, positive blood cultures in acute pancreatitis

A

Infected necrosis of pancreas

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59
Q

Tx: pancreatic abscess

A

Need surgical debridement

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60
Q

Is CT-guided drainage of infected pancreatic necrosis or pancreatic abscess effective?

A

Generally not effective

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61
Q

Gas in necrotic pancreas..

A

Infected necrosis or abscess (need open debridement)

62
Q

Leading cause of death with pancreatitis

A

Infection (usually GNRs)

63
Q

When is surgery indicated in pancreatitis?

A

Only for infected pancreatitis or pancreatic abscess

64
Q

Most important risk factor for necrotizing pancreatitis

65
Q

Pancreatitis: complication related to phospholipases

A
  • ARDS

- Pancreatic fat necrosis

66
Q

Pancreatitis: complication related to proteases

A

Coagulopathy

67
Q

What is related to mild increases in amylase and lipase?

A

Can be seen with cholecystitis, perforated ulcer, sialoadenitis, small bowel obstruction, and intestinal infarction

68
Q

What is associated with chronic pancreatitis?

A

Pancreatic pseudocysts

69
Q

Cysts NOT associated with pancreatitis..

A

Need to r/o CA (eg, mucinous cystadenocarcinoma)

70
Q

Symptoms: pain, fever, weight loss, bowel obstruction from compression

A

Pancreatic pseudocysts

71
Q

Where do pancreatic pseudocysts often occur?

A

The head of the pancreas; is a non-epitheliazed sac

72
Q

TX: pancreatic pseudocysts

A

Most resolve spontaneously (especially if

73
Q

When is surgery indicated in pancreatic pseudocysts?

A

Continued symptoms (tx: cystogastrostomy, open or percutaneous) or pseudocysts that are growing (tx: resection r/o CA)

74
Q

Complications of pancreatic pseudocysts

A

Infection of cyst, portal or splenic vein thrombosis

75
Q

Management: incidental cysts not associated with pancreatitis

A

Should be resected (worry about intraductal papillary-mucinous neoplasms (IPMNs) or mutinous cystuadenocarcinoma) unless the cyst is purely serous and non-complex

76
Q

Management of non-complex , purely serous cyst adenomas

A

Have an extremely low malignancy risk (

77
Q
  • most close spontaneously (especially if low output
A

Pancreatic fistulas

78
Q

Pancreatic fistulas: tx for failure to resolve with medical management

A

Can try ERCP, sphincterotomy and pancreatic stent placement (fistula will usually close, then remove stent)

79
Q

What causes pancreatitis-associated pleural effusion (or ascites)?

A

Caused by retroperitoneal leakage of pancreatic fluid from the pancreatic duct or a pseudocyst (is not a pancreatic-pleural fistula); majority close on their own

80
Q

Tx: pancreatitis-associated pleural effusion (or ascites)

A

Thoracentesis (or paracentesis) followed by conservative tx (NPO, TPN, and octreotide - follow pancreatic fistula pathway above)
- amylase will be elevated in the fluid

81
Q

Pathophysiology of chronic pancreatitis

A

Corresponds to irreversible parenchymal fibrosis

82
Q

MCC chronic pancreatitis

A

1) ETOH 2) Idiopathic

83
Q

Pain most common problem, anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis

A

Chronic pancreatitis

84
Q

Endocrine / exocrine chronic pancreatitis

A
  • Endocrine function: usually preserved (Islet cell preserved)
  • Exocrine function: decreased
85
Q

Nutritional deficiency in chronic pancreatitis

A

Can cause malabsorption of fat-soluble vitamins

- Tx: pancrelipase

86
Q

Dx: chronic pancreatitis

A
  • Abdominal CT: shrunken pancreas with calcifications
  • US: pancreatic ducts > 4mm, cysts and atrophy
  • ERCP: very sensitive
87
Q

How does advanced chronic pancreatitis affect pancreatic duct?

A

Advanced disease - chain of Lakes - alternating segments of dilation and stenosis in pancreatic ducts

88
Q

Tx: chronic pancreatitis

A

Supportive, including pain control and nutritional support (pancrelipase)

89
Q

Surgical indications: chronic pancreatitis

A

Pain that interferes with quality of life, nutrition abnormalities, addiction to narcotics, failure to rule out CA, biliary obstruction

90
Q

Surgical options

A

Puestow procedure, Distal pancreatic resection, Whipple, Beger-Frey, Bilateral thoracoscopic splanchnicectomy or celiac glanglionectomy

91
Q

Chronic pancreatitis: Puestow procedure

A

Pancreaticojejunostomy, for enlarge ducts > 8mm (most patients improve) -> open along main pancreatic duct and drain into jejunum

92
Q

Chronic pancreatitis: distal pancreatic resection

A

For normal or small ducts and only distal portion of the gland is affected

93
Q

Chronic pancreatitis: whipple

A

For normal or small ducts with isolated pancreatic head disease

94
Q

Chronic pancreatitis: beger-frey

A

Duodenal preserving head (“core-out”) - for normal or small ducts with isolated pancreatic head enlargement

95
Q

Chronic pancreatitis: techniques for pain control

A

Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy

96
Q

Chronic pancreatitis: causes CBD dilation

A

Common bile duct stricture
- Tx: hepaticojejunostomy or choledochojejunostomy for pain, jaundice, progressive cirrhosis, or cholangitis (make sure the stricture is not pancreatic CA)

97
Q

MCC splenic vein thrombosis

A

Chronic pancreatitis

98
Q

Tx: splenic vein thrombosis

A

Can get bleeding from isolated gastric varies that form as collaterals
- Tx: splenectomy for isolated bleeding gastric varices

99
Q

What causes pancreatic insufficiency?

A

Usually the result of long-standing pancreatitis or occurs after total pancreatectomy (over 90% of the function must be lost)
- Generally refers to exocrine function

100
Q

Symptoms: pancreatic insufficiency

A

Malabsorption and steatorrhea

101
Q

Dx: pancreatic insufficiency

A

Fecal fat testing

102
Q

Tx: pancreatic insufficiency

A

High-carbohydrate, high-protein, low-fat diet; pancreatic enzymes (pancrease)

103
Q

Jaundice workup

A

Ultrasound first

  • positive CBD stones, no mass -> ERCP (allows extraction of stones)
  • No CBD stones, no mass-> MRCP
  • Positive mass-> MRCP
104
Q
  • male predominance; usually 6th-7th decades of life

- symptoms: weight loss (MC symptom), jaundice, pain

A

pancreatic adenocarcinoma

105
Q

5 year survival rate with resection of pancreatic adenocarcinoma

106
Q

1 risk factor for pancreatic adenocarcinoma

107
Q

Serum marker / mutation for pancreatic CA

A
  • CA19-9: serum marker

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

108
Q

How does pancreatic adenocarcinoma spread?

A

Lymphatic spread first

109
Q

Where are pancreatic adenocarcinomas found?

A
  • 70% head

- 90% ductal adenocarcinoma

110
Q

How does pancreatic adenoCA in the head usually present?

A

50% invade portal vein, SMV, or retroperitoneum at time of diagnosis (unresectable disease)

111
Q

What indicates unresectable disease in pancreatic adenoma?

A

Metastases to peritoneum, omentum or liver. Metastases to celiac or SMA nodal system (nodal systems outside area of resection)

112
Q

What offers the best chance of cure in pancreatic adenoCA?

A

Most cures in patients with pancreatic head disease

113
Q

What offers a more favorable prognosis in ductal adenocarcinoma?

A

Papillary or mucinous cyst-adenocarcinoma

114
Q

Labs: pancreatic adenocarcinoma

A

Increased conjugated bilirubin and alkaline phosphatase

115
Q

Do patients with resectable pancreatic adenocarcinoma need a biopsy?

A

Do not need a biopsy because you are taking it out regardless. if the patient appears to have metastatic disease, a biopsy is warranted to direct therapy

116
Q

Good at differentiating dilated ducts secondary to chronic pancreatitis vs CA

117
Q

Signs of CA on MRCP

A

Duct with regular narrowing, displacement, destruction; can also detect vessel involvement

118
Q

What will abdominal CT show in pancreatic adenocarcinoma?

A

May show the lesion and double-duct sign for pancreatic hear tumors (dilation of both the pancreatic duct and CBD)

119
Q

Mananagement unresectable pancreatic adenoCA

A

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

120
Q

Complications from Whipple

A

Delayed gastric emptying (#1 - tx: metoclopramide), fistula (tx; conservative therapy), leak (place drains and tx like a fistula), marginal ulceration (tx: ppi)

121
Q

1 complication after Whipple

A

Delayed gastric emptying

122
Q

Management: bleeding after Whipple or other pancreatic surgery

A

Go to angio for embolization (the tissue planes are very friable early after surgery, and bleeding is hard to control operatively)

123
Q

Postop management pancreatic adenoCa

A

Chemo-XRT usual post op (gemcitabine)

124
Q

Prognosis for non-metastatic disease pancreatic adeno ca

A

Prognosis for non-metastatic disease related to nodal invasion and ability to get a clear margin

125
Q

Represent 1/3 of pancreatic endocrine neoplasms

- tend to have a more indolent and protracted course compared with pancreatic adenoCA

A

Non-functional endocrine tumors

126
Q

Malignancy potential of non-functional endocrine tumors

A

90% of the nonfunctional tumors are malignant

127
Q

Surgical management: non-functional endocrine tumors

A

Resect these lesions: metastatic disease precludes resection

128
Q

Chemotherapy: non-functional endocrine tumors

A

5FU and streptozocin may be effective

129
Q

MC site of metastases in non-functional endocrine tumors

130
Q

Represent 2/3 of pancreatic endocrine neoplasms

- all tumors respond to debulking

A

Functional endocrine pancreatic tumors

131
Q

Treatment effective for insulinoma, glucagonoma, gastrinoma, VIPoma

A

Octreotide

132
Q

Functional endocrine pancreatic tumors: most common in pancreatic head

A

Gastrinoma, somatostatinoma

133
Q

Metastases of functional endocrine pancreatic tumors

A

Liver metastatic spread - 1st for all

134
Q
  • MC islet cell tumor of the pancreas
  • Whipple’s triad
  • 90% are benign and evenly distributed throughout pancreas
A

Insulinoma

135
Q
  • Fasting hypoglycemia (
A

Whipple’s triad

136
Q

Dx: insulinoma

A
  • Insulin to glucose ratio > 0.4 after fasting

- Increased C peptide and proinsulin (if not elevated, suspect Munchausen’s syndrome)

137
Q

Tx: insulinoma

A

Enucleate if 2 cm

- For metastatic disease: 5-FU and streptozocin; octreotide

138
Q
  • Most common pancreatic islet cell tumor in MEN-1 patients
  • 50% malignant and 50% multiple
  • 75% spontaneous and 25% MEN-1
A

Gastrinoma (Zollinger-Ellison Syndrome (ZES))

139
Q

Where are most gastrinomas found?

A

Gastrinoma triangle: common bile duct, neck of pancreas, third portion of the duodenum

140
Q

Symptoms: refractory or complicated ulcer disease and diarrhea (improved with PPI)
- Serum gastrin usually > 200; 1,000s is diagnostic

A

Gastrinoma (ZES)

141
Q

Secretin stimulation test in gastrinoma

A
  • ZES: increase gastrin (>200)

- Normal: decrease gastrin

142
Q

Treatment: gastrinoma

A

Enucleation if 2 cm

  • Malignant disease: excise suspicious nodes
  • Can’t find it: perform duodenostomy and look inside duodenum for tumor (15% of microgastrinomas there)
  • Duodenal tumor: resection with primary closure, may need Whipple
  • Debulking, can improve symptoms
  • Octreotide scan
143
Q

Single best test for localizing tumor

A

Octreotide scan

144
Q
  • Symptoms: diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema), weight loss
  • Diagnosis: fasting glucagon level
  • Most malignant; most in distal pancreas
A

Glucagonoma

145
Q

What can treat skin rash in glucagonoma?

A

Zinc, amino acids, or fatty acids may treat skin rash

146
Q

Verner-Morrison syndrome

147
Q

Symptoms: watery diarrhea, hypokalemia (diarrhea), and achlorhydria (WDGA)

A

VIPoma (Verner-Morrison syndrome)

148
Q

Dx: VIPoma

A

Exclude other causes of diarrhea; increased VIP levels

149
Q

Characteristics of VIPoma

A
  • Most malignant
  • Most in distal pancreas
  • 10% extrapancreatic (retroperitoneal, thorax)
150
Q
  • very rare
  • symptoms: diabetes, gallstones, steatorrhea, hypochlorhydria
  • most malignant, most in head of pancreas
A

Somatostatinoma

151
Q

Dx: somatostatinoma

A

fasting somatostatin level

152
Q

Tx: somatostatinoma

A

Perform cholecystectomy with resection

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