Chapter 33: Pancreas Flashcards
Rests on aorta, behind SMV
Uncinate process
Lays behind neck of pancreas
SMV and SMA
Forms behind the neck (SMV and splenic vein)
Portal vein
Blood supply to head of pancreas
Superior (off GDA) and inferior (off SMA), pancreaticoduoenal arteries (anterior and posterior branches for each)
Blood supply to body of pancreas
great, inferior, and caudal pancreatic arteries (all off splenic artery)
Blood supply to tail of pancreas
Splenic, gastroepiploic and dorsal pancreatic arteries
Venous drainage of the pancreas
Portal system
Lymphatics for pancreas
Celiac and SMA nodes
Pancreas: cells secrete HCO3- solution (have carbonic anhydrase)
Ductal cells
Pancreas: cells secrete digestive enzymes
Acinar cells
Exocrine function of the pancreas
Amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase, HCO3-
Only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains
Amylase
Endocrine function of the pancreas:
- Alpha
- Beta
- Delta
- PP or F cells
- Islet cells
- Alpha: glucagon
- Beta: (center of islets): insulin
- Delta: somatostatin
- PP or F cells: pancreatic polypeptide
- Islet cells: also produce VIP, serotonin
Endocrine: receive majority of blood supply related to size
Islets cells
- after islets, blood goes to acinar cells
Released by the duodenum, activates trypsinogen to trypsin
Enterokinase
After being activated by enterokinase, Activates pancreatic enzymes, including trypsinogen
Trypsin
Hormonal control of pancreatic excretion
Secretin, CCK, Acetylcholine, somatostatin, glucagon, CCK and secretin
Increases HCO3- mostly
Secretin
Increases pancreatic enzymes mostly
CCK
Increases HCO- and enzymes
Acetylcholine
Decreases exocrine function
Somatostatin and glucagons
Mostly released by cells in the duodenum
CCK and secretin
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
Ventral pancreatic bud
Body, tail, and superior aspect of the pancreatic head; has duct of Santorini
Dorsal pancreatic bud
Major pancreatic duct that merges with CBD before entering duodenum
Duct of Wirsung
Small accessory pancreatic duct that drains directly into duodenum
Duct of Santorini
2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal XR; get duodenal obstruction (N/V, abdominal pain)
Annular pancreas
What is annular pancreas associated with?
Down syndrome; forms the ventral pancreatic bud from failure of clockwise rotation
Tx: annular pancreas
Duodenojejunostomy and duodenoduodenostomy; possible sphincteroplasty
- pancreas not resected
Failed fusion of the pancreatic ducts; can result in pancreatitis from duct of Santorini (accessory duct) stenosis
- Most are asymptomatic; some get pancreatitis
Pancreas divisum
Dx: pancreas divisum
ERCP - minor papilla will show long and large duct of Santorini; major papilla will show short duct of Wirsung
Tx: pancreas divisum
ERCP with sphincteroplasty; open sphincteroplasty if that fails
- Most commonly found in duodenum
- usually asymptomatic
- surgical resection if symptomatic
heterotopic pancreas
Acute pancreatitis: Most common etiologies in the US
Gallstones and ETOG
Etiologies of acute pancreatitis
Gallstones, ETOH, ERCP trauma, HLD, Hyper-Ca, viral infection, medications (azathioprine, furosemide, steroids, cimetidine)
How do gallstones cause acute pancreatitis?
Can obstruct the ampulla of Vater, causing impaired extrusion of zymogen granules and activation of degradation enzymes -> leads to pancreatic auto-digestion
How does alcohol cause acute pancreatitis?
Can cause auto-activation of the pancreatic enzymes while still in the pancreas
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)
Acute pancreatitis
Mortality rate of acute pancreatitis
Mortality rate 10%; hemorrhagic pancreatitis mortality 50%
What do you need to worry about in pancreatitis without an obvious cause?
Need to worry about malignancy
Ranson’s criteria on admission
Age > 55 WBC > 16 Glucose > 200 AST > 250 LDH > 350
Ranson’s criteria after 48 hours
Hct decrease 10%
BUN increase of 5
Ca 4
Fluid sequestration > 6L
What is a patient has 8 components of the Ranson’s criteria?
Mortality rate near 100%
Labs: acute pancreatitis
Increased amylase, lipase, and WBCs
Ultrasound: acute pancreatitis
Needed to check for gallstones and possible CBD dilatation
Abdominal CT: acute pancreatitis
To check for complications (necrotic pancreas will not uptake contrast)
Tx: acute pancreatitis
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
When is ERCP needed in acute pancreatitis?
Gallstone pancreatitis and retained CBD stones -> perform sphincterotomy and stone extraction
When are antibiotics needed for acute pancreatitis?
Stones, severe pancreatitis, failure to improve, or suspected infection
What is the role of cholecystectomy with acute pancreatitis?
Patients with gallstone pancreatitis should undergo cholecystectomy when recovered from pancreatitis (same hospital admission)
Why is morphine avoided in acute pancreatitis?
Should be avoided as it can contract the sphincter of Oddi and worsen attack
Sign: flank ecchymosis
Grey Turner sign (bleeding)
Sign: periumbilical ecchymosis
Cullen’s sign (bleeding)
Sign: inguinal ecchymosis
Fox’s sign (bleeding)
What are three physical exam signs of bleeding?
- Grey turner (flank)
- Cullen’s (periumbilical)
- Fox’s (inguinal)
Rate of pancreatic necrosis
15% get pancreatic necrosis; leave sterile necrosis alone
Management: infected pancreatic necrosis
- May need to sample necrotic pancreatic fluid with CT-guided aspiration to get diagnosis
- Surgical debridement
Fever, positive blood cultures in acute pancreatitis
Infected necrosis of pancreas
Tx: pancreatic abscess
Need surgical debridement
Is CT-guided drainage of infected pancreatic necrosis or pancreatic abscess effective?
Generally not effective