Chapter 33: Pancreas COPY Flashcards
1
Q
Rests on aorta, behind SMV
A
Uncinate process
2
Q
Lays behind neck of pancreas
A
SMV and SMA
3
Q
Forms behind the neck (SMV and splenic vein)
A
Portal vein
4
Q
Blood supply to head of pancreas
A
Superior (off GDA) and inferior (off SMA), pancreaticoduoenal arteries (anterior and posterior branches for each)
5
Q
Blood supply to body of pancreas
A
great, inferior, and caudal pancreatic arteries (all off splenic artery)
6
Q
Blood supply to tail of pancreas
A
Splenic, gastroepiploic and dorsal pancreatic arteries
7
Q
Venous drainage of the pancreas
A
Portal system
8
Q
Lymphatics for pancreas
A
Celiac and SMA nodes
9
Q
Pancreas: cells secrete HCO3- solution (have carbonic anhydrase)
A
Ductal cells
10
Q
Pancreas: cells secrete digestive enzymes
A
Acinar cells
11
Q
Exocrine function of the pancreas
A
Amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase, HCO3-
12
Q
Only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains
A
Amylase
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
14
Q
Endocrine: receive majority of blood supply related to size
A
Islets cells
- after islets, blood goes to acinar cells
15
Q
Released by the duodenum, activates trypsinogen to trypsin
A
Enterokinase
16
Q
After being activated by enterokinase, Activates pancreatic enzymes, including trypsinogen
A
Trypsin
17
Q
Hormonal control of pancreatic excretion
A
Secretin, CCK, Acetylcholine, somatostatin, glucagon, CCK and secretin
18
Q
Increases HCO3- mostly
A
Secretin
19
Q
Increases pancreatic enzymes mostly
A
CCK
20
Q
Increases HCO- and enzymes
A
Acetylcholine
21
Q
Decreases exocrine function
A
Somatostatin and glucagons
22
Q
Mostly released by cells in the duodenum
A
CCK and secretin
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
24
Q
Body, tail, and superior aspect of the pancreatic head; has duct of Santorini
A
Dorsal pancreatic bud
25
Major pancreatic duct that merges with CBD before entering duodenum
Duct of Wirsung
26
Small accessory pancreatic duct that drains directly into duodenum
Duct of Santorini
27
2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal XR; get duodenal obstruction (N/V, abdominal pain)
Annular pancreas
28
What is annular pancreas associated with?
Down syndrome; forms the ventral pancreatic bud from failure of clockwise rotation
29
Tx: annular pancreas
Duodenojejunostomy and duodenoduodenostomy; possible sphincteroplasty
- pancreas not resected
30
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
31
Dx: pancreas divisum
ERCP - minor papilla will show long and large duct of Santorini; major papilla will show short duct of Wirsung
32
Tx: pancreas divisum
ERCP with sphincteroplasty; open sphincteroplasty if that fails
33
- Most commonly found in duodenum
- usually asymptomatic
- surgical resection if symptomatic
heterotopic pancreas
34
Acute pancreatitis: Most common etiologies in the US
Gallstones and ETOG
35
Etiologies of acute pancreatitis
Gallstones, ETOH, ERCP trauma, HLD, Hyper-Ca, viral infection, medications (azathioprine, furosemide, steroids, cimetidine)
36
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
37
How does alcohol cause acute pancreatitis?
Can cause auto-activation of the pancreatic enzymes while still in the pancreas
38
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
39
Mortality rate of acute pancreatitis
Mortality rate 10%; hemorrhagic pancreatitis mortality 50%
40
What do you need to worry about in pancreatitis without an obvious cause?
Need to worry about malignancy
41
Ranson's criteria on admission
```
Age > 55
WBC > 16
Glucose > 200
AST > 250
LDH > 350
```
42
Ranson's criteria after 48 hours
Hct decrease 10%
BUN increase of 5
Ca 4
Fluid sequestration > 6L
43
What is a patient has 8 components of the Ranson's criteria?
Mortality rate near 100%
44
Labs: acute pancreatitis
Increased amylase, lipase, and WBCs
45
Ultrasound: acute pancreatitis
Needed to check for gallstones and possible CBD dilatation
46
Abdominal CT: acute pancreatitis
To check for complications (necrotic pancreas will not uptake contrast)
47
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
48
When is ERCP needed in acute pancreatitis?
Gallstone pancreatitis and retained CBD stones -> perform sphincterotomy and stone extraction
49
When are antibiotics needed for acute pancreatitis?
Stones, severe pancreatitis, failure to improve, or suspected infection
50
What is the role of cholecystectomy with acute pancreatitis?
Patients with gallstone pancreatitis should undergo cholecystectomy when recovered from pancreatitis (same hospital admission)
51
Why is morphine avoided in acute pancreatitis?
Should be avoided as it can contract the sphincter of Oddi and worsen attack
52
Sign: flank ecchymosis
Grey Turner sign (bleeding)
53
Sign: periumbilical ecchymosis
Cullen's sign (bleeding)
54
Sign: inguinal ecchymosis
Fox's sign (bleeding)
55
What are three physical exam signs of bleeding?
- Grey turner (flank)
- Cullen's (periumbilical)
- Fox's (inguinal)
56
Rate of pancreatic necrosis
15% get pancreatic necrosis; leave sterile necrosis alone
57
Management: infected pancreatic necrosis
- May need to sample necrotic pancreatic fluid with CT-guided aspiration to get diagnosis
- Surgical debridement
58
Fever, positive blood cultures in acute pancreatitis
Infected necrosis of pancreas
59
Tx: pancreatic abscess
Need surgical debridement
60
Is CT-guided drainage of infected pancreatic necrosis or pancreatic abscess effective?
Generally not effective
61
Gas in necrotic pancreas..
Infected necrosis or abscess (need open debridement)
62
Leading cause of death with pancreatitis
Infection (usually GNRs)
63
When is surgery indicated in pancreatitis?
Only for infected pancreatitis or pancreatic abscess
64
Most important risk factor for necrotizing pancreatitis
Obesity
65
Pancreatitis: complication related to phospholipases
- ARDS
| - Pancreatic fat necrosis
66
Pancreatitis: complication related to proteases
Coagulopathy
67
What is related to mild increases in amylase and lipase?
Can be seen with cholecystitis, perforated ulcer, sialoadenitis, small bowel obstruction, and intestinal infarction
68
What is associated with chronic pancreatitis?
Pancreatic pseudocysts
69
Cysts NOT associated with pancreatitis..
Need to r/o CA (eg, mucinous cystadenocarcinoma)
70
Symptoms: pain, fever, weight loss, bowel obstruction from compression
Pancreatic pseudocysts
71
Where do pancreatic pseudocysts often occur?
The head of the pancreas; is a non-epitheliazed sac
72
TX: pancreatic pseudocysts
Most resolve spontaneously (especially if
73
When is surgery indicated in pancreatic pseudocysts?
Continued symptoms (tx: cystogastrostomy, open or percutaneous) or pseudocysts that are growing (tx: resection r/o CA)
74
Complications of pancreatic pseudocysts
Infection of cyst, portal or splenic vein thrombosis
75
Management: incidental cysts not associated with pancreatitis
Should be resected (worry about intraductal papillary-mucinous neoplasms (IPMNs) or mutinous cystuadenocarcinoma) unless the cyst is purely serous and non-complex
76
Management of non-complex , purely serous cyst adenomas
Have an extremely low malignancy risk (
77
- most close spontaneously (especially if low output
Pancreatic fistulas
78
Pancreatic fistulas: tx for failure to resolve with medical management
Can try ERCP, sphincterotomy and pancreatic stent placement (fistula will usually close, then remove stent)
79
What causes pancreatitis-associated pleural effusion (or ascites)?
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
Tx: pancreatitis-associated pleural effusion (or ascites)
Thoracentesis (or paracentesis) followed by conservative tx (NPO, TPN, and octreotide - follow pancreatic fistula pathway above)
- amylase will be elevated in the fluid
81
Pathophysiology of chronic pancreatitis
Corresponds to irreversible parenchymal fibrosis
82
MCC chronic pancreatitis
1) ETOH 2) Idiopathic
83
Pain most common problem, anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis
Chronic pancreatitis
84
Endocrine / exocrine chronic pancreatitis
- Endocrine function: usually preserved (Islet cell preserved)
- Exocrine function: decreased
85
Nutritional deficiency in chronic pancreatitis
Can cause malabsorption of fat-soluble vitamins
| - Tx: pancrelipase
86
Dx: chronic pancreatitis
- Abdominal CT: shrunken pancreas with calcifications
- US: pancreatic ducts > 4mm, cysts and atrophy
- ERCP: very sensitive
87
How does advanced chronic pancreatitis affect pancreatic duct?
Advanced disease - chain of Lakes - alternating segments of dilation and stenosis in pancreatic ducts
88
Tx: chronic pancreatitis
Supportive, including pain control and nutritional support (pancrelipase)
89
Surgical indications: chronic pancreatitis
Pain that interferes with quality of life, nutrition abnormalities, addiction to narcotics, failure to rule out CA, biliary obstruction
90
Surgical options
Puestow procedure, Distal pancreatic resection, Whipple, Beger-Frey, Bilateral thoracoscopic splanchnicectomy or celiac glanglionectomy
91
Chronic pancreatitis: Puestow procedure
Pancreaticojejunostomy, for enlarge ducts > 8mm (most patients improve) -> open along main pancreatic duct and drain into jejunum
92
Chronic pancreatitis: distal pancreatic resection
For normal or small ducts and only distal portion of the gland is affected
93
Chronic pancreatitis: whipple
For normal or small ducts with isolated pancreatic head disease
94
Chronic pancreatitis: beger-frey
Duodenal preserving head ("core-out") - for normal or small ducts with isolated pancreatic head enlargement
95
Chronic pancreatitis: techniques for pain control
Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy
96
Chronic pancreatitis: causes CBD dilation
Common bile duct stricture
- Tx: hepaticojejunostomy or choledochojejunostomy for pain, jaundice, progressive cirrhosis, or cholangitis (make sure the stricture is not pancreatic CA)
97
MCC splenic vein thrombosis
Chronic pancreatitis
98
Tx: splenic vein thrombosis
Can get bleeding from isolated gastric varies that form as collaterals
- Tx: splenectomy for isolated bleeding gastric varices
99
What causes pancreatic insufficiency?
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
Symptoms: pancreatic insufficiency
Malabsorption and steatorrhea
101
Dx: pancreatic insufficiency
Fecal fat testing
102
Tx: pancreatic insufficiency
High-carbohydrate, high-protein, low-fat diet; pancreatic enzymes (pancrease)
103
Jaundice workup
Ultrasound first
- positive CBD stones, no mass -> ERCP (allows extraction of stones)
- No CBD stones, no mass-> MRCP
- Positive mass-> MRCP
104
- male predominance; usually 6th-7th decades of life
| - symptoms: weight loss (MC symptom), jaundice, pain
pancreatic adenocarcinoma
105
5 year survival rate with resection of pancreatic adenocarcinoma
20%
106
#1 risk factor for pancreatic adenocarcinoma
tobacco
107
Serum marker / mutation for pancreatic CA
- CA19-9: serum marker
| - 95% have p16 mutation (tumor suppressor, binds cyclin complexes)
108
How does pancreatic adenocarcinoma spread?
Lymphatic spread first
109
Where are pancreatic adenocarcinomas found?
- 70% head
| - 90% ductal adenocarcinoma
110
How does pancreatic adenoCA in the head usually present?
50% invade portal vein, SMV, or retroperitoneum at time of diagnosis (unresectable disease)
111
What indicates unresectable disease in pancreatic adenoma?
Metastases to peritoneum, omentum or liver. Metastases to celiac or SMA nodal system (nodal systems outside area of resection)
112
What offers the best chance of cure in pancreatic adenoCA?
Most cures in patients with pancreatic head disease
113
What offers a more favorable prognosis in ductal adenocarcinoma?
Papillary or mucinous cyst-adenocarcinoma
114
Labs: pancreatic adenocarcinoma
Increased conjugated bilirubin and alkaline phosphatase
115
Do patients with resectable pancreatic adenocarcinoma need a biopsy?
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
Good at differentiating dilated ducts secondary to chronic pancreatitis vs CA
MRCP
117
Signs of CA on MRCP
Duct with regular narrowing, displacement, destruction; can also detect vessel involvement
118
What will abdominal CT show in pancreatic adenocarcinoma?
May show the lesion and double-duct sign for pancreatic hear tumors (dilation of both the pancreatic duct and CBD)
119
Mananagement unresectable pancreatic adenoCA
Consider palliation with biliary stents or hepaticojejunostomy (for biliary obstruction), gastrojejunostomy (for duodenal obstruction), and celiac plexus ablation (for pain)
120
Complications from Whipple
Delayed gastric emptying (#1 - tx: metoclopramide), fistula (tx; conservative therapy), leak (place drains and tx like a fistula), marginal ulceration (tx: ppi)
121
#1 complication after Whipple
Delayed gastric emptying
122
Management: bleeding after Whipple or other pancreatic surgery
Go to angio for embolization (the tissue planes are very friable early after surgery, and bleeding is hard to control operatively)
123
Postop management pancreatic adenoCa
Chemo-XRT usual post op (gemcitabine)
124
Prognosis for non-metastatic disease pancreatic adeno ca
Prognosis for non-metastatic disease related to nodal invasion and ability to get a clear margin
125
Represent 1/3 of pancreatic endocrine neoplasms
| - tend to have a more indolent and protracted course compared with pancreatic adenoCA
Non-functional endocrine tumors
126
Malignancy potential of non-functional endocrine tumors
90% of the nonfunctional tumors are malignant
127
Surgical management: non-functional endocrine tumors
Resect these lesions: metastatic disease precludes resection
128
Chemotherapy: non-functional endocrine tumors
5FU and streptozocin may be effective
129
MC site of metastases in non-functional endocrine tumors
Liver
130
Represent 2/3 of pancreatic endocrine neoplasms
| - all tumors respond to debulking
Functional endocrine pancreatic tumors
131
Treatment effective for insulinoma, glucagonoma, gastrinoma, VIPoma
Octreotide
132
Functional endocrine pancreatic tumors: most common in pancreatic head
Gastrinoma, somatostatinoma
133
Metastases of functional endocrine pancreatic tumors
Liver metastatic spread - 1st for all
134
- MC islet cell tumor of the pancreas
- Whipple's triad
- 90% are benign and evenly distributed throughout pancreas
Insulinoma
135
- Fasting hypoglycemia (
Whipple's triad
136
Dx: insulinoma
- Insulin to glucose ratio > 0.4 after fasting
| - Increased C peptide and proinsulin (if not elevated, suspect Munchausen's syndrome)
137
Tx: insulinoma
Enucleate if 2 cm
| - For metastatic disease: 5-FU and streptozocin; octreotide
138
- Most common pancreatic islet cell tumor in MEN-1 patients
- 50% malignant and 50% multiple
- 75% spontaneous and 25% MEN-1
Gastrinoma (Zollinger-Ellison Syndrome (ZES))
139
Where are most gastrinomas found?
Gastrinoma triangle: common bile duct, neck of pancreas, third portion of the duodenum
140
Symptoms: refractory or complicated ulcer disease and diarrhea (improved with PPI)
- Serum gastrin usually > 200; 1,000s is diagnostic
Gastrinoma (ZES)
141
Secretin stimulation test in gastrinoma
- ZES: increase gastrin (>200)
| - Normal: decrease gastrin
142
Treatment: gastrinoma
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
Single best test for localizing tumor
Octreotide scan
144
- Symptoms: diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema), weight loss
- Diagnosis: fasting glucagon level
- Most malignant; most in distal pancreas
Glucagonoma
145
What can treat skin rash in glucagonoma?
Zinc, amino acids, or fatty acids may treat skin rash
146
Verner-Morrison syndrome
VIPoma
147
Symptoms: watery diarrhea, hypokalemia (diarrhea), and achlorhydria (WDGA)
VIPoma (Verner-Morrison syndrome)
148
Dx: VIPoma
Exclude other causes of diarrhea; increased VIP levels
149
Characteristics of VIPoma
- Most malignant
- Most in distal pancreas
- 10% extrapancreatic (retroperitoneal, thorax)
150
- very rare
- symptoms: diabetes, gallstones, steatorrhea, hypochlorhydria
- most malignant, most in head of pancreas
Somatostatinoma
151
Dx: somatostatinoma
fasting somatostatin level
152
Tx: somatostatinoma
Perform cholecystectomy with resection
