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Surgery Rotation > EOR GI part 11-chronic pancreatitis, pancreatic pseudocyst, pancreatic carcinoma > Flashcards

EOR GI part 11-chronic pancreatitis, pancreatic pseudocyst, pancreatic carcinoma Flashcards

1
Q

What is chronic pancreatitis?

A

Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine tissue

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2
Q

What are the subtypes of chronic pancreatitis?

A

Chronic calcific pancreatitis

Chronic obstructive pancreatitis

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3
Q

Causes of chronic pancreatitis

A 
EtOH abuse (MC)
Idiopathic
Hypercalcemia (hyperparathyroidism)
HLD
Familial
Trauma
Iatrogenic
Gallstones
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4
Q

Sx of chronic pancreatitis

A

Epigastric and/or back pain
Wt loss
Steatorrhea

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5
Q

Associated signs of chronic pancreatitis

A

Type 1 DM
Steatorrhea
Wt loss

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6
Q

What are the signs of pancreatic exocrine insufficiency?

A

Steatorrhea

Malnutrition

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7
Q

What are the signs of pancreatic endocrine insufficiency?

A

DM

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8
Q

What are the common pain patterns in chronic pancreatitis?

A

Unrelenting pain

Recurrent pain

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9
Q

DDx of chronic pancreatitis

A 
PUD
Biliary dz
AAA
Pancreatic CA
Angina
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10
Q

Appropriate lab tests for chronic pancreatitis

A

Amylase/lipase
72-hr fecal fat analysis
Glucose tolerance test

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11
Q

Why may amylase/lipase be normal in a pt with chronic pancreatitis?

A

Because of extensive pancreatic tissue loss

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12
Q

What radiographic tests should be performed for chronic pancreatitis?

A

CT scan- has greatest sensitivity for gland enlargement/atrophy, calcification, masses, pseudocysts
KUB- Calcification in the pancreas
ERCP- Ductal irregularities with dilation and stenosis, pseudocysts

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13
Q

Medical tx for chronic pancreatitis

A

Discontinuation of EtOH use- can reduce attacks, though parenchymal damage continues secondary to ductal obstruction and fibrosis
Insulin for type 1 DM
Pancreatic enzyme replacement
Narcotics for pain

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14
Q

Surgical tx for chronic pancreatitis

A

Pestow- longitudinal pancreaticojejunostomy (pancreatic duct must be dilated)
Duval- distal pancreaticojejunostomy
Near-total pancreatectomy

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15
Q

What is the Frey procedure?

A

Longitudinal pancreaticojejunostomy with core resection of the pancreatic head

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16
Q

What is the indication for surgical tx of chronic pancreatitis?

A

Severe, prolonged/refractory

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17
Q

What are the possible complications of chronic pancreatitis?

A 
Insulin dependent DM
Steatorrhea
Malnutrition
Biliary obstruction
Splenic vein thrombosis
Gastric varices
Pancreatic pseudocyst/abscess
Narcotic addiction
Pancreatic ascites/pleural effusion
Splenic artery aneurysm
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18
Q

What is a pancreatic pseudocyst?

A

Encapsulated collection of pancreatic fluid

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19
Q

What makes a pancreatic pseudocyst a pseudocyst?

A

Wall is formed by inflammatory fibrosis, NOT epithelial cell lining

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20
Q

Associated RFs of pancreatic pseudocyst

A

Acute pancreatitis < chronic pancreatitis from EtOH

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21
Q

What is the MCC of pancreatic pseudocyst in the US?

A

Chronic alcoholic pancreatitis

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22
Q

Sx of pancreatic pseudocyst

A 
Epigastric pain/mass
Emesis
Mild fever
Wt loss
Should be suspected when a pt with acute pancreatitis fails to resolve pain
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23
Q

Signs of pancreatic pseudocyst

A

Palpable epigastric mass
Tender epigastrium
Ileus

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24
Q

What is the DDx of pancreatic pseudocyst

A

Cystadenocarcinoma

Cystadenoma

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25
Q

What are the possible complications of a pancreatic pseudocyst?

A 
Infection
Bleeding into the cyst
Fistula
Pancreatic ascites
Gastric outlet obstruction
SBO
Biliary obstruction
26
Q

Tx of pancreatic pseudocyst

A

Drainage of the cyst or observation

27
Q

What is the waiting period before a pancreatic pseudocyst should be drained?

A

It takes 6 wks for pseudocyst walls to mature or become firm enough to hold sutures, and most will resolve during this period if they are going to

28
Q

What percentage of pancreatic pseudocysts resolve spontaneously?

A

~50%

29
Q

What is the tx for pseudocyst with bleeding into cyst?

A

Angiogram and embolization

30
Q

What is the tx for pancreatic pseudocyst with infection?

A

Percutaneous external drainage/ IV abx

31
Q

What size pancreatic pseudocyst should be drained?

A

Pseudocysts >5 cm have a small chance of resolving and have a higher chance of complications
Calcified cyst wall
Thick cyst wall

32
Q

What are three tx options for pancreatic pseudocyst?

A

Percutaneous aspiration/drain
Operative drainage
Transpapillary stent via ERCP (pseudocyst must communicate with pancreatic duct)

33
Q

What is an endoscopic option for drainage of a pancreatic pseudocyst?

A

Endoscopic cystogastrostomy

34
Q

What must be done during a surgical drainage procedure for a pancreatic pseudocyst?

A

Bx of the cyst wall to r/o a cystic carcinoma

35
Q

What is the MCC of death d/t pancreatic pseudocyst?

A

Massive hemorrhage into the pseudocyst

36
Q

Associated RFs of pancreatic carcinoma

A 
Smoking 3x risk
DM
Heavy EtOH use
Chronic pancreatitis
Diet high in fried meats
Previous gastrectomy
37
Q

Average age of pancreatic carcinoma

A

> 60 yrs

38
Q

What are the different types of pancreatic carcinoma?

A

> 80% are duct cell adenocarcinomas

Other types include cystadenocarcinoma and acinar cell carcinoma

39
Q

What percentage of pancreatic carcinomas arise in the pancreatic head?

A

66%

33% arise in the body and tail

40
Q

Why are most pancreatic cancers in the tail nonresectable?

A

These tumors grow without sx until it is too late and they have already spread- head of the pancreas tumors draw attention earlier because of biliary obstruction

41
Q

What are the s/sx of pancreatic carcinoma in the head of the pancreas?

A 
Painless jaundice from obstruction of common bile duct
Wt loss
Abd pain
Back pain
Weakness 
Pruritis from bile salts in skin
Anorexia
Courvoisier's sign
Acholic stools
Dark urine
DM
42
Q

S/sx of pancreatic carcinoma in the body or tail

A 
Wt loss and pain (90%)
Migratory thrombophlebitis (10%)
Jaundice (<10%)
Nausea and vomiting
Fatigue
43
Q

What are the MC sx of pancreatic carcinoma of the pancreatic head?

A

Wt loss
Pain
Jaundice

44
Q

What is Courvoisier’s sign?

A

Palpable, nontender, distended gallbladder

45
Q

What is the classic presentation of pancreatic CA in the head of the pancreas?

A

Painless jaundice

46
Q

Associated lab findings of pancreatic carcinoma

A

Increased direct bilirubin and alk phos (as a result of biliary obstruction)
Increased LFTs
Elevated pancreatic tumor markers

47
Q

Which tumor markers are associated with pancreatic CA?

A

CA 19-9

48
Q

What diagnostic studies are performed for pancreatic carcinoma?

A

Abdominal CT
U/s
Cholangiography (ERCP to r/o choledocholithiasis and cell brushings)
Endoscopic u/s with bx

49
Q

Treatment for pancreatic CA in head of pancreas

A

Whipple (pancreaticoduodenectomy)

50
Q

Tx of pancreatic CA in body or tail

A

Distal resection

51
Q

What factors signify inoperability in pancreatic carcinoma?

A 
Vascular encasement
Liver metastasis
Peritoneal implants
Distant LN metastasis (periaortic/celiac nodes)
Distant metastasis
Malignant ascites
52
Q

Is portal vein or SMV involvement an absolute CI for resection in pancreatic carcinoma?

A

No- can be resected and reconstructed with vein interposition graft at some centers

53
Q

What mortality rate is associated with a Whipple?

A

<5% at busy high volume centers

54
Q

What is the pylorus-preserving Whipple?

A

No antrectomy

Anastomose duodenum to jejunum

55
Q

What are the possible post-Whipple complications?

A

Delayed gastric emptying (if antrectomy is performed)
Anastomotic leak (from the bile duct or pancreatic anastomosis), causing pancreatic/biliary fistula
Wound infection
Postgastrectomy syndromes
Sepsis
Pancreatitis

56
Q

Why must the duodenum be removed if the head of the pancreas is resected?

A

They share the same blood supply

57
Q

What is the postop adjuvant therapy in pancreatic CA?

A

Chemo +/- radiation therapy

58
Q

What is the palliative tx if the pancreatic tumor is inoperable and biliary obstruction is present?

A

Percutaneous transhepatic cholangiography or ERCP and placement of stent across obstruction

59
Q

What is the prognosis at 1 yr after dx of pancreatic CA?

A

Dismal

90% of pts die within 1 yr of dx

60
Q

What is the survival rate of pancreatic CA at 5 yrs after resection?

A

20%

Surgery Rotation (19 decks)

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