Fiser ABSITE Ch. 33 Pancreas Flashcards
Uncinate process
on aorta, behind SMA
Pancreatic Blood supply
Head - GDA, SMA; Body - splenic; Tail - Splenic, gastroepiploic, dorsal pancreatic
Acinar cells
secrete Cl- and digestive enzymes
amylase
secreted in active form
Endocrine pancreas
Alpha cells - glucagon; Beta - insulin; Delta - somatostatin; PP/F - pancreatic polypeptide; Islet - VIP, serotonin, neuropeptide Y, gastrin-releasing peptide
Enterokinase
trypsinogen to trypsin
trypsin
activates all pancreatic enzymes
Decrease pancreatic exocrine function
somatostatin and glucagon
Which is the major and minor duct of pancreas? What is pancreas divisum?
Santorini is Small duct, Wirsung is major duct. Pancreas divisum = failure of fusion (5% of population, prone to pancreatitis), Santorini is then major duct
Duct of Wirsung
primary, ventral pancreatic bud (uncinate and inferior head)
Duct of Santorini
accessory, dorsal pancreatic bud (superior head, body, tail), drains directly into duodenum
Annular pancreas: abdominal x-ray, associated congenital anomaly, treatment
double bubble on abdominal x-ray; Down syndrome; dudenoJ or duodenoduodeno and sphincteroplasty
Pancreas divisum: pathophy, clinical manifestation, dx, tx
failed fusion of pancreatic ducts; Duct of Santorini stenosis -> pancreatitis; Dx: ERCP; Tx: sphincteroplasty and stent, longitudinal PJ
Heterotopic Pancreas: MC location, symptom, tx
Most commonly found in duodenum; usually asymptomatic; resection if symptomatic
Pancreatitis without cause
malignancy
Ranson’s Criteria
GALAW and CHOBBS – On admission: glucose > 200, AST > 250, LDH > 350, age > 55, WBC > 16,
Acute pancreatitis: Underlying pathology
Intra-acinar activation of pancreatic proenzymes leading to autodigestion and release of proinflammatory mediators
Acute pancreatitis: Signs
Grey Turner sign (flank ecchymosis), Cullen’s sign (periumbilical ecchymosis), Fox’s sign (inguinal ecchymosis)
Pancreatic abscess
overt gas in previous pancreatic necrosis (8 weeks ltr), ABSOLUTE indication for surgical debridement
Incidental pancreatic cyst, tx
resect
Pancreatic pseudocyst
chronic pancreatitis, head, MRCP/ERCP -> cystogastrostomy if duct involved. Complications: SBO, infxn, portal/splenic v thrombosis.
Most important risk factor for necrotizing pancreatitis
Obesity
Chronic pancreatitis
fibrosis, pain, ETOH, exocrine tissue calcified, islet cells preserved, “chain of lake” appearance, malabsorption. Rx: Puestow: PJ (longitudinal)
ARDS in pancreatitis is due to
Release of phospholipases
Splenic vein thrombosis cause
chronic pancreatitis, bleeding gastric varices -> splenectomy
Pancreatic AC
Sx: weight loss, jaundice, pain. Tobacco, CA 19-9, lymphatic spread, 70% in head. Local invasion = unresectable. 90% ductal. Only biopsy if mets. Tx: Gemcitabine/XRT. Prognosis: vascular, nodal invasion, margins
Bleeding after Whipple
embolization
Nonfunctional Endocrine Tumors
1/3 of panc endocrine neoplasms, 90% malig, resect, 5FU/streptozocin, liver mets, 50% survival
Octreotide effective for
insulin-, glucagon-, gastrin-, VIPoma
Pancreatic Head neoplasms
gastrinoma, somatostatinoma
insulinoma
1 islet cell tumor, Sx: Whipple’s Triad (fasting hypo, catecholamine surge, relief with glucose), benign, I:G >0.4. Tx: streptozocin/octreotide/5FU if mets, o/w enucleation
Gastrinoma
ZES, #1 panc islet cell tumor in MENI, 50% multiple and malig. Sx: ulcer dz, diarrhea. Dx: gastrin >200, secretin stim test (ZES: inc gastrin). Tx: enucleate if
Gastrinoma triangle
CBD, pancreatic neck, D3
cannot find gastrinoma
duodenostomy, resect with primary closure
study for localizing pancreatic tumor
somatostatin receptor scintigraphy
Relation of SMA and SMV to pancreas
SMA and SMV lay behind neck of pancreas
Relation of portal vein to pancreas
Forms behind the neck of the pancreas (SMV and splenic vein)
Venous drainage of pancreas
Drains into portal system
Lymphatics of pancreas
Celiac and SMA nodes
Released by duodenal epithelial cells; located on brush border; activates trypsinogen to trypsin; Trypsin then activates other pancreatic enzymes including trypsinogen
Enterokinase
Major pancreatic duct that merges with CBD before entering the duodenum
Duct of Wirsung
mortality of pancreatic CA
overall 90% dead in one year
mutation in pancreatic cancer? marker?
CA 19-9 (serum marker) is generally high in pancreatic CA. 90% have mutated K-Ras.
what type of block can be done for non resectable cancer?
celiac plexus block is effective pain relief for non-resectable CA (50% EtOH on both sides of aorta near celiac)
gallstones, steatorrhea, pancreatitis, diabetes
Somatostatinoma
diabetes, glossitis, stomatitis, migratory necrolytic erythema, streptozocin and octreotide help
Glucagonoma
WDHA syndrome = Watery Diarrhea Hypokalemia Achlohydria. Diarrhea does not improve with NGT or H2 blockers
VIPoma
