Fiser ABSITE Ch. 33 Pancreas

Question 1

Uncinate process

Answer 1

on aorta, behind SMA

Question 2

Pancreatic Blood supply

Answer 2

Head - GDA, SMA; Body - splenic; Tail - Splenic, gastroepiploic, dorsal pancreatic

Question 3

Acinar cells

Answer 3

secrete Cl- and digestive enzymes

Question 4

amylase

Answer 4

secreted in active form

Question 5

Endocrine pancreas

Answer 5

Alpha cells - glucagon; Beta - insulin; Delta - somatostatin; PP/F - pancreatic polypeptide; Islet - VIP, serotonin, neuropeptide Y, gastrin-releasing peptide

Question 6

Enterokinase

Answer 6

trypsinogen to trypsin

Question 7

trypsin

Answer 7

activates all pancreatic enzymes

Question 8

Decrease pancreatic exocrine function

Answer 8

somatostatin and glucagon

Question 9

Which is the major and minor duct of pancreas? What is pancreas divisum?

Answer 9

Santorini is Small duct, Wirsung is major duct. Pancreas divisum = failure of fusion (5% of population, prone to pancreatitis), Santorini is then major duct

Question 10

Duct of Wirsung

Answer 10

primary, ventral pancreatic bud (uncinate and inferior head)

Question 11

Duct of Santorini

Answer 11

accessory, dorsal pancreatic bud (superior head, body, tail), drains directly into duodenum

Question 12

Annular pancreas: abdominal x-ray, associated congenital anomaly, treatment

Answer 12

double bubble on abdominal x-ray; Down syndrome; dudenoJ or duodenoduodeno and sphincteroplasty

Question 13

Pancreas divisum: pathophy, clinical manifestation, dx, tx

Answer 13

failed fusion of pancreatic ducts; Duct of Santorini stenosis -> pancreatitis; Dx: ERCP; Tx: sphincteroplasty and stent, longitudinal PJ

Question 14

Heterotopic Pancreas: MC location, symptom, tx

Answer 14

Most commonly found in duodenum; usually asymptomatic; resection if symptomatic

Question 15

Pancreatitis without cause

Answer 15

malignancy

Question 16

Ranson’s Criteria

Answer 16

GALAW and CHOBBS – On admission: glucose > 200, AST > 250, LDH > 350, age > 55, WBC > 16,

Question 17

Acute pancreatitis: Underlying pathology

Answer 17

Intra-acinar activation of pancreatic proenzymes leading to autodigestion and release of proinflammatory mediators

Question 18

Acute pancreatitis: Signs

Answer 18

Grey Turner sign (flank ecchymosis), Cullen’s sign (periumbilical ecchymosis), Fox’s sign (inguinal ecchymosis)

Question 19

Pancreatic abscess

Answer 19

overt gas in previous pancreatic necrosis (8 weeks ltr), ABSOLUTE indication for surgical debridement

Question 20

Incidental pancreatic cyst, tx

Answer 20

resect

Question 21

Pancreatic pseudocyst

Answer 21

chronic pancreatitis, head, MRCP/ERCP -> cystogastrostomy if duct involved. Complications: SBO, infxn, portal/splenic v thrombosis.

Question 22

Most important risk factor for necrotizing pancreatitis

Answer 22

Obesity

Question 23

Chronic pancreatitis

Answer 23

fibrosis, pain, ETOH, exocrine tissue calcified, islet cells preserved, “chain of lake” appearance, malabsorption. Rx: Puestow: PJ (longitudinal)

Question 24

ARDS in pancreatitis is due to

Answer 24

Release of phospholipases

Question 25

Splenic vein thrombosis cause

Answer 25

chronic pancreatitis, bleeding gastric varices -> splenectomy

Question 26

Pancreatic AC

Answer 26

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

Question 27

Bleeding after Whipple

Answer 27

embolization

Question 28

Nonfunctional Endocrine Tumors

Answer 28

1/3 of panc endocrine neoplasms, 90% malig, resect, 5FU/streptozocin, liver mets, 50% survival

Question 29

Octreotide effective for

Answer 29

insulin-, glucagon-, gastrin-, VIPoma

Question 30

Pancreatic Head neoplasms

Answer 30

gastrinoma, somatostatinoma

Question 31

insulinoma

Answer 31

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

Question 32

Gastrinoma

Answer 32

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

Question 33

Gastrinoma triangle

Answer 33

CBD, pancreatic neck, D3

Question 34

cannot find gastrinoma

Answer 34

duodenostomy, resect with primary closure

Question 35

study for localizing pancreatic tumor

Answer 35

somatostatin receptor scintigraphy

Question 36

Relation of SMA and SMV to pancreas

Answer 36

SMA and SMV lay behind neck of pancreas

Question 37

Relation of portal vein to pancreas

Answer 37

Forms behind the neck of the pancreas (SMV and splenic vein)

Question 38

Venous drainage of pancreas

Answer 38

Drains into portal system

Question 39

Lymphatics of pancreas

Answer 39

Celiac and SMA nodes

Question 40

Released by duodenal epithelial cells; located on brush border; activates trypsinogen to trypsin; Trypsin then activates other pancreatic enzymes including trypsinogen

Answer 40

Enterokinase

Question 41

Major pancreatic duct that merges with CBD before entering the duodenum

Answer 41

Duct of Wirsung

Question 42

mortality of pancreatic CA

Answer 42

overall 90% dead in one year

Question 43

mutation in pancreatic cancer? marker?

Answer 43

CA 19-9 (serum marker) is generally high in pancreatic CA. 90% have mutated K-Ras.

Question 44

what type of block can be done for non resectable cancer?

Answer 44

celiac plexus block is effective pain relief for non-resectable CA (50% EtOH on both sides of aorta near celiac)

Question 45

gallstones, steatorrhea, pancreatitis, diabetes

Answer 45

Somatostatinoma

Question 46

diabetes, glossitis, stomatitis, migratory necrolytic erythema, streptozocin and octreotide help

Answer 46

Glucagonoma

Question 47

WDHA syndrome = Watery Diarrhea Hypokalemia Achlohydria. Diarrhea does not improve with NGT or H2 blockers

Answer 47

VIPoma