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ABSITE > Fiser Chapter 33. PANCREAS > Flashcards

Fiser Chapter 33. PANCREAS Flashcards

1
Q

Blood supply of pancreas

A

Superior and inferior pancreaticoduodenal arteries (superior off GDA, inferior off SMA); splenic artery, gastroepiploic and great/inferior/caudal/dorsal pancreatic arteries

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2
Q

Pancreatic venous drainage

A

Portal system. PV is behind neck of pancreas (where SMV and splenic vein meet)

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3
Q

Pancreatic lymphatics

A

Celiac and SMA nodes

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4
Q

Pancreatic ductal cells

A

Secrete HCO3- solution (have carbonic anhydrase)

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5
Q

Pancreatic acinar cells

A

Secrete digestive enzymes

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6
Q

Pancreatic exocrine function

A 
Amylase (only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains)
Lipase
Trypsinogen
Chymotrypsinogen
Carboxypeptidase
HCO3-
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7
Q

Pancreatic endocrine function

A

Alpha cells: glucagon

Beta cells (at center of islets): insulin

Delta cells: somatostatin
PP or F cells: pancreatic polypeptide

Islet cells: also produce VIP and serotonin

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8
Q

Enterokinase

A

Released by duodenum, activates trypsinogen to trypsin

Trypsin activates other pancreatic enzymes including trypsinogen

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9
Q

Hormonal control of pancreatic excretion

A

Secretin increases HCO3- mostly (from ductal cells)

CCK increases pancreatic enzymes mostly (from acinar cells)

Acetylcholine increases HCO- and enzymes

Somatostatin and glucagons decrease exocrine function

CCK and secretin: most released by cells in duodenum

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10
Q

Ventral and dorsal pancreatic buds

A

Ventral: duct of Wirsung (major duct that merges with CBD before entering duo), migrates posteriorly to the R and clockwise to fuse with dorsal bud; forms uncinated and inferior portion of head

Ductal: body, tail, and superior aspect of pancreatic head; has duct of Santorini (small accessory duct that drains directly into duo)

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11
Q

Double bubble

A

Duodenal obstruction, can be from annular pancreas causing 2nd portion of duo to be trapped in pancreatic band

Annular pancreas is associated with Down syndrome; forms from ventral pancreatic bud from failure of clockwise rotation

Tx of annular pancreas is duodenojejunostomy or duodenoduodenostomy; possible sphincteroplasty; pancreas NOT resected

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12
Q

Pancreatitis from duct of Santorini stenosis

A

Can be from pancreas divisum (failed fusion of pancreatic ducts)

Most with pancreas divisum are asymptomatic, some get pancreatitis

Dx: ERCP shows minor papilla with long and large duct of Santorini; major papilla with short duct of Wirsung

Tx: ERCP with sphincteroplasty; open sphincteroplasty if fails

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13
Q

Most common location of heterotopic pancreas

A

Duodenum. Usually asymptomatic. Surgical resection if symptomatic

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14
Q

MCC acute pancreatitis

A

Gallstones and EtOH

Other: ERCP, trauma, HLD, hyperCa, viral infection, meds (azathioprine, furosemide, steroids, cimetidine)

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15
Q

Gallstone pancreatitis mech

A

Can obstruct ampulla of Vater, causing impaired extrusion of zymogen granules and activation of degradation enzymes -> pancreatic autodigestion

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16
Q

EtOH pancreatitis mech

A

Auto-activation of enzymes while still in pancreas

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17
Q

Abdominal pain radiating to back, nausea, vomiting, anorexia; possibly jaundice, L effusion, ascites, or sentinel loop

A

Acute pancreatitis

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18
Q

Mortality rate of acute pancreatitis

A

10%

50% if hemorrhagic pancreatitis

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19
Q

Pancreatitis without obvious cause

A

Malignancy?

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20
Q

Ranson’s criteria (on admit and at 48 hr)

A

Admit: Age > 55, wbc > 16, glucose < 200, AST < 250, LDH > 350

28hr: Hct decreased by 10%, BUN increased by 5, Ca < 8, PaO2 < 60, base deficit > 4, fluid sequestration > 6 L

If 8 criteria met, mortality near 100%

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21
Q

Necrotic pancreas on abdominal CT

A

will NOT uptake contrst

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22
Q

Acute pancreatitis tx

A

NPO, fluid resuscitation

ERCP if gallstone panc and retained CBD stones, with sphincterotomy and stone extraction

Abx for stones, severe pancreatitis, failure to improve (?)

Avoid morphine

If gallstone panc, chole same admission

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23
Q

Flank ecchymosis

A

Grey-Turner sign (bleeding)

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24
Q

Periumbilical ecchymosis

A

Cullen’s sign (bleeding)

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25
Q

Inguinal ecchymosis

A

Fox’s sign (bleeding)

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26
Q

Pancreatic necrosis

A

15% get it

If sterile, no abx

If infected (fever, sepsis, positive blood cultures): may need to sample with CT-guided aspiration to get diagnosis; then treatment is surgical debridement

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27
Q

Pancreatic abscess tx

A

Surgical debridement

Perc drainage of panc abscess or necrosis is generally NOT effective

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28
Q

Gas in necrotic pancreas

A

infected necrosis or abscess, need open debridement

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29
Q

Leading cause of death with pancreatitis

A

Infection (usually GNRs)

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30
Q

Most important risk factor for necrotizing pancreatitis

A

Obesity

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31
Q

ARDS in pancreatitis is from what?

A

Release of phospholipases

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32
Q

Coagulopathy in pancreatitis is from what?

A

Related to release of proteases

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33
Q

Pancreatic fat necrosis is related to what?

A

Release of phospholipases

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34
Q

Mild increase in amylase and lipase causes

A

Pancreatitis, cholecystitis, perforated ulcer, sialoadenitis, SBO, and intestinal infarction

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35
Q

Pancreatic pseudocyst

A

MCC chronic pancreatitis (otherwise need to check for ca e.g. mucinous cystadenocarcinoma); most often in head; non-epithelialized sac

Most resolve spontaneously (especially if <5cm)

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36
Q

Pancreatic pseudocyst tx

A

Expectant mgt for 3 months, allows pseudocyst to mature if cystogastrostomy required. May need TPN if unable to eat. Surgery only for continued symptoms (cystogastrostomy, open or percutaneous) or growing pseudocysts (resection to r/o ca)

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37
Q

Pseudocyst complications

A

Infection, PVT, splenic vein thrombosis

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38
Q

Incidental pseudocyst, no hx of pancreatitis

A

Resect (worry about intraductal papillary-mucinous neoplasms or mucinous cystadenocarcinoma) unless cst is purely serous and non-complex

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39
Q

Non-complex, purely serous cystadenoma

A

Extremely low malignancy risk (<1%), just follow

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40
Q

Pancreatic fistula tx

A

Most close spontaneously (especially if low output <200 cc/day)

Remove drain when drain amylase < serum amylase

Drain, NPO, TPN, octreotide

If failure to resolve with medical mgt, can try: ERCP, sphincterotomy, pancreatic stent placement

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41
Q

Pancreatitis-associated effusion or ascites causes

A

Retroperitoneal leakage of pancreatic fluid from pancreatic duct of pseudocyst (NOT a fistula)

Most close on their own

Tx: thoracentesis or paracentesis, NPO, TPN, octreotide

42
Q

Chronic pancreatitis

A

Irreversible parenchymal fibrosis

MCC: EtOH, then idiopathic

43
Q

Most common problem with chronic pancreatitis

A

Pain

Can also have anorexia, weight loss, malabsorption (fat-soluble vitamins), steatorrhea, recurrent acute panc

44
Q

Endocrine and exocrine function in chronic panc

A

Endocrine usually preserved (islet cells)

45
Q

CT with shrunken pancreas with calcifications

A

Chronic panc

46
Q

US of chronic panc

A

Panc ducts > 4mm, cysts, atrophy

47
Q

Dx of chronic panc

A

ERCP very sensitive

Advanced disease shows chain of lakes -> alternating segments of dilation and stenosis in PD

48
Q

Tx of chronic panc

A

Supportive, including pain control and pancrelipase

Surgery for pain that interferes with QoL, nutrition abnormalities, addiction to narcs, failure to r/o Ca, and biliary obstruction

49
Q

Surgery for chronic panc

A
  1. Peustow
  2. Distal pancreatic resection
  3. Whipple
  4. Begre-Frey
  5. Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy for pain control
  6. Hepaticojejunostomy or choledochojejunostomy for CBD stricture with pain, jaundice, progressive cirrhosis, or cholangitis (first make sure its not cancer)
50
Q

Peustow

A

pancreaticojejunostomy, for enlarge ducts > 8mm (most patients improve): open along main PD and dran into jejunum

51
Q

Distal pancreatic resection

A

For normal or small ducts and only distal portion of gland affected

52
Q

Whipple for chronic panc

A

For normal or small ducts with isolated pancreatic head disease

53
Q

Beger-Frey

A

Duodenal preserving head core-out: for normal or small ducts with isolated pancreatic head enlargement

54
Q

Most common cause of splenic vein thrombosis

A

Chronic pancreatitis

Tx: splenectomy for isolated bleeding gastric varices

55
Q

Pancreatic insufficiency

A

Usually due to long-standing pancreatitis or after total pancreatectomy (over 90% of function must be lost)

Generally refers to exocrine function

Symptoms: malabsorption and steatorrhea

Dx: Fecal fat testing

Tx: High carb, high protein, low fat diet; and pancrease

56
Q

Jaundice workup

A

Ultrasound

If CBD stones but no mass -> ERCP to extract stones

No stones or mass -> MRCP

Positive mass -> MRCP

57
Q

Pancreas cancer survival

A

20% at 5 years with resection

58
Q

Risk factors for panc ca

A

Tobacco #1

59
Q

Serum marker for panc ca

A

CA19-9

60
Q

Most common mutation in panc cancer

A

p16 (in 95%): tumor suppressor, binds cyclin complexes

61
Q

Panc ca spread

A
  1. Lymphatic
62
Q

Panc ca locations

A

70% are in head

63
Q

Unresectable panc ca

A

Invasion of PV, SMV, or retroperitoneum

Mets to peritoneum, omentum, or liver

Mets to celiac or SMA nodal system (nodes outside area of resection)

64
Q

Panc ca histology

A
  • Ductal adenocarcinoma (90%)

- Papillary or mucinous cyst adenocarcinoma (more favorable prognosis)

65
Q

Signs of cancer (versus dilated duct from chronic panc) on MRCP

A
  • Irregular narrowing
  • DIsplacement
  • Destruction
66
Q

Double duct sign

A

Dilation of both PD and CBD in pancreatic head tumors on CT scan

67
Q

Treatment of unresectable panc ca

A

Biliary stents or hepaticoJ for biliary obstruction

GastroJ for duodenal obstruction

Celiac plexus ablation for pain

68
Q

Whipple complications

A

Delayed gastric emptying most common (tx with metoclopramide)

Fistula (conservative tx)

Leak (drains and tx like fistula)

Marginal ulceration (PPI)

69
Q

Bleeding after Whipple or other pancreatic surgery

A

Angio for embolization (tissue planes very friable early after surgery, and bleeding hard to control operatively)

70
Q

Postop chemoXRT for panc ca

A

Gemcitabine

71
Q

Prognosis of panc ca (if non metastatic)

A

Related to nodal invasion and ability to get a clear margin

72
Q

Pancreatic endocrine neoplasms

A

1/3 are nonfunctional

90% of nonfunctional are malignant

More indolent and protracted course

Metastatic disease precludes resection

73
Q

Meds for nonfunctional PETs

A

5FU and streptozocin

74
Q

Most common mets in nonfunctional and functional PETs

A

Liver

75
Q

Endocrine pancreatic tumors: functional or nonfunctional?

A

2/3 are functional

76
Q

Octreotide in PET?

A

Effective for insulinoma, glucagonoma, gastrinoma, VIPoma

77
Q

PETs location?

A

Gastrinom and somatostatinoma in pancreatic head

78
Q

Most common islet cell tumors?

A

Insulinoma; Gastrinoma in MEN-1 patients

79
Q

Fasting hypoglycemia (<50), symptoms of hypoglycemia (palps, tachy, diaphoresis), and relief with glucose?

A

Whipple’s triad for insulinoma

80
Q

Insulinomas

A

90% are benign and distributed throughout the pancreas

81
Q

Dx of insulinoma

A

Insulin to glucose ratio > 0.4 after fasting

Increased C-peptide and proinsulin (if not elevated, suspect Munchausen’s syndrome)

82
Q

Tx of insulinoma

A

Enucleate if < 2 cm; formal resection if > 2 cm

For metastatic disease: 5-FU and streptozocin; octreotide

83
Q

ZES

A

Gastrinoma

50% malignant, 50% multiple

75% spontaneous, 25% MEN-1

Most in gastrinoma triangle (Pessaro’s): CBD, neck of pancreas, third portion of duodenum

84
Q

Refractory or complicated ulcer disease and diarrhea (improved with PPI)

A

Gastrinoma

85
Q

Dx of gastrinoma

A

Serum gastrin > 1000
(Is at least greater than 200 usually)

Secretin stimulation test: increases gastrin in ZES (in normal patients it decreases gastrin)

86
Q

Tx of gastrinoma

A

Enucleation if < 2 cm, formal resection if > 2 cm

Malignant disease: excise suspicious nodes

87
Q

What do you do if you cannot find the tumor in gastrinoma?

A
  1. IOUS

2. Perform duodenostomy and look inside duo for tumor (15% of microgastrinomas there)

88
Q

Duodenal gastrinoma

A

Resect with primary closure; may need Whipple if extensive; be sure to check pancreas for primary

89
Q

Debulking

A

Can improve symptoms in gastrinoma, all functional PETs

90
Q

Single best study for localizing gastrinoma?

A

Octreotide scan

91
Q

Diabetes, stomatitis, dermatitis, weight loss

A

Glucagonoma (necrolytic migratory erythema - can treat with zinc, aas, or fatty acids))

92
Q

Dx of glucagonoma

A

Fasting glucagon > 500

93
Q

Glucagonoma

A

Most are malignant

Most are in distal pancreas

94
Q

Tx of glucagonoma

A

Debulking and octreotide

95
Q

Hypokalemia, achlorhydria, diarrhea

A

VIPoma aka Werner-Morrison syndrome

WDHA

96
Q

Dx of VIPoma

A

Exclude other causes of diarrhea; high VIP levels

97
Q

VIPomas

A

Most are malignant and in distal panc (like glucagonoma); 10% are extrapancreatic (retroperitoneal, thorax)

98
Q

Diabetes, gallstones, steatorrhea, hypochlorhydria

A

Somatostaninoma: very rare

99
Q

Dx of somatostatinoma

A

Fasting somatostatin level > 10

100
Q

Somatostatinomas

A

Most malignant; Most in HEAD of pancreas (also peri-ampullary, proximal panc, panc-duodenal groove)

101
Q

Tx of somatostatinoma

A

Cholecystectomy with resection

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