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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
Inguinal ecchymosis
Fox's sign (bleeding)
26
Pancreatic necrosis
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
27
Pancreatic abscess tx
Surgical debridement Perc drainage of panc abscess or necrosis is generally NOT effective
28
Gas in necrotic pancreas
infected necrosis or abscess, need open debridement
29
Leading cause of death with pancreatitis
Infection (usually GNRs)
30
Most important risk factor for necrotizing pancreatitis
Obesity
31
ARDS in pancreatitis is from what?
Release of phospholipases
32
Coagulopathy in pancreatitis is from what?
Related to release of proteases
33
Pancreatic fat necrosis is related to what?
Release of phospholipases
34
Mild increase in amylase and lipase causes
Pancreatitis, cholecystitis, perforated ulcer, sialoadenitis, SBO, and intestinal infarction
35
Pancreatic pseudocyst
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)
36
Pancreatic pseudocyst tx
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)
37
Pseudocyst complications
Infection, PVT, splenic vein thrombosis
38
Incidental pseudocyst, no hx of pancreatitis
Resect (worry about intraductal papillary-mucinous neoplasms or mucinous cystadenocarcinoma) unless cst is purely serous and non-complex
39
Non-complex, purely serous cystadenoma
Extremely low malignancy risk (<1%), just follow
40
Pancreatic fistula tx
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
41
Pancreatitis-associated effusion or ascites causes
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
Chronic pancreatitis
Irreversible parenchymal fibrosis MCC: EtOH, then idiopathic
43
Most common problem with chronic pancreatitis
Pain Can also have anorexia, weight loss, malabsorption (fat-soluble vitamins), steatorrhea, recurrent acute panc
44
Endocrine and exocrine function in chronic panc
Endocrine usually preserved (islet cells)
45
CT with shrunken pancreas with calcifications
Chronic panc
46
US of chronic panc
Panc ducts > 4mm, cysts, atrophy
47
Dx of chronic panc
ERCP very sensitive Advanced disease shows chain of lakes -> alternating segments of dilation and stenosis in PD
48
Tx of chronic panc
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
Surgery for chronic panc
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
Peustow
pancreaticojejunostomy, for enlarge ducts > 8mm (most patients improve): open along main PD and dran into jejunum
51
Distal pancreatic resection
For normal or small ducts and only distal portion of gland affected
52
Whipple for chronic panc
For normal or small ducts with isolated pancreatic head disease
53
Beger-Frey
Duodenal preserving head core-out: for normal or small ducts with isolated pancreatic head enlargement
54
Most common cause of splenic vein thrombosis
Chronic pancreatitis | Tx: splenectomy for isolated bleeding gastric varices
55
Pancreatic insufficiency
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
Jaundice workup
Ultrasound If CBD stones but no mass -> ERCP to extract stones No stones or mass -> MRCP Positive mass -> MRCP
57
Pancreas cancer survival
20% at 5 years with resection
58
Risk factors for panc ca
Tobacco #1
59
Serum marker for panc ca
CA19-9
60
Most common mutation in panc cancer
p16 (in 95%): tumor suppressor, binds cyclin complexes
61
Panc ca spread
1. Lymphatic
62
Panc ca locations
70% are in head
63
Unresectable panc ca
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
Panc ca histology
- Ductal adenocarcinoma (90%) | - Papillary or mucinous cyst adenocarcinoma (more favorable prognosis)
65
Signs of cancer (versus dilated duct from chronic panc) on MRCP
- Irregular narrowing - DIsplacement - Destruction
66
Double duct sign
Dilation of both PD and CBD in pancreatic head tumors on CT scan
67
Treatment of unresectable panc ca
Biliary stents or hepaticoJ for biliary obstruction GastroJ for duodenal obstruction Celiac plexus ablation for pain
68
Whipple complications
Delayed gastric emptying most common (tx with metoclopramide) Fistula (conservative tx) Leak (drains and tx like fistula) Marginal ulceration (PPI)
69
Bleeding after Whipple or other pancreatic surgery
Angio for embolization (tissue planes very friable early after surgery, and bleeding hard to control operatively)
70
Postop chemoXRT for panc ca
Gemcitabine
71
Prognosis of panc ca (if non metastatic)
Related to nodal invasion and ability to get a clear margin
72
Pancreatic endocrine neoplasms
1/3 are nonfunctional 90% of nonfunctional are malignant More indolent and protracted course Metastatic disease precludes resection
73
Meds for nonfunctional PETs
5FU and streptozocin
74
Most common mets in nonfunctional and functional PETs
Liver
75
Endocrine pancreatic tumors: functional or nonfunctional?
2/3 are functional
76
Octreotide in PET?
Effective for insulinoma, glucagonoma, gastrinoma, VIPoma
77
PETs location?
Gastrinom and somatostatinoma in pancreatic head
78
Most common islet cell tumors?
Insulinoma; Gastrinoma in MEN-1 patients
79
Fasting hypoglycemia (<50), symptoms of hypoglycemia (palps, tachy, diaphoresis), and relief with glucose?
Whipple's triad for insulinoma
80
Insulinomas
90% are benign and distributed throughout the pancreas
81
Dx of insulinoma
Insulin to glucose ratio > 0.4 after fasting Increased C-peptide and proinsulin (if not elevated, suspect Munchausen's syndrome)
82
Tx of insulinoma
Enucleate if < 2 cm; formal resection if > 2 cm For metastatic disease: 5-FU and streptozocin; octreotide
83
ZES
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
Refractory or complicated ulcer disease and diarrhea (improved with PPI)
Gastrinoma
85
Dx of gastrinoma
Serum gastrin > 1000 (Is at least greater than 200 usually) Secretin stimulation test: increases gastrin in ZES (in normal patients it decreases gastrin)
86
Tx of gastrinoma
Enucleation if < 2 cm, formal resection if > 2 cm Malignant disease: excise suspicious nodes
87
What do you do if you cannot find the tumor in gastrinoma?
1. IOUS | 2. Perform duodenostomy and look inside duo for tumor (15% of microgastrinomas there)
88
Duodenal gastrinoma
Resect with primary closure; may need Whipple if extensive; be sure to check pancreas for primary
89
Debulking
Can improve symptoms in gastrinoma, all functional PETs
90
Single best study for localizing gastrinoma?
Octreotide scan
91
Diabetes, stomatitis, dermatitis, weight loss
Glucagonoma (necrolytic migratory erythema - can treat with zinc, aas, or fatty acids))
92
Dx of glucagonoma
Fasting glucagon > 500
93
Glucagonoma
Most are malignant Most are in distal pancreas
94
Tx of glucagonoma
Debulking and octreotide
95
Hypokalemia, achlorhydria, diarrhea
VIPoma aka Werner-Morrison syndrome WDHA
96
Dx of VIPoma
Exclude other causes of diarrhea; high VIP levels
97
VIPomas
Most are malignant and in distal panc (like glucagonoma); 10% are extrapancreatic (retroperitoneal, thorax)
98
Diabetes, gallstones, steatorrhea, hypochlorhydria
Somatostaninoma: very rare
99
Dx of somatostatinoma
Fasting somatostatin level > 10
100
Somatostatinomas
Most malignant; Most in HEAD of pancreas (also peri-ampullary, proximal panc, panc-duodenal groove)
101
Tx of somatostatinoma
Cholecystectomy with resection

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