lipase lasts longer Flashcards
serous membrane that lines the abdominopelvic walls
peritoneum
contiguous with visceral
where is the lesser sac
aka omental bursa
- potential space for ascites
posterior to stomach
anterior to pancreas
inferior to caudate
omental bursa communicates with the greater sac via the __
epiploic foramen
relationship of pancreas to peritoneum
retroperitoneal
Panc vasculature supplied by which vessels
GDA
SA
SMA
what is the name of the capsule surrounding the pancreas
trick question
it does not have a capsule
the uncinate process forms from the __
ventral pancreatic bud
what type of gland is the pancreas
heterocrine
exocrine -> 80%
endocrine ->20%
exocrine component of pancreas performs functions via __ within ducts
acinar cells
‘berry’ cells
what does the exocrine pancreas do for the body
digestive enzymes secretes into ducts
what enzymes are associated with pancreas
amylase (carbs)
lipase (fats)
trypsin protease (proteins)
which ducts does pancreas dump into
main panc duct OF WIRSUNG -> major duodenal papilla -> duo no. 2
accessory panc duct OF SANTORINI -> minor duo papilla -> duo no. 2
what does endocrine panc do
secretes into bloodstream
endocrine panc performs functions via __ cells
islet cells
islet cells aka
islets of langerhans
where do the islet cells live
most in tail
- surround exocrine tissue
types of islet cells
alpha cells
beta cells
G cells
also D cells
glucagon aka
alpha cells
- raise blood sugar
insulin aka
beta cells
- lower blood sugar
gastrin aka
G cells
- stimulate gastric acid production
embryology of panc
2 duodenal buds
rotate ventral bud alongside duodenum and bile ducts to join dorsal bud
- dorsal bud is bigger; becomes the superior head, neck, body, tail
annular pancreas aka
bifid ventral bud
- incomplete rotation
- can cause duo obstruction
failure of fusion of duo buds
pancreas divism
leads to minor papilla draining most of pancreas
hypoechoic ventral pancreas due to __
uneven lipomatosis (deposition of fat)
sono appearance change with age
children -> isoechoic to liver
adult -> iso/echo to liver
senior -> hypoechoic to liver
- also atrophies over time
why does panc get more hypoechoic with age
increased fat in liver making in more echogenic comparatively
structures related to panc tail
lesser sac
stomach antrum
LLL
Ao
etc.
max normal diameter f main panc duct
<2mm
primary cause of ductal dilatation is __
obstruction from tumour
types of acute pancreatitis
edematous
hemorrhagic
which type of acute pancreatitis is more concerning
hemorrhagic because it is necrotizing
20% of acute cases
** epi pain, nausea, vomiting
edematous pancreatitis tx
usually self limiting
resolves spontaneously with or without tx
+/- complications
common causes for acute pancreatitis
biliary calculi
* female >50y
alcohol abuse
* male >40y
blunt trauma
* children
drug related
* children (antibiotics/sulfa; diuretic/thiazides)
epigastric pain acute onset and severe (some improvement with bending, radiates to back)
nausea
vomiting
acute pancreatitis
lab values tested for acute pancreatitis
serum
* elevated
amylase (urinary)
* 3x normal
lipase (serum or stool)
* elevated
+/- WBC
+?- hypocalcemia
which lab value is detected later and lasts a long time; lab value for pancreatitis and panc disease
amylase
which lab value is more specific
lipase
lasts ~12days
* longer than amylase
sono findings of acute pancreatitis
normal most of the time
sometimes diffuse enlargement; may be focal
+/- hypoechoic
+/- peripanc fluid
+/- dilated duct
complication from acute pancreatitis
portosplenic vein thrombosis
hemorrhage
duodenal obstruction
pseudocyst
phlegmon
abscess
pseudocyst vs. true cyst
no epithelial lining
- walled off fluid collection containing enzymes, fluid and debris
pseudocysts take __ to develop
4-6 w
- pancreatitis causes extravasation of panc enxymes
sono features of pseudocyst
body, tail, lesser sac, ant pararenal space
unilocular, smoth walled anechoic
enhancement
+/- loculations
+/- complex
+/- solid appearance
avascular
typical size and journey of pseudocyst resolution
50% self limiting
usually <5cm
if >5cm, often persisting; can become infected and rupture
pseudoaneurysm vs. pseudocyst
break in vessel wall
check with Doppler
pseudoaneurysm shows YINYANG sign
acute, inflammatory soft tissue solid mass that is not drainable; may regress with antibiotics or progress to an abscess
phlegmon
- focal hypoechoic mass
+/- enhancement
localized infection containing pus
abscess
- complex cystic mass
+/- gas
avascular
febrile, chills, elevates WBC, sepsis, pain worsening with time
likely abscess
tx needs drainage
repeated bouts of sub clinical pancreatitis
chronic pancreatitis
longstanding __ results in progressive destruction of pancreas, fibrosis, decreased panc function
chronic pancreatitis
what is the most common cause for chronic pancreatitis
alcohol abuse
chronic epi pain, anorexia, weight loss, steatorrhea, +/- DM, lipase and amylase come back normal; ETOH consumption
chronic pancreatitis
sono features for chronic pancreatitis
atrophy, increased echogenicity
calcification
* ductal
+/- parenchymal calc
ductal dilatation, tortuosity, irregularity
atrophy, increased echogenicity, calc, ductal dilatation, tortuosity
chronic pancreatitis
4 patterns of ductal dilatation generally
tumoural obstruction
- smooth
- beaded
chronic pancreatitis
- irregular (angular)
- with calcifications
complications with chronic pancreatitis
pseudocysts
obstruction of biliary tree
duodenal obstruction
portosplenic vein thrombosis
splenic artery aneurysm/ pseudoaneurysm
lethal, genetic disease usually dx in early childhood characterized by increased secretions of mucous by exocrine glands
cystic fibrosis
- lung, pancreas, biliary tree
frequent infection, panc insufficiency, biliary cirrhosis associated with __
cystic fibrosis
sono appearance of cystic fibrosis
often poor acoustic windows
echogenic panc, atrophies
heterogeneous echo texture
+/- small cysts
+/- dilated panc duct and CBD
most pancreatic tumours are __
solid and malignant
subsets of solid panc tumours
adenocarcinoma
islet cell tumour
* functioning
* non functioning
metastases
subtypes of cystic panc tumours
serous cystic
mucinous cystic
* IPMN
* SPEN
cancer of the exocrine panc originating in the glandular epithelium
adenocarcinoma
*90% of panc tumours
male >45y, smoking, chronic pancreatitis, ETOH, family hx, DM
increased risks for adenocarcinoma
adenocarcinoma usually in __ of panc
head
ampulla of vater (hepatopanc)
- cause for biliary obstruction and jaundice
weight loss, +/- pain, +/- jaundice, palpable RUQ mass, nontender gb, +/- DVT
adenocarcinoma symptoms
lab findings with adenocarcinoma
often normal, amylase/lipase may be elevated
LFTs may be elevated with metastatic disease
tumour marker CA19-9
sono features of adenocarcinoma
poorly defined, hypoechoic focal mass
diffuse hypoechoic panc involvement
+/- compression of adj structures
+/- dilated COURVOISIER GB (with jaundice)
+/- biliary dilatation
+/- panc duct dilatation
*DOUBLE DUCT SIGN
+/- lymphadenopathy, mets
courvoisier gb associated with __
adenocarcinoma
- thin walls, NONTENDER
- due to malignant obstruction of distal CBD
- +/- sluge
- results in distension, jaundice and enlarged gb
cancer of the endocrine panc
islet cell tumours
**TAIL b/c islet cells
most islet cell tumours are __
functioning
types of functioning islet cell tumours
insulinoma
* B cell
* most common
gastrinoma
* G cell
less common:
glucagonoma
* alpha cell
somastatinoma
* D cell
which panc tumour is of the B cell
insulinoma
functioning islet cell tumour
which panc tumour increases insulin causing hypoglycemia, heart palpitations and sweating
insulinoma
sono feature of insulinoma
usually small
echo poor
typically benign and in tail
which panc tumour is of the G cells
gastrinoma
which panc tumour increases gastrin causing diarrhea, too much gastric acid and peptic ulcers
gastrinoma
- functioning islet cell tumour
what is Zollinger-Ellison syndrome and what is it associated with
increased gastric acid build up
associated with gastrinoma
which functioning islet cell tumour is usually malignant
gastrinoma
glucagonoma
which panc tumour decreases insulin; encouraging DM and inhibition of endocrine function
somastatinoma
- D cell functioning islet cell tumour
which panc tumour increases glucagon, causing hyperglycemia and DM
glucagonoma
- alpha cell functioning islet cell tumour
which type of islet cell tumours are larger but harder to dx
non functioning
- high incidence of malignancy
which panc tumour is most common malignant tumour
adenocarcinoma
sono features of non functioning islet cell tumours
in the head of the panc
double duct sign
intrahepatic biliary dilatation
courvoisier gb
MEN syndrome aka
multiple endocrine neoplasia
neoplastic / hyperplastic involvement in several endocrine glands
genetic autosomal dominant
MEN syndrome is genetic, autosomal __
dominant
type I MEN syndrome
pituitary
parathyroid
pancreas
type II MEN syndrome
thyroid
parathyroid
adrenal
mets to the panc are very __ ; and are associated with which primaries
uncommon
lung, breast, thyroid, melanoma
OR direct extension form kidney, stomach, lymph nodes
only consider a met in pancrease if pt has what hx
hx of a known primary
serous vs. mucinous cystic neoplasms of the panc
serous = microscopic, benign, old people
mucinouse = big, complex, malignant, women
cystic neoplasm of panc with well defined cystic or solid appearance, very small, and has central scar in some instances
serous cystic neoplasm
thin walled cystic neoplasm ddx pseudocyst
mucinous cystic neoplasm
what are the 2 main types of mucinous cystic neoplasms seen in the panc
IPMN
SPEN
IPMN aka
intraductal papillary mucinous neoplasm
- old ladies
- some malignant
- complex, biliary and ductal dilatation
SPEN aka
solid pseudopapillary epithelial neoplasm
- young women
- slow rate of growth
- variety of appearances
which types of panc neoplasm is mostly found in young women
SPEN
which panc neoplasm with hx of abd pain, nausea, vomiting, weight loss, acute pancreatitis, and an old woman
IPMN
cystic lesions of the panc associated with __
ADPKD
Von Hippel-Lindau disease
genetic tumour-producing disease (autosomal dominant) the predisposes patient to develop benign and malignant tumours
Von Hippel-Lindau disease
associated lesions
- CNS
- retinal hemangioblastoma
- clear cell renal carcinoma
- pheochromocytoma
- panc cysts
where will you find a pancreatic transplant
iliac crest (lower quadrant)
what is the most common procedure performed for pancreatic conditions
Wipple procedure
when performing endoscopic evaluation of the pancreas, the frequency should be around __ MHz
10MHz
what structure is seen coursing transversely through the anterior head of the pancreas
gastroduodenal artery
what would be the use of employing colour Doppler to a pt ?pancreatitis
r/o pseudoaneurysm
