Midterm 1 Flashcards
1
Q
where does the CBD lie in relation to the pancreas?
A
posterior to the head
2
Q
what is the endocrine functions of the pancreas?
A
- Islet cells of Langerhans secrete hormones directly into the bloodstream
- Failure to secrete sufficient insulin leads to diabetes
3
Q
what do alpha cells secrete?
A
glucogon (increases blood glucose)
4
Q
what do beta cells secrete?
A
insulin (decreases blood glucose)
5
Q
what is the exocrine function of the pancreas?
A
Digestive enzymes secreted by the acinar cells drain into the duodenum through pancreatic ducts
6
Q
what does amylase break down?
A
carbohydrates
7
Q
what does lipase break down?
A
fats
8
Q
what does trypsin break down?
A
proteins
9
Q
what does serum amylase increase with?
A
- Acute pancreatitis
- Pancreatic pseudocyst
- Intestinal obstruction
- Peptic ulcer disease
10
Q
what does serum amylase decrease with?
A
-hepatitis and cirrhosis
11
Q
urine amylase
A
Remains increased longer than serum amylase in episodes of acute pancreatitis
12
Q
what does serum lipase increase with?
A
Pancreatitis Obstruction of the pancreatic duct Pancreatic carcinoma Acute cholecystitis Cirrhosis Severe renal disease
13
Q
what does glucose increase with?
A
Severe diabetes mellitus
Chronic liver disease
Overactivity of endocrine glands
14
Q
what does glucose decrease with?
A
Tumors of islets of Langerhans in the pancreas
15
Q
pseudomass
A
- not different shape
ex) larger head bulging to right of GDA
16
Q
what measurement may indicate acute pancreatitis?
A
if the body exceeds 3cm AP
17
Q
what is the most common variant of the pancreas?
A
pancreatic divisum
18
Q
what is annular pancreas?
A
normal variant where the 2nd part of duodenum is surrounded by ring of pancreatic tissue (continuous with head of pancreas)
19
Q
what patient history indicator could be pancreatitis?
A
epigastric pain
20
Q
when would we use doppler when scanning the pancreas?
A
- if splenic vein does not appear anechoic and is overdistended
- pancreatitis
- any mass seen
21
Q
what are some indications for exam of the pancreas?
A
- Severe epigastric pain
- Elevated pancreatic enzymes
- Biliary disease
- Abdominal distension
- Pancreatitis
- Weight loss/anorexia
- Pancreatic neoplasm
- Evaluate mass seen on CT
22
Q
what is acute pancreatitis?
A
acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems associated with raised pancreatic enzyme levels in blood or urine
23
Q
what are the causes of acute pancreatitis?
A
- gall stones
- alcoholism
- idiopathic
24
Q
what are some other causes if acute pancreatitis?
A
- Choledocholithiasis
- Biliary sludge
- Neoplasm
- Infection
- Toxins
- Drugs
- e.t.c
25
what is shown up on blood tests for acute pancreatitis?
amylase and lipase elevated
26
what the sonographic findings of acute pancreatitis?
- GB and bile ducts assessed for stones
| - enlargement of the pancreas also occurs
27
how can the pancreas tissue appear with acute pancreatitis?
can appear hypoechoic and or enlarged due to interstitial edema
28
what else do we look at when scanning for acute pancreatitis?
- surrounding tissue and potential spaces (sacs to look for fluid)
- biliary system
29
what appears on sonography with pancreatitis?
- hypoechoic or anechoic collections that conform to the retroperitoneal or peritoneal space
- ascites
30
what are some local complications that can occur with pancreatitis?
- Acute fluid collections
- Pseudocysts (fluid collection persisting >6wks)
- Abscess
- Necrosis
31
what are some vascular complications that can occur with pancreatitis?
- Hemorrhage
- Venous thrombosis
- Pseudoaneurysms
32
what percent of patients with acute pancreatitis develop acute fluid collections?
40%
33
what is a pseudocyst?
fluid collection persist over 6wks
34
why is a pseudocyst not considered a true cyst?
Not considered true cyst or cystic neoplasm b/c does not have epithelial lining
35
what percent does the pseudocyst comprise cystic lesion of the pancreas?
75-90%
36
where are pseudocysts most commonly seen?
chronic pancreatitis
37
what is the sonographic appearance of pseudocysts?
Can range in appearance from almost purely cystic to collections with considerable mural irregularity, septations and internal echogenic debris from
- necrosis
- hemorrhage
- infection
38
what is a pseudocyst hard to differentiate from?
cystic neoplasm
| WE KNOW FROM IMPORTANACE OF CLINICAL INFORMATION
39
when does necrosis and abscess occur?
- parachyma over 3cm
- abcess occurs if fluid collection becomes infected-pus filled collections-air
- psedocysts that become infected can be drained or excised
40
what are the 2 most useful modalities for acute pancreatitis?
- CECT
| - abdominal US
41
when is CECT used?
necrosis
42
when is CT used?
- determining delayed complications of acute pancreatitis
| - guiding aspiration and drainage
43
what is chronic pancreatitis?
Intermittent pancreatic inflammation with progressive irreversible damage to the gland
44
what is the predominant cause of chronic pancreatitis?
alcoholism
45
what are some other causes of chronic pancreatitis?
- Pancreatic duct obstruction
- Hypertriglyceremia
- Hypercalcemia
- Auto-immune pancreatitis
- Tropical pancreatitis
- Genetic mutations
46
what are the signs and symptoms of chronic pancreatitis?
- pain
- malabsorption
- diabetes
47
what does chronic pancreatitis lead to?
- Fibrosis
- Cellular damage
- Chronic inflammation
- Distorted/blocked ducts
- permanent structural changes
- Deficient endocrine and exocrine function
48
what are some sonographic findings of chronic pancreatitis?
- Altered parenchymal texture
- Glandular atrophy
- Or gland enlargement
- Focal masses
- Dilation and beading of pancreatic duct with calcifications
- Pseudocysts
49
what is the treatment of uncomplicated chronic pancreatitis?
- alleviate pain
| - control malabsorption
50
what is the treatment of complicated chronic pancreatitis?
surgery and endoscopy
51
what are the complications of chronic pancreatitis?
- Pseudocysts (more common in chronic)
- Abscesses
- Malignancies
- Thrombosis of portals
- Pancreatic and bile duct obstruction----double duct sign
52
the presence of what points to chronic pancreatitis?
calcification
53
where may masses be located with chronic pancreatitis?
head of the pancreas may cause dilation of CBD and pancreatic duct
54
Phlegmon
infected pseudocyst
55
what is the most common vascular complication in the pancreas?
splenic vein thrombosis
56
Sinistral
left sided portal hypertension
57
when do Pseudoaneurysm form?
when enzyme-rich peripancreatic fluid, often within a pseudocyst, leads to autodigestion and weakening of the walls of adjacent arteries
58
where does thrombosis occur?
chronic pancreatitis
59
thrombosis occurs in chronic pancreatitis due to what?
- intimal injury due to recurrent inflammation
| - results in chronic fibrosis
60
what is thrombosis caused by?
pseudocyst compression on the adjacent vessels
61
what is Endoscopic retrograde cholangio-pancreatography (ERCP)?
Provides important information that cannot be obtained by other diagnostic examinations
62
what therapeutic measures can be taken at the time of ERCP?
- remove stones in the bile ducts
| - relieve obstruction of the bile ducts
63
what are the neoplasms of the pancreas?
- periampullary
- cystic
- Pseudopapillary
- Endocrine,lipoma,and mets
64
what are the types of Periampullary neoplasms?
- Pancreatic ductal adenocarcinoma
- Ampullary carcinoma
- Duodenal carcinoma
- Distal cholangiocarcinoma
65
what is the most common pancreatic neoplasm?
Pancreatic ductal adenocarcinoma-66
66
what is the most common presentation of periampullary neoplasm?
jaundice
67
what is perimpullary managed with?
whipples procedure
68
is there a cure for Pancreatic ductal adenocarcinoma
rare
69
what are some risk factors for Pancreatic ductal adenocarcinoma?
```
Slight male predominence
60-80 yrs of age
Smoking
Obesity
Chronic pancreatitis
Diabetes
Cirrhosis
Family history of pancreatic CA
```
70
what are the classic symtoms of Pancreatic ductal adenocarcinoma?
- jaundice
- pain
- weight loss
71
what is Pancreatic ductal adenocarcinoma associated with?
- increased bilirubin and ALP
- urine is dark
- stools are pale
- pruritis
72
what are the sonographic signs of Ductal /periampullar adenocarcinoma
- Double-duct sign
- CBD and pancreatic duct dilation
- Solid mass in the pancreatic head region
- Variable echotexture
- (can lead to Courvoisier GB)
73
Courvoisier Gallbladder
-enlarged palpable gallbladder in a patient with carcinoma of the head of the pancreas
74
what is Courvoisier Gallbladder associated with?
jaundice due to obstruction of the CBD
75
when would a Ductal adenocarcinoma be unrespectable?
- Tumor larger than 2 cm
- Extracapsular extension
- Lymphadenopathy
- Metastatic disease
76
what does whipples procedure involve the removal of?
- Head of the pancreas and uncinate process where the mass is located
- Duodenum
- Proximal 6 inches of jejunem
- Gallbladder and CBD
- Distal stomach
77
what is the result of whipples procedure?
Surgical anastomosis of the CHD and remaining pancreas and
| stomach to the jejunem is the result
78
what are the affects after whipples procedure?
hepatic function decreases
- fatigue and anorexia
- Bruising due to loss of clotting factors
- Increased mortality rate in centers that do not do a lot of these procedures
79
true or false, cystic neoplasm can be benign or malignant
true
80
what are majority of cystic lesions?
pseudocysts
81
what is important in diagnosing pseudocysts?
patient history of pancreatitis
82
what are high risk features of cystic pancreatic lesions?
```
Symptomatic Patients
Growth on serial examinations
Diameter >3cm
Internal soft tissue
Mural or septal thickening
```
83
where are simple cysts in pancreas seen?
patients with cystic fibrosis
84
what are some inherited diseases from pancreatic cysts?
- polycystic kidney disease (ADPKD)
| - Von Hippel-Lindau Disease(VHL)
85
Von Hippel Lindau Disease
- connective tissue disorder
| - multiple simple pancreatic cysts
86
what other lesions are associated with VHL?
- Serous cystic neoplasm
- Pancreatic endocrine tumors
- Ductal adenocarcinoma
87
mucinous tumors are often ________
malignant
88
what are the most common cystic neoplasms?
- Serous cystic
- Intraductal papillary mucinous
- Mucinous cystic
- Solid pseudopapillary
89
what is another name for serous cystic neoplasm?
Microcystic adenoma
90
serous cystic neoplasm
- Benign tumor
- More frequently in women
- Most often in pancreatic head
91
what is the sonographic appearance of Serous cystic neoplasm?
- tiny cysts too hard to see
- Echogenic appearance due to multiple reflective wall interfaces
- Posterior enhancement
- Fibrous pattern may be present
- Central calcification -30-50% of the time
92
Intraductal papillary Mucinous neoplasm risk factors?
- Arises from pancreatic ducts
- Head region (usually)
- older population
- Male & female equally
- Often presents as acute pancreatitis-
- Mucin travels to ampulla of Vater
- May be benign or malignant
- Adenocarcinoma often present-30-70
93
IPMN sonographic appearance
- prominent ductal dilation (hallmark on US)
| - mucin (sludge)
94
where is Mucinous cystic neoplasm most common?
perimenopausal women in pancreatic body and tail
95
what are the sonographic imaging features?
- May be unilocular or multilocular
- Thick or thin wall
- May have septations,thick or thin
- Internal debris is common
96
where does Solid-pseudopapillary tumor most often occur?
- young female patients
| - tail of pancreas
97
Solid-pseudopapillary tumor sonographic appearance
- Round encapsulated masses
- Variable amounts of necrotic,cystic and soft tissue foci within
- Variable echotexture- anechoic/hypoechoic
- Posterior enhancement
98
what are some other pancreatic masses?
- endocrine tumors
- metastases
- lipoma
99
Hyperfunctioning lesions
- Comprises 90%-tend to be small
| - Cause clinical symptoms early
100
Non-hyperfunctioning lesions
- Cause no endocrine related symptoms
| - Discovered when they are larger and cause pain
101
Lipoma sonographic features
Hypoechoic compared to usual echogenic appearance of fat
| May be mixed or hyperechoic and have internal echoes
102
Metastatic tumors
Most common pancreatic neoplasm seen on autopsy, 4x’s as often as pancreatic cancer
103
what are the primary sources of pancreatic masses?
- renal cell carcinoma
- breast
- lung
- colon
- melanoma
- stomach
104
what does severe fatty replacement occur with?
- cystic fibrosis
- diabetes
- obesity
- NASH
- old age
105
what is pseudomass caused by?
fatty sparing in the uncinate process
106
What is the most common benign tumor of the liver?
hemangioma
107
What is the second most commonly seen benign tumor of the liver?
FNH
108
What infectious disease may lead to cirrhosis?
acute viral hepatitis
109
What does gas in a hepatic mass usually signify?
abscess
110
The ultrasound feature of multiple tiny abscesses points to what disease in the liver
candidiasis
111
An obese 30 year old male who abuses alcohol went for an abdominal ultrasound complaining of RUQ pain-the US scan likely shows –
- hepatomegaly
- steatosis
- poor penetration of the liver
112
A 50 year old female who abuses alcohol presented clinically with hepatomegaly,jaundice and ascites,her ultrasound most likely reveals-
cirrhosis
113
A 50 year old male who abuses alcohol presents with epigastric pain, nausea,vomiting,increased lipase and amylase. His ultrasound probably reveals-
acute pancreatitis
114
A 50 year old male, a long time smoker : his ALT was discovered to be elevated,he appeared jaundiced and c/o weight loss-his liver ultrasound could reveal masses that appear -
hypoechoic or target appearance based on his smoking he may have lung cancer history
115
what are other causes of hepatomegaly?
- alcohol abuse
- primary liver cancer
- hemochromatosis
116
The most common disease leading to eventual liver transplantation is-
hepatitis C
117
A 40 year old woman presents to the emergency department with fever, RUQ pain and tenderness,her blood screen revealed increased ALP and bilirubin-her ultrasound most likely revealed-
acute cholecystitis
118
what are some causes of GB wall thickening?
- colitis
- perforated duodenal ulcer
- diverticulitis
119
A 65 year old female presented for ultrasound complaining of LLQ pain. Her gallbladder ultrasound revealed multiple small polypoid masses,non shadowing and less than 10 mm in size,with negative murphy’s sign.These most likely represent-
cholesterol polyps
120
A 40 year old male presents to the emergency department with RUQ and epigastric pain-his ultrasound reveals gallstones,dilated intrahepatic ducts and choledocholithiasis -the US probably reveals-
secondary choledocholithiasis
121
what does mirizzi syndrome include?
- fever
- painful jaundice
- stone impacted in cystic duct or neck
- fistula between cystic and CH ducts
- obstruction of the bile ducts
122
A 35 year old female arrives at the emergency department with clinical presentation of- classic Charcot’s triad as well as leukocytosis and increased ALP and bilirubin-her ultrasound reveals CBD stones,she more than likely has-
acute bacterial cholangitis
123
Fibrosing inflammation of small and large bile ducts is-
primary sclerosing cholangitis
124
Besides gallstones and alcoholism ,other causes of acute pancreatitis include what?
- neoplasm
- infection
- toxins
125
A 40 year old female presents to her doctor after several bouts of pancreatitis over the last 6 weeks.She was sent for a follow up ultrasound which revealed a large cystic mass in the lesser sac which most likely is a-
pseudocyst
126
Findings-Altered parenchymal texture,glandular atrophy,dilation of pancreatic duct with calcifications -
chronic pancreatitis
127
all the following is true of portal/splenic thrombosis except-
A-occurs in both acute and chronic pancreatitis
B-portal vein thrombosis is the most common
C-may result in upper GI bleed from gastric varices
D-result of intimal wall injury due to recurrent inflammation
B- splenic vein thrombosis is the most common-sinistral-
128
“Double- duct “sign most likely indicates-
solid mass in the pancreatic head region
129
Whipples procedure involves all of the following except-
A-removal of the head of pancreas and uncinate process
B-removal of duodenum
C-preservation of gallbladder
D-anastomosis of CHD to jejunum
C- the gallbladder is removed as well as distal stomach,CBD and duodenum
130
true or false, Emphysematous cholecystitis appears as a large distended GB when a mass is found in the pancreatic head
False-it appears as gas within the wall and lumen due to necrosis
Courvoisiers GB results in obstruction of the CBD due to mass in pancreatic head
131
true or false, A positive murphy’s sign is evident in chronic cholecystitis?
False
| Also lacking is GB wall hyperemia and GB distension
