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SURGERY CARDS > NMS Pancreas 1 (includes gallbladder) > Flashcards

NMS Pancreas 1 (includes gallbladder) Flashcards

0
Q

annular pancreas

A

usually presents in infancy w duodenal obstruction (postprandial vomiting). caused by malrotation of ventral pancreas –> ring of pancreatic tissue around second portion of duodenum

pancreatitis and peptic ulcers also may result

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1
Q

Pancreas divisum

A

due to failure of ventral and dorsal ducts to fuse, majority of pancreatic drainage is accomplished via accessory papilla and duct of Santorini.

–> most common congenital anomaly of pancreas (5% of population) but usually asymptomatic.

rarely chronic pain and recurrent pancreatitis result from inadequate drainage

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2
Q

heterotopic pancreas

A

pancreatic tissue in an abnormal location (stomach, duodenum, Meckel’s diverticulum)

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3
Q

why does resection of head of pancreas require resection of duodenum

A

bc they have shared blood supply (gastroduodenal –> pancreaticoduodenal artery)

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4
Q

pancreatic ducts

A
  • duct of wirsung is main duct; runs entire length of pancreas. it joins common bile duct and empties into 2nd part of duodenum at ampulla of vater
  • duct of santorini (small duct) is an accessory duct often joining the duodenum more proximally than ampulla of vater
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5
Q

blood supply of pancreas

A
  1. head: anterior and posterior superior pancreaticoduodenal arteries = branches of gastroduodenal artery;
    anterior and posterior inferior pancreaticoduodenal arteries=branches of SMA
  2. NECK, BODY, TAIL: splenic artery and branches (dorsal pancreatic artery)
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6
Q

exocrine physiology of pancreas

A

secretion of 1-2L/d of clear, isosmotic alkaline fluid containing digestive enzymes.

exocrine pancreas makes up 85% of pancreatic volume;
endocrine pancreas accounts for only 2%, with the rest composed of extracellular matrix and vessels or ducts

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7
Q

what kind of block can be done for pain control in pancreatic dz

A

celiac plexus block

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8
Q

secretin

A

most potent endogenous stimulant for bicarbonate secretion

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9
Q

endocrine function of pancreas

A

Islets of Langerhans make up 2% of pancreas by weigh:

1) insulin: from beta cells in islets of Langerhans (glucose absorption and storage);
2) glucagon: from islet alpha cells (glycogenolysis and release of glucose);
3) somatostatin: from islet delta cells (generally –> inhibitory function of GI tract)

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10
Q

uses of somatostatin

A
  1. treat symptoms of neuroendocrine tumors (islet cell, carcinoid, gastrinoma, VIPoma, and acromegaly)
  2. convert high output fistulae to low output fistula (bc of its antimotility and antisecretory effects)
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11
Q

acute pancreatitis

A

inflammation of pancreas due to parenchymal autodigestion by proteolytic enzymes

CAUSES: 1) alcohol abuse (40-50%); 2) gallstones (40%)

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12
Q

Less common causes of acute pancreatitis

A
  1. hyperlipidemia
  2. hypercalcemia: 2/2 hyper PTH
  3. trauma
  4. post op and post ERCP
  5. pancreatic duct obstruction (tumor, pancreatic divisum)
  6. vasculitis
  7. scorpion venom
  8. viral infections
  9. drugs (azathioprine, INH, cimetidine)
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13
Q

signs and symptoms of acute pancreatitis

A
  1. severe, constant epigastric pain radiating to the back. pain may be improved by sitting forward or standing
  2. nausea/vomiting
  3. low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but no rebound. bowel sounds may be absent due to adynamic ileus.

signs of hypovolemic shock may also be present due to massive retroperitoneal fluid sequestration and dehydration

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14
Q

cullens sign

A

bluish discoloration of periumbilicus

hemorrhagic pancreatitis

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15
Q

grey-turners sign

A

bluish discoloration of flank

hemorrhagic pancreatitis

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16
Q

fox’s sign

A

bluish discoloration of inguinal ligament

hemorrhagic pancreatitis

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17
Q

cullens, grey turners, fox’s sign

A

indicative of severe, hemorrhagic pancreatitis

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18
Q

MEDVIPS: drug-induced pancreatitis

A
  1. methyldopa/metronidazole
  2. estrogen
  3. didanosine (inhibits HIV DNA polymerase reverse transcriptase)
  4. valproate
  5. INH
  6. pentamidine
  7. sulfonamides
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19
Q

elevate lipase

A

only found in gastric and intestinal mucosa and liver, in addition to pancreas, so is more specific for pancreatitis than amylase

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20
Q

elevated amylase

A

also found in salivary glands, small bowel, ovaries, skeletal muscle (+pancreas) so not specific marker for pancreatitis

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21
Q

Ranson’s criteria : on admission

A
  1. age>55
  2. blood glucose>200
  3. AST>250
  4. LDH> 350
  5. WBC >16k
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22
Q

Ranson’s criteria: after 48 h

A
  1. base deficit >4
  2. increase in BUN >5
  3. fluid deficit > 6L
  4. Calcium 10%
  5. PO2 < 60 mm Hg
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23
Q

diagnostic choice for acute pancreatitis

A

CT scan: 90% sensitive, 100% specific.

demonstrates pseudocysts, phlegmon, abscess, or pancreatic necrosis

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24
Q

causes of elevated amylase levels

A

high amylase levels are seen in intestinal disease, perforated ulcer, ruptured ectopic pregnancy, salpingitis, salivary gland disorders, renal failure, and diabetic ketoacidosis

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25
Q

treatment of acute pancreatitis

A
  1. aggressive hydration with electrolyte monitoring to maintain adequate intravascular volume
  2. NG tube if vomiting
  3. antibiotics if infection identified
  4. NPO with nutritional support via post-pyloric feeding or TPN
  5. avoid morphine-possible spasm of sphincter of Oddi (use IV fentanyl or hydromorphone; meperidine favored over morphine)
  6. surgery indicated for either infected necrosis of pancreas or correction of associated biliary tract dz
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26
Q

chronic pancreatitis

A

chronic inflammation or recurrent acute pancreatitis causes irreversible parenchymal fibrosis, destruction, and calcification –> loss of endocrine and exocrine function

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27
Q

causes of chronic pancreatitis

A
  1. EtOH abuse (70%)
  2. idiopathic (20%)
  3. other (10%): hyper PTH, HLD, congenital pancreatic abnormalities, hereditary, obstruction
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28
Q

signs and symptoms of chronic pancreatitis

A
  1. recurrent or constant epigastric/back pain
  2. malabsorption/malnutrition (exocrine dysfunction)
  3. steatorrhea (exocrine dysfunction-fat soluble vitamin deficiency (ADEK)
  4. Type 1 diabetes mellitus
  5. polyuria
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29
Q

diagnosis of chronic pancreatitis

A
  1. pancreatic calcifications
  2. chain of lakes pattern on ERCP with ductal irregularities/dilatation/stenosis
  3. pseudocysts with gland enlargement/atrophy, masses
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30
Q

Pseudocysts

A

nonepithelialized, encapsulated pancreatic fluid collections. up to 30% of pseudocysts resolve on their own with bowel rest (TPN and NPO). if after 6 wks they have not resolved and are > 6 cm in size, internal drainage of the mature cysts indicated via cyst gastrostomy or Roux-en-Y cyst jejunostomy.

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31
Q

pancreatic adenocarcinoma

A
  1. originate in exocrine pancreas (ductal cells)
  2. 2/3 occur in head of pancreas

risk factors:

  1. male
  2. african-american
  3. tobacco user
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32
Q

Courvoisier’s sign

A

jaundice with palpable gallbladder that is nontender

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33
Q

signs and symptoms of pancreatic adenocarcinoma

A
  1. weight loss
  2. (painless) jaundice
  3. posterior epigastric pain radiating to the back
  4. migratory thrombophlebitis (Trousseau’s syndrome esp seen in tumors of body or tail)
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34
Q

diagnosis of pancreatic adenocarcinoma

A
  1. elevated CEA or CA19-9
  2. CT scan is study of choice
  3. PTC and ERCP useful in periampullary lesions
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35
Q

treatment of pancreatic adenocarcinoma

A
  1. tumors of head: Whipple procedure (pancreaticoduodenectomy)
  2. tumors of body/tail: distal near-total pancreatectomy
  3. if unresectable 2/2 liver or peritoneal mets, nodal mets beyond zone of resection, or tumor invasion of SMA, palliative procedures considered
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36
Q

Whipple procedure

A

removal of gallbladder, common bile duct, antrum of stomach, duodenum, proximal jejunum and head of pancreas (en bloc);

reconstruction with pancreaticojejunostomy , choledochojejunostomy, and gastrojejunostomy

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37
Q

prognosis for adenocarcinoma

A

median survival for patients who undergo successful resection is approximately 12-19 months, with 5y survival rate of 15-20%

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38
Q

pancreatic cystadenocarcinoma

A
  1. commonly seen in females 40-60y
  2. occurs in body/tail
  3. accounts for <2% of all pancreatic exocrine tumors
  4. prognosis better than adenocarcinoma
  5. TREATMENT: distal/total pancreatectomy
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39
Q

pancreatic cystadenoma

A
  1. seen in older/middle aged women
    two types:
    a. serious: benign
    b. mucinous: generally benign, but potential to be malignant
  2. treatment: surgical resection
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40
Q

insulinoma

A

beta cell neoplasm with overproduction of insulin

  1. MC islet cell tumor
  2. 90% are benign
  3. most are solitary lesions with even distribution in head/body/tail of pancreas
  4. if associated with MEN I (<10% of all cases), then multiple insulinomas may be present
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41
Q

diagnosis of insulinoma

A
  1. fasting serum insulin level >10 uU/mL [nL is 0.3

3. prosinulin or C-peptide levels should be measured to rule out surreptitious exogenous insulin administration

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42
Q

treatment for insulinoma

A
  1. surgical enucleation/resection usually curative

2. diazoxide can improve hypoglycemic symptoms by inhibiting pancreatic insulin release

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43
Q

what is Whipple’s triad

A

characterizes insulinoma

  1. symptoms of hypoglycemia with fasting
  2. fasting glucose <50 mg/dL
  3. relief of symptoms after eating (glucose)
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44
Q

gastrinoma

A

neoplasm associated with overproduction of gastrin; aka Zollinger-Ellison syndrome

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45
Q

epidemiology of gastrinomas

A
  1. second most common islet cell tumor
  2. 90% are located in gastrinoma triangle bordered by junction of second and third part of duodenum, cystic duct, and SMA under the neck of the pancreas
  3. 25% of gastrinomas are associated with MEN-1
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46
Q

signs and symptoms of gastrinomas

A
  1. signs mimicking peptic ulcer dz
  2. epigastric pain most prominent after eating
  3. profuse, watery diarrhea
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47
Q

diagnosis of gastrinoma

A
  1. fasting serum gastrin level > 500 pg/mL [nl: <100 pg/mL]
  2. secretin stimulation test will cause paradoxical increase in gastrin in patients with Zollinger-Ellison syndrome
  3. ulcers in unusual locations (ie, 3rd part of duodenum or jejunum) is highly suggestive
  4. octreotide scan to localize tumor
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48
Q

treatment of gastrinoma

A
  1. PPI
  2. surgical resection
  3. chemotherapy
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49
Q

VIPoma

A

overproduction of VIP; aka Verner Morrison syndrome or WDHA syndrome (Watery Diarrhea, Hypokalemia, Achlorhydria);

most are malignant and majority have metastasized to lymph nodes and the liver at time of dx

10% extrapancreatic

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50
Q

signs and symptoms of VIPoma

A
  1. severe, watery diarrhea

2. signs of hypokalemia-palpitations/arrhythmias, muscle fasciculations/tetany, paresthesias

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51
Q

treatment of VIPoma

A

fasting serum VIP>800 pg/mL (normal<200 pg/mL) with exclusion of other causes of diarrhea

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52
Q

glucagonoma

A

rare alpha cell neoplasm resulting in overproduction of glucagon

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53
Q

signs and symptoms of glucagonoma

A
  1. mild diabetes (hyperglycemia)
  2. anemia
  3. mucositis
  4. weight loss due to low amino acid levels
  5. severe dermatitis: often a red psoriatic like rash with serpiginous borders over trunk and lower limbs
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54
Q

skin condition associated with glucagonoma

A

necrolytic migratory erythema

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55
Q

diagnosis of glucagonoma

A
  1. fasting serum level glucagon > 1000 pg/mL

2. skin bx to confirm presence of necrolytic migratory erythema

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56
Q

common bile duct forms in which pancreatic bud

A

ventral

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57
Q

which pancreatic bud migrates to fuse with other

A

ventral

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58
Q

what does ventral pancreatic bud form in adult

A

uncinate process and inferior aspect of pancreatic head

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59
Q

what does dorsal bud form

A

superior aspect of head, body, tail

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60
Q

from which pancreatic bud does small accessory pancreatic duct of santorini form

A

from dorsal bud

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61
Q

main duct of wirsung forms from entire ventral pancreatic duct which fuses with …

A

distal pancreatic duct of dorsal bud

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62
Q

what abnormality arises if ventral pancreatic bud migrates posteriorly AND anteriorly to fuse with dorsal pancreatic bud

A

annular pancreas

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63
Q

name parts of pancreas

A

head, neck, body, tail

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64
Q

on what structure does pancreatic head rest

A

IVC, renal vessels

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65
Q

on what structure does uncinate process rest

A

aorta

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66
Q

what lies behind pancreatic neck

A

SMA

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67
Q

how is blood supplied to head of pancreas from celiac axis

A

gastroduodenal artery branches into SUPERIOR posterior and anterior pancreaticoduodenal artery

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68
Q

how is blood supplied to pancreatic head from celiac axis (2)

A

SMA branches into INFERIOR posterior and anterior branches of pancreaticoduodenal

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69
Q

which arteries supply body and tail of pancreas

A

splenic –> dorsal pancreatic –> joining branch from SMA –> forming inferior pancreatic

also multiple branches from splenic + inferior pancreatic arteries supply tail

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70
Q

into which veins do pancreatic veins drain

A

splenic vein into portal vein

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71
Q

which nodal groups drain pancreas

A

head: subpyloric, portal, mesocholic, aortocaval
body and tail: retroperitoneal in splenic hilum
to mesocolic, mesenteric, aortocaval

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72
Q

what do islet cells make

A

insulin (beta)
glucagon (alpha)
somatostatin (delta)

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73
Q

type of cells in exocrine pancreas

A

acinar, centroacinar, intercalated ductal, ductal

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74
Q

pH of pancreatic secretions

A

8

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75
Q

enzymes from pancreas

A

peptidases, trypsin, chymotrypsin, elastase, kallikrein, carboxypeptidase A and B

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76
Q

what stimulates exocrine secretion

A

bicarb: vagal efferents and secretin
enzymes: cholecystokinin and acetylcholine

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77
Q

what GI hormone is structurally similar to CCK

A

gastrin

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78
Q

what activates peptidases

A

enterokinase

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79
Q

what % acute pancreatitis is idiopathic

A

10%

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80
Q

metabolic causes of pancreatitis

A

hyperlipidemia, hypercalcemia

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81
Q

other surgical dzs causing pancreatitis

A

perforating peptic ulcer, Crohn dz of duodenum

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82
Q

diagnostic GI test that can cause pancreatitis

A

ERCP

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83
Q

arachnid bite that can cause pancreatitis

A

scorpion

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84
Q

worms that can cause obstructive pancreatitis

A

Ascaris, clonorchis sinensis

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85
Q

tests for diagnosing acute pancreatitis

A

amylase in serum, peritoneal fluid and urinary amylase

serum lipase, WBC, total bilirubin, LFT

AXR, US, CT

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86
Q

what is a sentinel loop

A

adynamic, dilated loop of small bowel associated with a focal area of inflammation initially described in relation to pancreatitis-associated ileus

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87
Q

when can patients with pancreatitis be fed

A

NOT early; this causes reactivation

but i saw that early enteral feeds is good…what??

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88
Q

should abx be used in treatment of acute pancreatitis

A

yes, necrotizing pancreatitis

this is controversial i think?

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89
Q

which abx to use for necrotizing pancreatitis

A

imipenem/cilastatin

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90
Q

how many patients with acute pancreatitis need surgery

A

10%

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91
Q

does early use of minidose heparin prevent intravascular thrombosis during acute pancreatitis or alter the course of pancreatitis

A

prob not

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92
Q

does peritoneal lavage alter clinical course of severe or necrotizing pancreatitis

A

controversial

recent study showed that patients with 5 or more of Ranson’s criteria had reduced sepsis/death (with peritoneal lavage)

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93
Q

how should patients with severe pancreatitis be nourished

A

TPN;

but when peristalsis returns, nasoenteric or enteric feeding tubes (early enteral feeds?) may offer better nutrition without worsening pancreatitis (beyond ligament of Treitz)

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94
Q

what causes gallstone pancreatitis

A
  • bile reflux into pancreas
  • reflux of duodenal succus from a loose sphincter of Oddi
  • stone blockage of pancreatic duct
95
Q

if surgically untreated, what % of patients with gallstone pancreatitis will have recurrence within 8 weeks

96
Q

what other causes of pancreatitis must be ruled out in a patient with gallstones?

A

alcohol abuse, medications, hyperlipidemia, hypercalcemia

97
Q

appropriate treatment of mild gallstone pancreatitis

A

laparoscopoic cholecystectomy; intraoperative cholangiogram on HD 3-5 if pancreatitis resolves

98
Q

definition of chronic pancreatitis

A

recurrent bounts of acute, chronic pain, exocrine and endocrine dysfunction, irreversible parenchymal fibrosis

99
Q

signs and symptoms of chronic pancreatitis

A

abdominal pain, diabetes, steatorrhea, pancreatic calcification

100
Q

anatomic pancreatic changes in chronic pancreatitis

A

sclerosis with duct stenosis and dilatation

loss of acinar tissue

101
Q

most common cause of chronic pancreatitis

A

alcohol abuse

102
Q

CT findings with chronic pancreatitis

A

dilated pancreatic duct, calcifications, parenchymal atrophy (pseudocyst)

103
Q

findings associated with chronic pancreatitis on CT

she may have meant ERCP

A

chain of lakes

did she mean ERCP?

104
Q

most sensitive test for chronic pancreatitis

105
Q

factors indicating surgery for chronic pancreatitis

A

refractory, disabling pain; frequent recurrent acute exacerbations; possible malignancy; GI or biliary obstruction; splenic vein thrombosis with portal HTN

106
Q

how are patients with chronic pancreatitis managed non-operatively

A

tx of pain; pancreatic exocrine replacement; insulin therapy

107
Q

what are pseudocysts

A

pancreatic juice enclosed by a false capsule of fibrous or granulation tissue that arises as a consequence of pancreatitis or trauma

108
Q

percentage of patients with acute pancreatitis forming pseudocysts

109
Q

what % of patients with chronic pancreatitis develop pseudocysts

110
Q

What % of ppl with acute pancreatitis develop persistent pseudocysts

111
Q

most common cause of pancreatic pseudocysts in kids

112
Q

signs/symptoms of pancreatic pseudocysts

A

persistent pain, persistent n/v, weight loss, abdominal mass, persistent amylase elevation, jaundice, distension

113
Q

% of patients with pseudocysts that have persistent abdominal pain

114
Q

% of patients with pseudocysts that have abdominal mass

115
Q

appropriate treatment of an infected pseudocyst

A

external drainage

no abx??

116
Q

avg time for 4 cm pseudocyst to resolve

A

2-3 months

117
Q

complications a/w pseudocyst

A 
hemorrhage
infection, 
leak
gastric outlet obstruction
bile duct obstruction
118
Q

treatment of an unstable patient with hemorrhage into pseudocyst

A

arteriogram and possible embolization

119
Q

what portion of pancreas gets carcinoma

120
Q

% of pop with pancreas divisum

121
Q

risk factors for pancreatic carcinoma

A 
advanced age, smoking
diabetes (esp in women)
heavy alcohol use
exposure to benzidine and naphthylamine
partial gastrectomy
122
Q

most common type of pancreatic carcinoma

A

90% adenocarcinoma

others are cystadenoma and acinar

123
Q

most common location of pancreatic carcinoma

A

2/3 in head

1/3 in body/tail

124
Q

signs/symptoms of pancreatic carcinoma

A

pain, weight loss, nausea, anorexia, painless jaundice

125
Q

tumor markers for pancreatic cancer

A

CA19-9, Ca50

126
Q

diagnostic test for pancreatic carcinoma

127
Q

diagnostic test for patients with jaundice

128
Q

why is tissue dx important for pancreatic carcinoma

A

ddx includes lymphoma, sarcoidosis, TB, choledocolithiasis, pancreatitis

129
Q

what is disadvantage of FNA

130
Q

when should tissue dx of potentially resectable tumors be performed

A

in OR (FNA)

but is this still done

131
Q

which patients are the best candidates for percutaneous needle bx of a periampullary tumor

A

nonoperative candidates

132
Q

which primary tumor location is associated with the most major vessel tumor involvement

A

head of pancreas

133
Q

what are main sites of metastasis for pancreatic cancer

A

liver, peritoneum

134
Q

what contraindicates resection in pancreatic cancer

A

mets, even just to local nodes; tumor involvement of SMA, SMV

135
Q

goal of pancreas surgery for carcinoma

136
Q

Kocher maneuver

A

to determine if SMA is involved in pancreatic carcinoma

–> hand needs to be able to identify a normal tissue plane between pancreas and SMA

137
Q

what intraoperative maneuvers simplify visualization of portal vein

A

cholecystectomy, transection of common hepatic duct

138
Q

what is appropriate treatment of distal pancreatic cancer

A

distal pancreatectomy with splenectomy

139
Q

what is appropriate treatment of cancer of head

A

Whipple, if resectable

140
Q

what is treatment option of unresectable pancreatic cancer

A

radiation and 5-fluoro

141
Q

what is an option for post-op adjuvant treatment (pancreatic cancer)

A

5-fluoro and radiation

142
Q

is pylorus preserving Whipple a/w any survival disadvantage

143
Q

what is current operative mortality rate with whipple

144
Q

what is most common postop complication of whipple

A

delayed gastric emptying

145
Q

appropriate treatment of delayed gastric emptying

A

metoclopramide

146
Q

percent of patients who develop a postop pancreatic fistula

147
Q

appropriate treatment of pancreatic fistula

A

controlled drainage, with or without somatostatin

148
Q

potential complications a/w standard whipple

A 
delayed gastric emptying (1/3)
pancreatic fistula (1/5)
abscess (1/10)
wound infection (1/12)
bile leak (1/20)
pancreatitis (1/20)
149
Q

what is prognosis for pancreatic cancer patients after resection

A

up to 20% are alive after 5 years

150
Q

what are most important post resection prognostic factors

A

positive lymph nodes, need for blood transfusions, clear margins, vascular invasion by histology

151
Q

various endocrine tumors of pancreas

A

insulinoma, glucagonoma, VIPoma, somatostatinoma, gastrinoma, calcitoninoma and neurotensin secreting tumors

152
Q

what is most common pancreatic endocrine tumor

A

insulinoma

153
Q

Whipple triad for insulinoma

A

fasting blood sugar <50
symptoms of hypoglycemia when fasting
symptomatic relief following glucose replacement

154
Q

diagnosing insulinoma

A

72h fast with blood glucose and insulin levels; insulin/glucose ratio > 0.4; elevated C protein and proinsulin

155
Q

do you image for pancreatic endocrine tumors

A

yes, CT with contrast

156
Q

location for insulomas

A

1/3 in each part of pancreas

157
Q

how to treat insulinomas

A

resection

enucleation for small tumors

158
Q

role of diazoxide for patients with unresectable dz (insulinoma)

A

can attenuate hypoglycemia (less insulin released)

159
Q

Zollinger-Ellison syndrome

A

pancreatic endocrine tumor that secretes gastrin

160
Q

how to dx gastrinoma

A

secretin stimulation test

161
Q

where are gastrinomas usually located

A

gastrinoma triangle:

  1. confluence of cystic and CBD
  2. junction of 2nd and 3rd portions of duodenum
  3. junction of neck and body of pancreas
162
Q

what % of gastrinomas are malignant

A

60% at time of dx

163
Q

treatment for gastrinoma

A

resection with medical anti-acid production therapy

164
Q

how to localize gastrinomas

A

CT with contrast, intraoperative ultrasound, duodenotomy, somatostatin, indium scan

165
Q

Verner-morrison syndrome (WDHA)

A

watery diarrhea, hypokalemia, achlorydiria

a/w VIPomas

166
Q

where are VIPomas usually

A

body and tail

167
Q

should VIPomas be resected

A

yes, though half have metastasized by dx

168
Q

what action should be taken if no tumor is identified in a patient with watery diarrhea, hypokalemia, achlorydria syndrome

A

subtotal pancreatectomy, bc there can be diffuse islet-cell hyperplasia

169
Q

what condition would a patient with diabetes and a migratory rash be likely to develop?

A

glucagonoma

170
Q

which enzyme, when activated, is thought to initiate many of the deleterious events a/w pancreatitis

171
Q

which lipolytic enzyme causes pancreatic necrosis in the presence of bile?

A

phospholipase A

172
Q

which enzyme is responsible for creating intrapancreatic hemorrhage

173
Q

what causes fat necrosis in pancreatitis

A

lipase, esp in presence of bile

174
Q

most important risk factor for severe necrotizing pancreatitis

A

obesity = more lipase

175
Q

% patients with cholelithiasis that develop gallstone pancreatitis

176
Q

peritoneal tap findings a/w severe necrotizing pancreatitis

A

dark brown, sterile, non-foul smelling fluid

177
Q

do NG tubes reduce the length of hospital stay or decrease pain in cases of acute pancreatitis

A

NO

just use for vomiting/ileus

178
Q

is somatostatin helpful in acute pancreatitis

A

NO

but does decrease pancreatic fistula output

179
Q

cause of coagulopathy in pancreatitis

A

release of proteases

180
Q

appropriate treatment for coagulopathies

A

fresh frozen plasma as required

181
Q

mxn for pulmonary dysfunction during pancreatitis

A

digestion of surfactant by phospholipase A

182
Q

appropriate treatment for pulmonary problems in acute pancreatitis

A

mechanical ventilation

183
Q

most common bacteria that infect necrotic pancreatic tissue

A

gram negative rods

184
Q

appropriate treatment of infected pancreatic tissue

A

surgical debridement, antibiotics

185
Q

presentation of acute pancreatitis

A

epigastric pain and tenderness, abdominal distension, fever, tachycardia, jaundice (when a/w gallstone pancreatitis)

186
Q

most common causes of acute pancreatitis

A

alcoholism, gallstone

187
Q

Ranson’s criteria utility

A

mortality in pancreatitis

188
Q

what 3 groups need asymptomatic gallstones removed

A
  1. immunocompromised
  2. porcelain gallbladder (chronic cholecystitis, at risk for adenocarcinoma of the gallbladder)
  3. larger than 3 cm
189
Q

6 factors that predispose to gallstones

A
  1. age >40
  2. fam hx of gallstones
  3. female
  4. obesity
  5. recent pregnancy
  6. prev dx gallstones
190
Q

RUQ due to cholelithiasis can radiate to where

A

right subscapular

191
Q

most efficient way to dx cholelithiasis

A

ultrasound

192
Q

lab values to expect with cholelithiasis

A

mild leukocytosis, mild jaundice, elevated bilis, alk phos and transaminases can also be elevated

193
Q

in uncomplicated cholelithiasis, what is abx regimen

A

1 dose preop 1G cephalosporin : cefalexin, cefazedone, cefazolin

194
Q

who needs abx in cholelithiasis

A

high riskers for sepsis: over 70, acute cholecystitis, hx obstructive jaundice, common duct stones, those with preop ERCP done

195
Q

whats major complication of lap chole

A

common bile duct injury: chronic biliary strictures, infection, cirrhosis;
injury to hepatic artery: hepatic ischemic injury, bile duct ischemia, strictures

196
Q

most common species for acute cholecystitis

A
  1. E. coli

2. enterobacter, klebsiella, enterococcus

197
Q

abx regimen for acute cholecystitis after blood cultures

A

2G cephalosporin for GNRs and anaerobes: Cefotetan, Cefoxitin

–> give preop and 24h postop

198
Q

when bili and/or liver enzymes are elevated, what to suspect? what to do?

A

common duct stone! preop or post op ERCP

199
Q

how should gallstone pancreatitis and symptomatic cholelithiasis be managed in pregnant pts

A

IV hydration and pain mgmt. avoid surg until after delivery if possible but safest to do in 2nd trimester. ERCP and sphincterotomy generally save

–> i also read that chole is safer than peritonitis so sometimes better to do elective? or am i thinking of appy…

200
Q

when biliary pancreatitis suspected, what procedure is necessary operatively?

A

operative cholangiogram. but delay surgery until complications from pancreatitis relieved: high fluid requirements, hypocalcemia, oliguria, hypotension, pulmonary complications.

201
Q

causes of pancreatitis mnemonic

A

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps (paramyxovirus and other viruses like epstein barr and cmv)
Autoimmune (PAN/SLE)
Scorpion
Hypercalcemia (or hyperlipidemia, hypertriglyceridemia, hypothermia)
ERCP
Drugs (steroids, sulfonamides, azathioprine, NSAIDs, diuretics, duodenal ulcers)

202
Q

clinical signs of pancreatitis

A
  • grey-turners sign: hemorrhagic discoloration of flanks
  • cullen’s sign: hemorrhagic discoloration of umbilicus
  • grunwald sign: appearance of ecchymosis around umbilicus due to local toxic lesion of vessels
  • korte sign (pain or resistance in zone where head of pancreas is located in epigastrium, 6-7 cm above umbilicus)
  • kamenchik’s sign (pain with pressure under xiphoid process)
  • mayo-robson sign (pain while pressing at top of angle lateral to erector spinae muscles and below left 12th rib =left costovertebral angle, CVA)
203
Q

RUQ pain and high fever would be suspicious for

A

acute cholecystitis and complication like cholangitis, empyema of gallbladder, pericholecystic abscess

204
Q

what ultrasound signs would you see with empyema of gallbladder

A

distended gallbladder with fluid that has internal echoes and gallstones

205
Q

Tx for empyema of gallbladder

A

emergent exploration, cholecystectomy, IV abx.

if general health is poor: percutaneous cholecystostomy to drain

206
Q

what does air in the biliary system mean? tx?

A

pneumobilia: suppurative cholangitis! gas forming organisms.
emergent ERCP w sphincterotomy, decompression of biliary tree, stone removal if feasible.
if unsuccessful: transhepatic cholangiogram and stone extraction, or cholecystectomy and CBD drainage

207
Q

Definition of SIRS/sepsis

A
  1. temp >38 (100.4) or 90
  2. RR>20, or PaCO212 or 10% bands

sepsis = SIRS + suspected infection
severe sepsis = sepsis + organ dysfunction
septic shock = sepsis induced hypotension NOT RESPONSIVE TO FLUIDS
(elderly get hypothermic and leukopenic in sepsis!)

208
Q

what does it mean when you have palpable gallbladder? what to do

A

inflamed gallbladder walled off by omentum. need emergent cholecystectomy when resuscitation occurs. high risk of rupture and mortality! watch out for change in mental status = sign of sepsis

209
Q

Charcot’s triad? meaning

A
  1. RUQ pain
  2. fever
  3. jaundice

means cholangitis

210
Q

tx of cholangitis

A
  1. IVF
  2. abx
  3. ultrasound
  4. ERCP if obstruction or dilatation of CBD seen
211
Q

what is a retained stone

A

common duct stone within 2 yrs of cholecystectomy. after 2 yrs = primary CBD stone

212
Q

post lap chole fever and pain might be?

A

infection/biliary leak/hepatic (CT scan) abscess/hepatic duct obstruction

213
Q

HIDA scan is good for detecting what

A

biliary leaks, cholecystitis, obstructions

214
Q

post lap chole cystic duct stump leak on HIDA or ERCP requires what

A

drainage and temporary stent

215
Q

if HIDA or ERCP shows complete CBD obstruction post cholecystectomy, what to do?

A
  1. biliary drainage using percutaneous drain

2. choledochojejunostomy (CBD to jejunum)

216
Q

differential for painless jaundice, pruritus, elevated liver enzymes?

A

biliary tree obstruction, cancer at head of pancreas, periampullary carcinoma, Klatskin tumor, CBD stricture, CBD stone (unusual for this presentation)

217
Q

if you see CBD dilation but no stones in ultrasound, what are next steps

A
  1. CT
  2. endoscopic ultrasound through duodenal wall to visualize head of pancreas
  3. ultrasound guided bx
218
Q

what would stop you from resecting a pancreatic adenocarcinoma at the head of pancreas

A

distant mets esp to liver, LN mets esp to periarotic or celiac region, bone pain, neuro symptoms, involvement of vena cava, aorta, SMA, SMV or portal veins

219
Q

procedure for resection of tumor at head of pancreas

A

pancreaticoduodenectomy

220
Q

what would you do if you found unresectable pancreatic adenocarcinoma with local spread

A

palliative biliary and gastric bypass to prevent gastric outlet or duodenal obstruction or bile duct obstruction. alcohol injection at celiac axis to decrease back and abdominal pain.

221
Q

painless jaundice + dilated intrahepatic ducts + no dilation of CBD

A

cholangiocarcinoma or Klatskin tumor!

222
Q

how to visualize cholangiocarcinoma or Klatskin

A

ERCP or percutaneous transhepatic cholangiography, which is better for proximal hepatic ducts

223
Q

are Klatskin tumors resectable

A

generally no, but may be able to do resection of gallbladder and bile ducts, hepatic lobectomy or trisegmentectomy

5yr survival with klatskins is 15% after curative resection

224
Q

what should you do with unresectable Klatskins or cholangiocarcinoma

A

palliative stenting of hepatic duct strictures

225
Q

type of biliary cancer with best prognosis

A

ampullary adenocarcinoma. requires a whipple (pancreaticoduodenectomy)

226
Q

what does a mass in the gallbladder fossa mean?

A

gallbladder adenocarcinoma. do open chole and wide resection of surrounding liver with hilar LN resection.

227
Q

porcelain gallbladder associated with what?

A

50% a/w adenocarcinoma

228
Q

when you suspect pancreatitis what imaging should you get to rule out other stuff

A

obstructive abdominal series to r/o perforated ulcer. will usually see generalized ileus

229
Q

tx for pancreatitis

A

NPO, IVF, pain control, observation, TPN if necessary

230
Q

tx for gallstone pancreatitis

A

IVF, NPO, pain control, observation, lap chole when stable

231
Q

tx of severe necrotizing pancreatitis

A

major fluid resuscitation, CT abd for additional causes of decompensation such as bowel necrosis, performations, abscess, biliary obstruction with infection

232
Q

Ransons criteria

A

admission: age>55, wbc>16, glucose>200, LDH>350, AST>250
48h: hct drop 10%, BUN increase 5, Ca6L

2 or less <5% mortality
3-4 15-20%
5-6 40%
7+ 99% mortality

233
Q

what do you do for a person with labored breathing and low pulse ox

A
  1. chest auscultation
  2. ABG
  3. CXR
  4. supply O2
234
Q

potential causes of resp distress in pancreatitis

A

pulm edema from overhydration, ARDS from response to pancreatitis, atelectasis, pneumonia

235
Q

do amylase levels correlate with severity or prognosis

236
Q

if a person with pancreatitis goes into sepsis, what should you suspect? what to do?

A

pancreatic abscess or other source of sepsis like pneumonia, IV access infection, UTI.

sample percutaneously under CT or ultrasound guidance, drain abscess surgically or percutaneously.

culture. give abx for GNR and anaerobes: imipenem alone or fluoroquinolone plus metronidazole.

SURGERY CARDS (8 decks)

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