Pancreas Flashcards
A 63-year-old woman presenting with painful calcific chronic pancreatitis (CP) is referred for further management of her abdominal pain. She has undergone noninvasive medical therapy including antioxidants, pregabalin, oxycodone, and PERT. She has managed to discontinue smoking, but the pain continues. CT scan is shown in the figure. Which of the following would be best for long-term (5 years) management of CP pain?
A. EUS-guided celiac plexus block
B. ERCP with ESWL ( extra corporal shock wave lithotripsy)
C. ERCP with pancreas duct (PD) stent
D. Pancreas surgery (resection or drainage)
- This is a patient with chronic pain in the setting of CP and CT shows a dilated, irregular main pancreatic duct with calcific parenchyma disease.
- Surgery is superior to endoscopic intervention at providing longer term pain relief in CP in this setting. One RCT reported in a 79-month follow-up period, 1 patient was lost and 7 died from unrelated causes. Of the patients treated by endoscopy, 68% required additional drainage compared with 5% in the surgery group (P = .001). Hospital stay and costs were comparable, but overall, patients assigned to endoscopy underwent more procedures (median, 12 vs 4; P = .001).
- Moreover, 47% of the patients in the endoscopy group eventually underwent surgery. Although the mean difference in Izbicki pain scores was no longer significant (39 vs 22; P = .12), surgery was still superior in terms of pain relief (80% vs 38%; P = .042). Levels of quality of life and pancreatic function were comparable.
44F Korean w/ abd pain. No panceratitis hx. Moderate tenderness in her upper abdomen without rebound tenderness. AUS fusiform dilatation of the common bile duct (CBD), and mild dilatation of the pancreatic duct. There is no choledocholithiasis. Gallbladder normal. CT with interstitial panc. CBD is observed to be tortuous and dilated, without evidence of stones or masses. MRCP shown. next step in management?
A. Surveillance with yearly MRCP
B. No further intervention
C. Colonoscopy
D. Surgical evaluation
E. IgG subclass 4
- type I choledochal cyst (CC) with anomalous pancreatobiliary junction (APBJ)- diffuse dilation of CBD
- APBJ is defined as a long common channel with a length greater than 1.5 cm.
- cholangiocarcinoma and gallbladder carcinoma (panc contents into bile) +pancreatitis (bile going to PD)
- An anomalous anatomical arrangement of the pancreaticobiliary ductal junction allows reciprocal reflux of bile and pancreatic juices into the biliary tree, which can cause inflammation, ectasia, and dilatation.
- Malignancy is most commonly associated with types I and IV cysts. Tx: surgery
A 77-year-old man with a history of ischemic cardiomyopathy (LVEF 20-25%) with an implantable cardioverter-defibrillator and compensated alcoholic cirrhosis presented with acute-onset right upper quadrant abdominal pain and fevers with chills. The patient was admitted to the hospital after transabdominal ultrasound in the emergency department revealed cholelithiasis, gallbladder wall thickening, and positive sonographic Murphy’s sign. Antimicrobial therapy was begun using piperacillin-tazobactam. On day 2 of hospitalization, the patient was transferred to the intensive care unit after development of sustained hypotension requiring initiation of norepinephrine infusion.
Laboratory workup revealed:
WBC 15,000/µL (normal: 4,000-10,000/µL)
Serum creatinine 2.4 mg/dL (eGFR 25)
INR 1.54 (normal: <1.4)
Total bilirubin 1.7 mg/dL (normal: 0.3-1.2 mg/dL)
ALT 28 U/L (normal: 0-35 U/L)
AST 71 U/L (normal: 0-35 U/L)
ALP 97 U/L (normal: 36-92 U/L)
Lactic acid 3 mg/dL (normal: 6-16 mg/dL)
Computed tomography of the abdomen/pelvis with IV contrast was obtained [figures A and B]. What should be your next step in management?
A. Percutaneous cholecystostomy
B. Endoscopic retrograde cholangiography (ERCP) with transpapillary gallbladder drainage
C. Surgery consultation
D. Endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stent
E. Continue medical management
- Surgery consultation is the best next step in this patient with septic shock due to acute calculous cholecystitis, now complicated by suspected gallbladder perforation. The CT images demonstrate a rim of enhancement along the hepatic capsule (Figure A arrows: peritonitis) and a defect in the gallbladder wall (Figure B arrow: perforation). The gallbladder otherwise shows classic findings of acute cholecystitis, including gallbladder wall thickening, pericholecystic fluid/stranding, and enhancement of the gallbladder mucosa. Emergency exploratory laparoscopy with the possibility of conversion to open exploration is indicated. Frequently, abdominal cavity washout and surgical drain placement are needed.
Initial nonoperative management with antimicrobials is recommended over immediate cholecystectomy for American Society of Anesthesiologists (ASA) classification III or IV patients with acute calculous cholecystitis who lack an indication for emergency cholecystectomy (i.e., operative risks outweigh benefits). Nonoperative gallbladder drainage is warranted among high-risk patients (ASA III/IV) who fail to clinically improve after 1-3 days of medical management, given that cholecystectomy is associated with ≤19% mortality rate in high-risk patients. Failure to improve after nonoperative biliary drainage requires re-evaluation of drain positioning and careful review for complications of acute cholecystitis. Regardless of surgical risk, emergency cholecystectomy is indicated for complicated acute cholecystitis (e.g., gallbladder necrosis, gallbladder perforation, or emphysematous cholecystitis).
65M incidental dilated main pancreatic duct up to 13 mm. No mass, CBD wnl. Asymptomatic, healthy, no FH. EUS with dilated PD and shows a granular appearance to the pancreas. Side-viewing endoscopy image shown. next step managing?
A. Pancreatic enzyme replacement therapy
B. Surgical referral
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Serial imaging with CT or MRI
E. Endoscopic papillectomy
- IPMN- image shows the ampulla with a dilated papilla extruding mucinous fluid.
- 70% malignancy risk pancreatic duct is 10 mm or larger.
- no CP - no stones or calcifications
- Another scenario with significant dilation of the pancreatic duct is chronic pancreatitis, which can be treated with pancreatic enzymes.
- Endoscopic papillectomy - ampullary adenomas, not IPMN
51F with incidental pancreatic cyst, no FH, no panc hx, Dx?
A. Pseudocyst
B. Serous cystadenoma - septated, lobular, rarely unilocular
C. Mucinous cystic neoplasm
D. Solid pseudopapillary neoplasm
- Solid pseudopapillary neoplasms usually occur in younger women and have a heterogeneous appearance with a capsule and hemorrhagic components.
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Mucinous cystic neoplasms occur almost exclusively in women due to their ovarian-like stroma
- body and tail
- appear unilocular
- malignant potential, surgery recommended
55F CT w/ 2.5-cm cyst in the body of the pancreas, described as having a honeycomb appearance with a central scar. diagnosis?
A. Mucinous cystic neoplasm
B. Serous cystadenoma = Sentral sCar
C. Solid pseudopapillary lesion
D. Pseudocyst
- Serous cystadenoma is also more likely to be seen in middle-aged women. The classic features are microcystic or having a honeycomb appearance. Approximately 1/3 have a central scar. Benign do not require intervention or surveillance.
- Solid pseudopapillary lesions are rare lesions, most often seen in younger women. They are usually seen with a mixed solid and cystic appearance. Since they may be aggressive, surgical resection is often recommended
55F RUQ pain+ inc LFTs since she had a cholecystectomy 2 years ago. AUS CBD is dilated to 9 mm. ERCP w biliary sphincterotomy- Biliary cannulation with ease and no pancreatic cannulation or pancreatogram performed. No CBD stones. Which increase risk of post-ERCP pancreatitis?
A. Age
B. Underlying etiology
C. Biliary cannulation technique
D. Dilated CBD
- type 1 SOD dysfunction which responds well to biliary sphincterotomy but does carry an increased risk for post-ERCP pancreatitis (PEP).
- Age (younger than 40) and female (combined) is considered a relatively minor risk factor for post-ERCP pancreatitis.
- Dilated CBD and easy biliary cannulation are both associated with lower rates of post-ERCP pancreatitis.
- Among the choices listed, the patient’s clinical diagnosis of SOD portends the highest risk for PEP.
- Factors associated with an inc risk of post-ERCP pancreatitis
- female sex, younger age
- suspected sphincter of Oddi (SOD) dysfunction
- prior post-ERCP pancreatitis
- recurrent pancreatitis
- pancreatic duct injection
- pancreatic sphincterotomy
- difficult or failed cannulation at the present ERCP
- use of pre-cut sphincterotomy and
- failed prophylactic PD stenting.
- Factors not associated
- small CBD diameter
- the presence of a periampullary diverticulum
- pancreas divisum
- prior failed ERCP
- allergy to contrast media, and
- intramural contrast injection
A 59-year-old woman with a history of total abdominal hysterectomy with bilateral salpingoophorectomy and hypothyroidism presents to discuss reflux symptoms. She has had burning in her chest after dinner on and off for the last 3 months. She tried famotidine as needed with no improvement. She has not tried a PPI. She takes levothyroxine and a multivitamin daily. She is up to date with colon cancer screening and had a normal colonoscopy at 55. Her father died of pancreatic cancer at 62, her cousin died of pancreatic cancer at age 46, and her paternal aunt was diagnosed with pancreatic cancer and is currently receiving neoadjuvant chemotherapy. In addition to starting a proton pump inhibitor for reflux, what would you recommend next?
A. Endoscopic ultrasound with FNA
B. MRI with MRCP
C. Genetic counseling and genetic testing
D. Serum Ca19-9
The patient’s family history is concerning for familial pancreatic cancer syndrome as she has 3 family members with pancreatic cancer, 1 diagnosed at a young age. If her father was still alive, he would definitely need to undergo genetic testing. She should have an evaluation with a genetic counselor and have genetic testing performed for germline mutations associated with pancreatic cancer. If a mutation is detected, she should be enrolled in a surveillance program with alternating endoscopic ultrasound and MRIs. Ca19-9 has not been shown to detect pancreatic cancer.
An 80-year-old woman presents to the emergency department with acute upper abdominal pain and fever. The patient has a past medical history of stage III lung cancer on home oxygen. On physical exam, the patient is febrile and hypotensive. Abdominal exam exhibits tenderness in the right upper quadrant. Laboratory studies demonstrate a WBC of 16,000/µL (normal: 4,000-10,000/µL). An abdominal sonogram reveals a thickened gallbladder wall with stones along with significant ascites. Intravenous antibiotics have been started. What is the best next step for this patient?
A. Conservative approach and continue antibiotics
B. Laparoscopic cholecystectomy
C. EUS-guided lumen-apposing metal stent (LAMS)
D. Percutaneous cholecystostomy tube
- high-risk surgical candidate due to advanced lung cancer on oxygen with acute cholecystitis. The patient is exhibiting signs of sepsis, so in addition to antibiotics, gallbladder decompression is required.
- Patients with ASCITES have a relative contraindication for percutaneous drainage via interventional radiology.
- There is a growing body of literature supporting the role of endoscopic drainage with LAMS for patients who are high risk for surgery
- A recent systematic review of 189 patients showed a technical success rate of over 95%. Endoscopic (EUS-guided) placement of LAMS should be considered in patients at high risk for percutaneous or surgical interventions, especially if the expertise is available.
A 72-year-old man presents with painless jaundice. He has no history of hepatobiliary diseases. On physical examination, his weight is 69 kg, he is afebrile, and his vital signs are within expected normal range. There is no tenderness in the right upper quadrant. His past medical history is significant for fatty liver and dyslipidemia. His medications include simvastatin 10 mg and occasional ibuprofen for headache. He denies any known allergy to medications. He does smoke 5 cigarettes every day but does not drink alcohol. There is no family history of pancreatic cancer or pancreatitis. His pertinent blood work showed AST 216 U/L (normal: 0-35 U/L), ALT 187 U/L (normal: 0-35 U/L), serum lipase 55 U/L (normal: <95 U/L), total bilirubin 6.7 mg/dL (normal: 0.3-1.2 mg/dL), and serum alkaline phosphatase 928 U/L (normal: 36-92 U/L). Abdominal ultrasound shows a dilated common bile duct (CBD), and MRCP confirms a 13-mm CBD and the presence of multiple stones in the CBD. You schedule an ERCP. What would be the best evidence-based strategy in preventing post-ERCP pancreatitis in this patient?
A. Prophylactic pancreatic stent placement
B. Rectal indomethacin 100 mg before the procedure
C. Rectal indomethacin 100 mg after the procedure
D. None is required given the low risk in this patient.
- patient is average risk for post-ERCP pancreatitis
- rectal indomethacin will prevent moderate to severe post-ERCP pancreatitis and death if given 30 minutes before the procedure.
- Giving the medication after the procedure has not been more effective than placebo
- Prophylactic stent placement is only indicated in high-risk patients.
A 71-year-old woman with no prior history of liver disease presented with 1 month of non-specific epigastric pain and was found to have mildly elevated transaminases, an alkaline phosphatase of 330 U/L and a bilirubin of 2.7 mg/dL on initial laboratory studies. Subsequent MRI imaging demonstrated a distal common hepatic duct/mid common bile duct stricture. The patient underwent ERCP for further evaluation showing findings consistent with the MRI. Which of the following techniques during ERCP would provide the greatest likelihood of achieving an accurate diagnosis regarding this stricture?
A. Biliary brushings
B. Fluoroscopically guided forceps biopsy
C. Fluoroscopically guided biopsy + brushings
D. Visual cholangioscopic impression
E. Cholangioscopically obtained forceps biopsy
- The sensitivity of biliary brushings or fluoroscopically guided biopsies alone in detecting malignancy within a biliary stricture are around 45-50%. Combining these 2 techniques increases the sensitivity to around 60%.
- Visual cholangioscopic sensitivity and accuracy appears to be better than that from histology obtained by cholangioscopic biopsies (90% vs. 80%). Newer versions of cholangioscopes with improved optics may increase/improve this sensitivity rate for cholangioscopically obtained biopsies.
- Of note, EUS-FNA appears to have a sensitivity of around 80% for distal biliary strictures and about 60% for more proximal (hilar) strictures.
A 76-year-old man with well-controlled hypertension, reflux esophagitis controlled with once daily proton pump inhibitor, and history of small colon polyps based on a colonoscopy 1 year ago, underwent a triple phase CT scan of the abdomen and pelvis, for vague abdominal discomfort. He was noted to have an 18-mm solitary cyst in the body of the pancreas, without an associated solid mass. The main pancreatic duct measured 3 mm in the head of the pancreas, 2 mm around the genu of the pancreas, and 7 mm upstream from the pancreatic cyst, towards the tail of the pancreas, with some upstream pancreatic atrophy. Patient denies any weight loss, change in bowel habits, or steatorrhea. He has no history of pancreatitis and denies any significant alcohol use. There is no family history of pancreatic cancer. His blood work, including CBC, chemistry panel, liver function tests, CA 19-9, and fasting blood sugar were all normal. Which of the following do you recommend regarding the pancreatic cyst?
A. MRI in 1 year
B. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)
C. Surgery for distal pancreatectomy
D. No further workup is necessary.
- CT scan w/ change in the main duct caliber with upstream atrophy warrant further evaluation with an EUS-FNA and consider referral to a multidisciplinary group.
- In a systematic review and meta-analysis of 358 IPMNs from 8 studies, main pancreatic ductal dilation of >6 mm was associated with an increased risk of high-grade dysplasia or pancreatic cancer with a pooled OR 7.27 (95% CI, 3.0-17.4).
- MRI in 1 year would be appropriate for a cyst size ranging 1-2 cm in the absence of the CT scan findings.
- referral to surgery- premature
Risk factors for post spchinterotomy bleeding
The incidence of post-endoscopic sphincterotomy bleeding is approximately 1%.
- anticoagulant therapy within 3 days after ERCP (OR 5.11)
- underlying coagulopathy (OR 3.32)
- active cholangitis (OR 2.59), and
- the occurrence of any observed bleeding during the procedure (OR 1.74). Cirrhosis and the use of aspirin or other NSAIDs were not associated with bleeding after sphincterotomy
A 52-year-old otherwise healthy man underwent an upper endoscopy for evaluation of heartburn. He denied abdominal pain, nausea, vomiting, or jaundice. A 25-mm polypoid lesion was seen in the second portion of the duodenum [figure A] and was biopsied. Pathology showed adenomatous tissue without high-grade dysplasia or carcinoma. An endoscopic ultrasound (EUS) was performed. A dilated common bile duct (CBD) and pancreatic duct (PD) was seen as shown in figure B. Which of the following would be recommended next for management?
A. ERCP with ampullectomy
B. Whipple surgery
C. Endoscopic ablation with argon plasma coagulation (APC)
D. Surveillance endoscopy with a side-viewing duodenoscope in 12 months
- papillary/ampullary adenoma
- Tx: ERCP with ampullectomy
- Whipple surgery would not be first-line therapy without evidence of carcinoma and without extension of the lesion into the bile duct or pancreatic duct
A 31-year old woman presents with a 3-month history of abdominal discomfort and early satiety. She denies melena, hematochezia, or bright red blood per rectum. She reports that she does not drink any alcoholic beverages or smoke cigarettes. Her previous work-up included negative upper endoscopy and colonoscopy. However, CT scan of the abdomen performed at an outside facility shows a 6-cm lesion in the tail of the pancreas [figure A], and EUS image is shown in figure B. Her physical exam shows no bulging, tenderness, or guarding of the abdomen. The CA 19-9 was normal. An EUS-guided biopsy was performed. What would the biopsy most likely reveal?
A. Adenocarcinoma
B. Pancreatic neuroendocrine tumor (PNET)
C. Pseudopapillary tumor
D. GIST
The CT scan shows a large mass with inhomogeneous density in the body/tail of the pancreas. EUS shows a hypoechoic mass with multiple small anechoic spaces. The images indicate the lesion is not a solid tumor. GIST is not a pancreatic lesion. While PNET could present with solid/cyst lesion, this is most likely a pseudopapillary tumor of the pancreas for the following reasons: 1) Pseudopapillary tumors predominantly occur in women (80%); 2) The median age at presentation is 30-38 years; 3) CT features of pseudopapillary tumor include encapsulated mass with varying solid and cystic components secondary to hemorrhagic degeneration. While symptoms are usually nonspecific, pseudopapillary tumors can present with palpable abdominal mass, indigestion, abdominal discomfort, epigastric pain, nausea, vomiting, asthenia, itching, weight loss, back pain, early satiety, bloating, jaundice, and/or pancreatitis. It comprises less than 4% of resected pancreatic cysts. EUS FNA with immunohistochemical staining is usually diagnostic. Most pseudopapillary tumors behave indolently, yet the treatment of choice is surgical resection with a 5-year survival close to 97%.
