Pancreas Flashcards
What is the duct Wirsung?
major pancreatic duct that forms in head and joins CBD to form common pancreaticobiliary channel proximal to ampulla of Vater
What is the duct of Santorini?
accessory pancreatic duct that drains the anterior portion of the pancreatic head
what is the blood supply to the head of the pancreas?
anterior and postero-superior pancreaticoduodenal arteries from GDA
forms collaterals with branches of SMA (inferoanterior and posterior pancreaticoduodenal arteries)
what is the venous drainage?
drains into portal system via SMV and splenic veins
which enzyme is responsible for pancreatic necrosis in the presence of bile?
phospholipase A
what is high output pancreatic fistula?
more than 200 ml/day
what are other causes of pancreatitis
hypercalcemia trauma hyperlipidemia pancreatic duct obstruction ischemia drugs familial idiopathic
what are the main causes of pancreatitis
gallstones and alcohol
how is pancreatitis dx?
needs 2 of the 3:
abdominal pain
serum amylase or lipase at least 3 times the upper limit of normal
characteristic findings of pancreatitis on CT
which enzyme is implicated in the etiology of pancreatitis?
trypsin
which serum enzyme rises within 2 hours of onset of pancreatitis and peaks within 48 hrs?
amylase
what are the early Ranson criteria (on admission)?
Glucose > 200 age > 55 LDH > 350 AST > 250 WBC >16k
what are the late ransom criteria (48 hours)?
calcium < 8 Hct drop > 10% PaO2 < 60 mmHg BUN increase by 5 or more base deficit > 4 fluid sequestration > 6 L
initial management of pancreatic duct stricture from chronic pancreatitis
pancreatic duct stenting
What is a Duval procedure?
distal pancreatectomy with end to end pancreaticojejunostomy
what is a Puestow procedure?
longitudinal pancreaticojejunostomy
lateral side to side pancreaticojejunostomy
most widely used and preferred for chronic pancreatitis with dilation of the pancreatic duct (7 mm or more); pancreatic resection, pancreatic denervation, islet cell transplantation (for T1DM)
what is a Frey procedure?
coring out diseased portion of pancreatic head with longitudinal dissection of pancreatic duct toward the tail and then lateral pancreaticojejunostomy for chronic pancreatitis
reserved for smaller inflammatory masses of the head and dilated pancreatic ducts (7 mm or more)
What is a Beger procedure?
duodenum preserving pancreatic head resection
uses 2 anastomoses with RNY jejunal loop to pancreatic tail remnant (end to side) and to the excavated pancreatic head (side to side)
For patients with a large inflammatory mass in the head with no evidence of distal ductal dilation – makes the end to side PJ the most appropriate anastomosis
what are the 4 types of acute pancreatitis complications per the revised Atlanta classification?
- acute peri pancreatic fluid collection or post necrotic/peripancreatic fluid collection (within 4 weeks), categorized as sterile or infected
- pancreatic pseudocyst or walled off necrosis (within 4 weeks), categorized as sterile or infected
How to manage a pseudocyst?
supportive for 4-6 weeks
if no resolution, wait until thick fibrous wall and do internal cyst drainage via open or endoscopic cystgastrostomy, cystojejunostomy, or cystuodenostomy
always perform biopsy to r/o malignancy
external drainage can be done for infected collections of pseudocysts
indication for surgical intervention for pseudocyst
has not resolved in 6 weeks and persistently greater than 6 cm
how is infected peripancreatic fluid collection or infected walled off necrosis dx?
CT guided perc FNA
what abs is used for pancreatic necrosis involving > 30% of the gland?
imipenem or meropenem
pancreatic tumor that exhibits sunburst central calcifications on CT scan?
serous cystadenoma
what are some inherited disorders that increase risk for pancreatic cancer
MEN hereditary pancreatitis FAP (APC gene) HNPCC (MLH1, MSH2, MSH6, PMS2, EPCAM) VHL, Gardner syndrome
what imaging is beneficial for assessing T stage of tumor
endoscopic US
what chemo agents MC used for pancreatic cancer
5-FU and gemcitabine
5-FU potentiates radiation therapy
FDA approved combo with gemcitabine for first line treatment of locally advanced, unresectable, or metastatic pancreatic cancer
Erlotinib (Tarceva)
T1 pancreatic cancer
tumor limited to the pancreas < 2 cm
T2 pancreatic cancer
tumor limited to pancreas >2 cm
T3 pancreatic cancer
tumor extends beyond the pancreas but without involvement of the celiac axis or SMA
T4 pancreatic cancer
tumor invades celiac axis or SMA (unresectable)
what reconstruction is performed during standard whipple
end to side PJ, HJ, GJ
what distinguishes mutinous cystic neoplasms from IPMN?
mutinous cystic neoplasm rarely communicates with main pancreatic duct
should a mutinous cystic neoplasm be resected?
yes, malignant potential
which islet cells do glucagonoma arise
alpha cells
what is another name for VIPoma
Verner Morner Syndrome
what is the triad of VIPoma
watery diarrhea, hypokalemia, achlorhydia
what is treatment for VIPoma
enucleation or surgical resection depending on location
what is the Whipple triad with insulinoma
symptoms of hypoglycemia with fasting
blood glucose < 50
relief of symptoms with glucose intake
what test is dx for insulinoma
72 hour fast, insulin and glucose measured q6h, sx’s of hypoglycemia develop in 12 hours
insulin:glucose ratio > 0.3 or seum insulin > 6
what is the treatment for insulinoma
enucleation
what are the 4 D’s of glucagonoma?
diabetes, dermatitis, DVT, depression
what is rarest pancreatic islet cell tumor?
somatostatinoma
what study should be used to define extent of pancreatic islet tumors
octreotide scan
what is the most malignant pancreatic endocrine tumor
gastrinoma
what is the most benign pancreatic endocrine tumor
insulinoma
what is the earliest manifestation of pancreatic transplant graft thrombosis?
hyperglycemia
preferred treatment for annular pancreas
duodenodeuodenostomy or duodenojejunostomy
branched duct IPMN can be observed if
less than 3 cm
main duct IPMN should be resected if duct is
> 10 mm
What gene is MC involved in adenocarcinoma?
KRAS
palpable non painful gallbladder filled with back of bile
Courvoisier sign
Blummer shelf
drop metastasis to the pelvis
autoimmune pancreatitis has increased
IgG
histology of MCN
ovarian like stroma
What is the Bern procedure
modified Berger procedure involves resection of the head
pancreas not transected at level of portal vein
reconstruction with single anastomosis with RNY jejunal loop to pancreas
no difference in outcomes between Beger and Bern procedures
For dilated duct and head involvement
Frey procedure
normal or small duct with head involvement
Beger or Bern
dilated duct without head involvement
Puestow
IPMN should be resected if
obstructive jaundice enhancing solid components main duct size 1 cm or more symptomatic lesions size 3 cm of more
fish mouth sign
main duct IPMN
needs surgical resection with negative margins
for grade III pancreatic trauma what vessels need to be exposed and preserved
splenic artery and vein
what is the Cullen sign
retroperitoneal hemorrhage to periumbilical area
what is the grey turner sign
retroperitoneal hemorrhage to flank
