Pancreas Flashcards
Characteristics of cystic lesions of pancreas
Pseudocyst: F=M, anywhere in panc, communicates w/ ducts, neg mucin, high amylase, low CEA, lacks epithelial lining
Serous cystic neoplasm: F»_space;M (4:1), anywhere in panc, no communication w/ ducts, neg mucin, low amylase, low CEA, cuboidal cells, stain positive for glycogen
Mucinous cystic neoplasm: F»_space;>M (10:1), body & tail»_space; head, no communication w/ ducts, + mucin, low amylase, high CEA, columnar cells w/ variable atypia
IPMN: F=M, head>diffuse>tail, communicates w/ ducts, +mucin, high amylase, high CEA, columnar cells w/ variable atypia
Solid pseudo papillary Neoplasm: W>M, Branching papillae with myxoid storm, Low Amylase, <200 CEA, don’t communicate with main panc duct.
High risk features of IPMNs in pancreas
High-risk: enhancing mural nodule >5mm, main panc duct dilation >10mm, obstructive jaundice, enhancing solid components
Worrisome: growth >=5mm/2 yrs, cyst size >=3 cm, enhancing mural nodule <5mm, main panc duct dilation 5-9mm, pancreatitis, elevated CA 19-9, thickened cyst walls
Endoscopic findings of dilated ampulla secreting mucin -> “fish-mouth sign” is pathognomonic for MD-IPMN.
Postop complications of pancreatic transplantation
graft pancreatitis = MC graft thrombosis = w/in first week due to poor blood flow to panc or poor outflow (suspect if insulin requirements go up) arterial PSA Intra-abd abscess 2/2 leak Bleeding Pseudocysts, pancreatic fistula Cystitis, hematuria
Hereditary Chronic pancreatitis
Irreversible damage to pancreas
AD Dz, cationic trypsinogen gene PRSS1 and mutation R122H (MC; replaces arginine for histidine at AA position 122 of trypsinogen protein)
Pancreatic pseudocyst
5-15% pts w/ peripancreatic fluid collections after AP, after 4 weeks. non-epithelial lined.
50% asxs, 70% regress
Tx: observe (most resolve) vs internal enteric drainage
Pancreas divisum
Congenital anomaly. Single pancreatic duct not formed, stays as 2 distinct dorsal (drains into minor papilla- duct of Santorini) and ventral ducts (drains into major papilla - Duct of Wirsung)
In utero, majority of pancreas is drained by dorsal duct -> minor papilla. In adults, 70% drained by ventral duct -> major papilla.
In panc divisum, major drainage occurs via dorsal duct -> minor papilla
Secretin-enhanced MRCP: imaging of choice.
+ findings: dorsal panc duct crossing ant to CBD, draining superiorly into minor papilla. Separate ventral panc duct
Tx: ERCP sphincterotomy (for +sxs, recurrent pancreatitis), refractory -> duodenal sparing panc head resection
Severe acute pancreatitis
Acute pancreatitis with 1+ of following:
Necrosis of > 1/3 of pancreas
MSOF indicated by: hypotension SBP <=90, renal failure creat >2.9, GI bleed, respiratory failure (PaO2 <=60), local complications (hemorrhage, abscess, pseudocyst)
Somatostatinoma
Rarest of PNETs
Sxs: steatorrhea, dm, hypochlorydria, cholelithiasis
Dx: Fasting plasma somatostatin >100
Insulinemia
Dx: serum glucose <50, Whipple’s triad
Gastrinoma
Dx: serum gastrin >200 (>1000 in hyperacidity, ulcer dz)
Glucagonoma
Dx: elevated fasting serum glucagon; secretin stim test to differentiate b/w gastronome/antral G-cell hyperplasia or hyperfunction
Chronic pancreatitis
loss of pancreatic tissue -> loss of pancreatic endocrine function (DM) and exocrine function (malabsorption)
Fat malabsorption -> deficiency of vitamin A, D, E, K
Vit D made in skin via sunlight on cholesterol -> Vit D deficiency leads to low Ca & Phos -> Hyper PTH (>150)
Resectability of pancreatic tumors
Resectable: No involvement of artery or veins
Borderline resectable: <180 involvement of SMA, Involvement of SMV or PV amenable to recon
Unresectable: Aortic invasion, >180 SMA encasement, celiac axis abutment, PV occlusion, IVC involvement, non-recon involvement of other venous structures
Periampullary cancer
Pancreatic (MC) vs duodenal (rarest) vs cholangiocarcinoma
P/w: painless jaundice, biliary obstruction (pruritus, icterus, dark urine, pale stools); 1/3 present w/ pain, severe pain c/f malignant spread to celiac axis
Tx: whipple
Mucinous cystic neoplasms
Mucin-producing tumors (mucin-producing columnar epithelium)
Lack communication with panc duct
Found in body/tail of pancreas
Risk of malignancy ranges from 10-50%
Tx: resection (2/2 malignant potential)
Rest of pancreas that remains is not at risk for developing MCNs so no need for long-term follow-up
Complications of pancreatic pseudocysts
Splenic vein thrombosis (d/t compression of splenic vein, needs EGD to assess for concurrent gastric or esophageal varices)
splenic artery PSA -> hemorrhage, possible rupture
Beger procedure
duodenum-preserving pancreatic head resection
panc head dissected to level of portal vein, cored out
leave thin rim of panc tissue abutting duodenum
reconstructed w/ 2 anastomoses:
1) RnY jejunal loop to panc tail (end to side anastomosis)
2) Jejunum to panc head (side to side anastomosis)
Used for patients w/ large inflammatory mass in panc head but no distal ductal dilation
Puestow procedure
longitudinal pancreaticojejunostomy
Done for pts w/ chronic pancreatitis and dilated panc duct >=7mm
Frey procedure
Core out head of panc, longitudinal dissection of panc duct toward tail, recon w/ RnY pancreaticojejunostomy
Done for smaller panc head masses with dilated distal duct >=7mm
Bern procedure
Modification of Beger procedure
No panc head resection, only 1 anastomosis - RnY jejunal loop to pancreas
Dilated duct with panc head mass
Frey procedure
Normal or small duct with panc head mass
Beger or Bern procedure
Dilated duct without head involvement
Puestow procedure
