Pancreas

Question 1

Characteristics of cystic lesions of pancreas

Answer 1

Pseudocyst: F=M, anywhere in panc, communicates w/ ducts, neg mucin, high amylase, low CEA, lacks epithelial lining

Serous cystic neoplasm: F&raquo_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&raquo_space;>M (10:1), body & tail&raquo_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.

Question 2

High risk features of IPMNs in pancreas

Answer 2

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.

Question 3

Postop complications of pancreatic transplantation

Answer 3

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

Question 4

Hereditary Chronic pancreatitis

Answer 4

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)

Question 5

Pancreatic pseudocyst

Answer 5

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

Question 6

Pancreas divisum

Answer 6

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

Question 7

Severe acute pancreatitis

Answer 7

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)

Question 8

Somatostatinoma

Answer 8

Rarest of PNETs
Sxs: steatorrhea, dm, hypochlorydria, cholelithiasis
Dx: Fasting plasma somatostatin >100

Question 9

Insulinemia

Answer 9

Dx: serum glucose <50, Whipple’s triad

Question 10

Gastrinoma

Answer 10

Dx: serum gastrin >200 (>1000 in hyperacidity, ulcer dz)

Question 11

Glucagonoma

Answer 11

Dx: elevated fasting serum glucagon; secretin stim test to differentiate b/w gastronome/antral G-cell hyperplasia or hyperfunction

Question 12

Chronic pancreatitis

Answer 12

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)

Question 13

Resectability of pancreatic tumors

Answer 13

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

Question 14

Periampullary cancer

Answer 14

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

Question 15

Mucinous cystic neoplasms

Answer 15

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

Question 16

Complications of pancreatic pseudocysts

Answer 16

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

Question 17

Beger procedure

Answer 17

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

Question 18

Puestow procedure

Answer 18

longitudinal pancreaticojejunostomy

Done for pts w/ chronic pancreatitis and dilated panc duct >=7mm

Question 19

Frey procedure

Answer 19

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

Question 20

Bern procedure

Answer 20

Modification of Beger procedure

No panc head resection, only 1 anastomosis - RnY jejunal loop to pancreas

Question 21

Dilated duct with panc head mass

Answer 21

Frey procedure

Question 22

Normal or small duct with panc head mass

Answer 22

Beger or Bern procedure

Question 23

Dilated duct without head involvement

Answer 23

Puestow procedure