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BTK Review 2023 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

What are the two most common causes of pancreatitis?

A

alcohol and gallstones

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2
Q

What is the terminology for fluid collections surrounding pancreatitis?

A

non-necrotizing:
- acute peri-pancreatic fluid collection
- pseudocyst if > 4 weeks
necrotizing:
- acute necrotic collection if < 4 weeks
- walled off necrosis if > 4 weeks

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3
Q

When are antibiotics indicated for pancreatitis? What antibiotic is used?

A
  • for necrotizing pancreatitis with signs of infection (fever, leukocytosis, FNA with positive cultures)
  • use imipenem
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4
Q

What is the step up approach to pancreatitis?

A
  • a strategy for the management of infected necrotizing pancreatitis
  • begins with supportive care, resuscitation, and nutrition
  • evolves to include perc drainage and antibiotics
  • then add drain upsizing
  • and finally add minimally invasive RP necrosectomy
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5
Q

How does chronic pancreatitis look on CT?

A

a fibrotic, atrophic, calcified gland

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6
Q

Describe the Puestow procedure.

A

longitudinal pancreaticojejunostomy

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7
Q

Describe the Beger procedure:

A

resection of the pancreatic head up to the wall of the duodenum with pancreaticojejunostomy

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8
Q

Describe the Frey procedure:

A

lateral longitudinal pancreaticojejunostomy with coring out of the pancreas head

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9
Q

Describe the following procedures:
- Puestow
- Beger
- Frey

A
  • Puestow: longitudinal PJ
  • Beger: resection of pancreatic head with PJ
  • Frey: core out the pancreatic head with longitudinal PJ
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10
Q

What is the correct operation for a patient with chronic pancreatitis and a dilated pancreatic duct?

A

Peustow procedure as long as the head is normal

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11
Q

What is the correct operation for a patient with chronic pancreatitis and head-dominant disease?

A

Frey procedure with or without duct dilatation

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12
Q

What is the correct operation for a patient with chronic pancreatitis and tail-dominant disease?

A

distal pancreatectomy

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13
Q

What is the correct operation of a patient with chronic pancreatitis and minimal change of the gland?

A

denervation with bilateral thoracoscopic splanchnicectomy

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14
Q

How are pancreatic pseudocysts managed?

A
  • most resolve spontaneously with three months of expectant management
  • consider intervention if >6cm or symptomatic
  • get an MRCP or ERCP prior to intervention because they are often associated with PD abnormality
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15
Q

What are the indications for intervention in someone with a pancreatic pseudocyst?

A

size > 6cm or symptomatic disease

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16
Q

What FNA finding is consistent with a mucinous cyst?

A

CEA > 192

17
Q

High amylase from a pancreatic cyst is suggestive of what diagnosis? What about CEA?

A
  • high amylase suggest pseudocyst or IPMN
  • high CEA (> 192) suggests a mucinous cyst
18
Q

How are serous cyst adenomas of the pancreas diagnosed and managed?

A
  • low CEA and low amylase on FNA
  • well-circumscribed with central stellate scar on imaging
  • resect only if symptomatic or growing
19
Q

How are mutinous cysts managed?

A
  • high CEA and low amylase on FNA
  • thick walled with internal septations on imaging
  • have malignant potential so all should be resected in fit patients
20
Q

Which has a higher risk of malignancy, main or branch duct IPMNs?

A

main duct IPMNs

21
Q

When should IMPNs be resected?

A
  • all MD-IPMNs should be resected
  • BD-IPMNs with any of the following: size > 3cm, thickened wall, non-enhancing mural nodules, lymphadenopathy, MPD > 1cm, abrupt cut off of MPD with distal atrophy, young patients with lesion > 2cm
22
Q

What are the indications for BD-IMPNs?

A
  • size greater than 3cm
  • size greater than 2cm in young patients
  • thick walls
  • mural nodules, usually non-enhancing
  • MPD > 1cm or MPD cutoff with distal atrophy
23
Q

Where are pNETs most commonly found?

A

in the head of the pancreas

24
Q

What is the most common type of functional pNET?

A

insulinoma

25
Q

What is Whipple’s triad?

A
  • characteristic triad associated with insulinomas
  • fasting hypoglycemia
  • neuroglycopenic symptoms (confusion, seizures, visual changes, LOC)
  • resolution of symptoms with glucose administration
26
Q

What labs are used to diagnose an insulinoma?

A
  • symptoms with plasma glucose less than 55
  • insulin level > 18
  • c-peptide level > 0.6
  • proinsulin level > 5
  • beta-hydroxybutyrate < 2.7
  • ## an increase in plasma glucose of at least 25 after glucagon administration
27
Q

How is an insulinoma localized?

A
  • start with triaphasic CT or MRI
  • second line is EUS
  • third line is selective intra-arterial calcium injection with hepatic venous sampling for insulin
28
Q

Are insulinomas usually benign or malignant?

A

most are benign

29
Q

Are gastrinomas usually benign or malignant?

A

usually malignant

30
Q

What is the gastronome triangle?

A

created by the following points:
- cystic duct and CBD junction
- junction of the 2nd and 3rd portions of the duodenum
- junction of the neck and body of the pancreas

31
Q

What is the classic triad for gastrinomas?

A
  • abdominal pain
  • diarrhea
  • weight loss
32
Q

How is a gastrinoma diagnosed and localized?

A
  • fasting gastrin level > 1000 is diagnostic
  • if < 1000, can perform a stimulation test (look for rise > 200 after secretin administration)
  • localize with CT, MRI, somatostatin receptor scintigraphy, EUS, or selective intra-arterial calcium injections with hepatic venous sampling for gastrin
  • if the above doesn’t localize, consider exploration (intra-op US, transduodenal palpation, intra-op EGD with transduodenal illumination, duodenotomy)
33
Q

How are gastrinomas treated?

A
  • tumors in the duodenal mucosa can be enucleated with a periduodenal lymphadenectomy
  • non-invasive tumors less than 5cm in the head of the pancreas can be enucleated with periduodenal lymphadenectomy
  • larger tumors should undergo whipple
  • distal lesions should undergo distal pancreatectomy
34
Q

Look at glucagonomas

A
35
Q

Look at somatostatinomas

A
36
Q

Look at VIPomas

A

BTK Review 2023 (18 decks)

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