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Pancreas Flashcards

1
Q

What two ducts drain the pancreas?

A

Duct of Wirsung—> ventral pancreatic duct—-> drains into major papilla (major drainage of pancreas)

Duct of Santorini—> dorsal pancreatic duct—-> drains directly into duodenum via minor papilla

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2
Q

What is pancreas divisum?

A

Dorsal/ventral pancreatic ducts fail to fuse

Majority of pancreas drained by duct of Santorini via minor papilla

Minor papilla can’t handle the influx of pancreatic juices; can get pancreatitis

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3
Q

Four types of islet cells of the endocrine pancreas?

A

A, B, D, F

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4
Q

What do B cells do?

A

Secrete insulin; comprise 70% of islet cell mass

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5
Q

What do A cells of endocrine pancreas make?

A

Glucagon

Make up 10% of islet cell mass

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6
Q

D cells of pancreas make what?

A

Somatostatin

Located throughout body and tail

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7
Q

F cells of pancreas make?

A

Pancreatic polypeptide

Located in uncinate process of pancreas

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8
Q

What does insulin and glucagon do?

A

Insulin; stores energy, promotes glucose entry into cells, inhibits glycogenolysis, prevents fatty acid breakdown, stimulates protein synthesis

Glucagon; increases blood glucose levels thru stimulation of fatty acid breakdown, glyocogenolysis and gluconeogenesis

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9
Q

Insulin promotes glucose intake into all cells except;

A

Hepatocytes
B cells of pancreas
Central nervous system

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10
Q

Grading of neuroendocrine tumors;

A
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11
Q

MEN1 syndrome;

A

Deletion in tumor suppressor gene menin

Chromosome 11q13

Inherited in AD fashion

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12
Q

MEN1 characterized by what?

A

PNET

Parathyroid hyperplasia

Pituitary adenomas

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13
Q

VHL dx?

A

VHL mutation

RCC + pheo + PNETs + CNS tumors, retina

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14
Q

Common genes mutated in PNETs?

A
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15
Q

If pancreatic neuroendocrine tumors cannot be localized using CT/MRI, what’s the next option?

A

EUS
90% sensitivity

Better than MRI/CT at detecting tumors <3 cm

EUS also allows for FNA for diagnosis

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16
Q

The abundance of somatostatin receptors on most PNETs make somatostatin receptor scintigraphy a good localization adjunct for most PNETs, except?

A

Insulinomas

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17
Q

Most PNETs require surgery/enucleation; what is the most common complication after surgery for PNETs?

A

Pancreatic fistula

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18
Q

PNETs tend to mets to what organ?

A

Liver

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19
Q

Most common functioning PNET?

A

Insulinoma

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20
Q

Whipples triad seen with insulinomas?

A

Neuroglycopenic symptoms consistent with hypoglycemia

Low serum glucose levels

Resolution of symptoms when glucose given

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21
Q

Where do we find insulinomas in the pancreas?

A

Evenly distributed throughout

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22
Q

Tx for insulinomas?

A

Surgery curative in 85-95% of cases

Most insulinomas are small and solitary

5% assc with MEN1 syndrome; tend to malignant and sporadic

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23
Q

Tx for insulinomas?

A

Enucleation is preferred

Should not be done if tumor is within 2 mm of main pancreatic duct

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24
Q

2nd most common functional PNET?

A

Gastrinomas

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25
Q

Where are 90% of gastrinomas found?

A
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26
Q

What do we see with gastrinomas (ZE syndrome)?

A

Acid hypersecretion
Refractory PUD

MC in duodenum, but jejunum can also be involved

Pt present with abdominal pain, some diarrhea

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27
Q

Pts with secretory diarrhea, refractory PUD, severe esophagitis?

A

Gastrinoma

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28
Q

Pts taking PPI and pts with pernicious anemias can have falsely elevated gastrin levels, what’s another test we can do?

A

Secretin stimulation test

Levels are obtained 2, 5, 10, 20 mins after secretin administered

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29
Q

Best predictor of survival with gastrinomas?

A

Liver mets NOT LN mets

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30
Q

VIPOmas?

A

Malignant

WDHA; watery diarrhea, hypokalemia, achlorhydria

Found in pancreatic body/tail

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31
Q

Tx for VIPOMAS?

A

Correct electrolyte derangements

Surgery warranted

Need formal resection in resectable dx; its malignant; need negative margins and lymphadenectomy

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32
Q

Glucagonomas?

A

Malignant

Found in body/tail

Presentation; 4 Ds; dermatitis, DVT, depression, diabetes

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33
Q

Characteristic rash seen in glucagonomas?

A

Necrolytic migrating erythema

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34
Q

Characteristic features of somatostatinonmas?

A

Steatorrhea
Diabetes
Hypochlorhydria
Gallstones

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35
Q

Where are somatostatinomas usually found?

A

Head of pancreas

Most are malignant

36
Q

Most common PNET seen in pts with MEN1 is?

A

Gastrinoma

Followed by insulinoma

37
Q

Pancreas divisum?

A

Dorsal and ventral pancreatic ducts don’t fuse during development

Ventral ducts drains with the biliary tree in the major papilla

Dorsal duct drains alone in the minor papilla

**most pancreatic secretions exit via the dorsal duct, if the dorsal duct is draining thru the minor papilla; you get back pressure leading to acute v chronic pancreatitis

38
Q

Annular pancreas?

A

Aberrant migration of ventral pancreatic bud

2nd portion of duodenum gets surrounded by pancreatic tissue

Assc w/: malrotation, cardiac issues, Down’s, intestinal atresia

39
Q

What enzyme activates trypsin in the duodenum?

A

Enterokinase

40
Q

What gene assc with development of chronic pancreatitis?

A

SPINK1

41
Q

MC complication after ERCP?

A

Acute pancreatitis

Seen in 5-10% of pts

42
Q

Most common cystic neoplasms of the pancreas?

A

MCN

43
Q

Histologically how do we define MCN?

A

Mucin rich cells with ovarian-like stroma

44
Q

Characteristics of mucinous cystic neoplasms?

A

Estrogen and progesterone positive

Common in women; usually 5th decade

Typically found in body and tail

45
Q

What do we see on CT with mutinous cystic neoplasms?

A

Solitary cyst, usually with septations, surrounded by rim of calcifications

46
Q

Fluid analysis of mucinous cystic neoplasms?

A

Mucin rich

Low amylase

High CEA

47
Q

Standard treatment for MCN?

A

Pancreatectomy

48
Q

What do we see on CT imaging with serous cystic neoplasms of the pancreas?

A

Sunburst appearance and central calcification

49
Q

Where do we find serous cystic neoplasms of the pancreas?

A

Head

50
Q

Treatment of serous cystic neoplasms?

A

Although considered benign, lesions >4 cm need resection with Pancreatectomy

51
Q

Fluid analysis of serous cystic neoplasms?

A

Low Mucin

High amylase (communicates with duct)

Low CEA

52
Q

Who gets serous cystic neoplasms?

A

F»M

60-70s

**(compared to MCN which is women in 50-60s)

53
Q

Three types of IPMNs:

A

Branched-duct IPMN

Main-duct IPMN

Mixed-IPMN

54
Q

Worrisome and high risk features of Branched-duct IPMN:

A
55
Q

What do we do with worrisome and high risk features of branched-duct IPMNs?

A

All worrisome features should have an EUS

All high risk features should have a resection

56
Q

Management of high risk vs worrisome features of branched-duct IPMNs;

A
57
Q
A

Main-duct IPMN showing patulous papilla

58
Q

Fluid analysis of IPMNs?

A

High amylase
High CEA
Positive for mucin

59
Q

What two gene mutations implicated in hereditary pancreatitis?

A

PRSS1- 80% of cases of hereditary pancreatitis

SPINK1 gene

60
Q

Peutz-Jeghers syndrome?

A

GI hamartomatous polyps
Pigmented mucocutaneous lesions

STK11 mutation

Also prone to breast, ovarian, testicular, lung Ca

Risk of pancreatic adenocarcinoma is >100x normal unaffected individuals

61
Q

Familial atypical mole and multiple melanoma syndrome predisposes to what?

A

> 40x increase in pancreatic adenocarcinoma

Gene mutation: CDKN2A

62
Q

Although Lynch syndrome commonly cause colon Ca due to mismatch repair genes, it also leads to an increased risk of pancreatic Ca:

A

Micro satellite instability

Genes involved; MLH1, MSH2, MSH6

63
Q

Atlanta classification of pancreatitis?

A
64
Q

Blummer’s shelf?

A

Pelvic drop mets from pancreatic ca

65
Q

Sister Mary Joseph nodules?

A

Periumbilical adenopathy seen in pancreatic Ca

66
Q

Beget procedure?

A

Duodenum preserving pancreatic head resection for pts with chronic pancreatitis with head dominant disease and lack of ductal dilated ion

Pancreatic head is dissected at level of portal vein and cored out, leaving a rim of tissue abutting the duodenum

This is reconstructed with a Roux-en-y jejunal loop to the pancreatic tail remnant and the pancreatic head

67
Q

Puestow procedure;

A

Longitudinal pancreaticojejunostomy
Usually done for chronic pancreatitis with duct dilation >7 mm

68
Q

Frey procedure;

A

Coring out pancreatic head with longitudinal dissection of pancreatic duct toward the tail followed by a Roux-en-y pancreaticojejunostomy

This is done for small masses of the head, with dilated ducts >7 mm

69
Q

Bern procedure;

A

Modification of Beger procedure; pancreas is not transected at level of portal vein (advantageous if there is significant inflammation)

A roux-en-y jejunal loop is brought up to the pancreas

70
Q

Glucagonomas typically form in the tail and body of pancreas, what’s the tx?

A

Distal Pancreatectomy (to the left of SMV/SMA) and splenectomy

Spleen is taken because they have malignant potential and are usually large

71
Q
A
72
Q

During resection of an IPMN, the resection margin shows low-grade dysplasia, what do we do next?

A
73
Q

When would we use the Frey procedure?

A

Chronic pancreatitis with heavily diseased pancreatic head and a dilated duct > 6-7 mm

74
Q

When is the Frey procedure indicated?

A

Indicated for chronic pancreatitis with a heavily diseased pancreatic head and a dilated duct >6-7 mm

75
Q

Puestow procedure;

A
76
Q

Treatment for peri-ampullary tumors?

A

Whipple

In most cases, the tumors are malignant, and Whipple indicated, in small number of cases transduodenal excision with 1-2 mm margins acceptable

77
Q

What gene mutation do we see with hereditary pancreatitis?

A

AD mutation in PRSS1 gene

78
Q

Most common congenital pancreatic anomaly?

A

Pancreas divisum (10% of population)

Secretin-enhanced MRCP is test of choice

79
Q

Annular pancreas?

A

Ventral bud does not rotate with the duodenum but envelops it

Neonates present with bilious emesis, distention, double bubble sign

Assc w/maternal polyhydramnios, down’s, atresias, imperforate anus

Tx: duodenoduodenostomy, gastrojejunostomy, duodenojejunostomy

80
Q

For metastatic pancreatic neuroendocrine tumors (like an insulinomas for example), what med can we use?

A

Everolimus—> mTOR inhibitor, has anti angiogenic and anti-tumor properties

81
Q

How do we diagnose suspected pancreas divisum? (12 y/o with recurrent pancreatitis).

A

Secretin-enhanced MRCP

82
Q

Checking for pancreas exocrine insufficiency;

A

Fecal elastase-1 levels are low

83
Q

What does secretin do?

A

Stimulates fluid and bicarbonate secretion from pancreas

84
Q

What does CCK do?

A

Stimulates pancreatic enzyme secretions

85
Q

Insulinomas:

A

<2 cm; enucleation

> 2 cm; Whipple or distal pancreatectomy

Unresectable insulinomas need medical therapy with diazoxide therapy

86
Q

How does diazoxide work with insulinomas?

A

Used for mets insulinomas where surgery not an option

Inhibits insulin release by opening ATP sensitive K channels

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