Pancreas

Question 1

What is the most effective dose of pancreatic enzyme replacement for pancreatic insufficiency?

Answer 1

A starting dose of 40,000 to 50,000 USP units of lipase is recommended with dose increase up to 90,000 USP units of lipase based on response to treatment.

Question 2

What is the differential for obstructive jaundice?

Answer 2

pancreatic cancer
-elevated IgG4
-atrophic pancreas
-dilated ducts

autoimmune pancreatitis
-elevated IgG4
-sausage-like pancreatic tissue with rim like hypoenhanement
-narrow bile ducts without marked upstream dilation

Question 3

What are the features of autoimmune pancreatitis?
histology
imaging
serology

Answer 3

histology- lymphoproliferative infiltrate

imaging- pancreatic lesion with rim hypoenhancement, diffusely enlarged pancreas, can have biliary stricture

serology- elevated IgG4 >2x ULN, can also have elevated CA 19-9

Question 4

What are the differences between AIP type 1 and type 2. Which is more likely to relapse?

Answer 4

Type 1- typically presents with painless jaundics, IgG4 related, associated with systemic disease (salivary gland, secondary sclerosing cholangitis, RP, lungs), high risk of relapse so may need maintenance, can use 1. pred or 2. rituximab

Tyle 2- typically presents with pancreatitis, low IgG4 levels, no systemic involvement, associated with iBD, low risk of relapse once treated

Question 5

Answer 5

Autoimmune pancreatitis

diffusely enlarged pancreas, can also have areas of rim enhancement

can’t distinguish between type 1 or type 2 based on radiologic imaging alone

Question 6

What are the features of chronic pancreatitis on EUS?

Answer 6

(Minimal standard terminology- MST)
lobularity
cysts
hyperechoic foci and strands
calcification of the duct
main PD dilation or irregularity
visible side-branches

Question 7

What are the most common meds associated with acute pancreatitis?

Answer 7

AZA, 6-MP, ACE-I, valproate, lasix, cimetidine, estrogens, tetracycline, HCTZ, salicylates, metronidazole

Question 8

Atlanta criteria

Answer 8

<4 weeks
acute peri-pancreatic fluid collection
acute necrotic collection

> 4 weeks
pseudocyst
WON

Question 9

What are the genetic causes of pancreatitis?

Answer 9

PRSS1- AD inheritance

The following mutations predispose to pancreatitis
CFTR mutation > SPINK-1 (AR inheritance)

Question 10

What are the diagnostic tests for pancreatic insufficiency?

Answer 10

fecal elastase <100, 72hr fecal fat >7g (while eating fat diet) - start with 40 to 50,000 U lipse/meal

fat soluble vitamin deficiencies

Question 11

What are the complications of CPI?

Answer 11

osteoporosis

pancreatic ascites (amylase >1000) Rx with TPN and octreotide

splenic thrombosis and IGV - if h/o bleeding then get splenectomy

Question 12

What is this and how is it managed?

Answer 12

Mucionus cystic neoplasm

CEA >200
low amylase
glucose <50
found in body and tail of pancreas

+malignant potential, surgical resection needed

Question 13

Answer 13

IPMN

CEA >200
high amylase because connected to ducts

Question 14

What are the worrisome features of an IPMN

Answer 14

-Main duct IPMN
-size >3cm
-enhancing mural nodule <5 = EUS, >5= surgery
-PD dilation >5 = EUS, >10 = -surgery
-growth >5mm/ 2 years

Question 15

Answer 15

Serous cyst adenoma

multiple microcysts with a central scar (honeycomb appearance)
low CEA, low amylase
low malignant potential, only remove if symptomatic

Question 16

Answer 16

Serous cyst adenoma
multiple microcysts with a central scar (honeycomb appearance)
low CEA, low amylase
low malignant potential, only remove if symptomatic

Question 17

Answer 17

Solid pseudopapillary neoplasm

young women
low cea and amylase
solid and cystic components
+malignancy, remove and annual surveillance

Question 18

How are cholesterol gallstones made?

Answer 18

supersaturation and nucleation grown
cholesterol crystal

Question 19

How are pigmented stones made?

Answer 19

precipitation
made from calcium bilirubinate
Black- unconjucated bili (i.e. hemolytic anemia, SC)
Brown= stasis or infection, often seen >2 years after cholecystectomy

Question 20

What are the indications for cholecystectomy?

Answer 20

-porcelain GB (GB wall calcifications)
-APBJ
-Polyp >8cm in PSC or >10cm in avg risk (follow with US q6-12 mo)
-use of somatostatin analog in pt with gallstones
-chronic salmonella

Question 21

What are the causes of bile leak after cholcystectomy?

Answer 21

cystic duct stump

ducts of luschka (from R IH ducts that connect directly with gb)

Question 22

What are the high risk and int risk criteria for choledocho?

Answer 22

HIGH RISK
-stone visualized
-cholangitis
-TB >4 and CBD >6 w/ GB or >8 w/o GB

INT RISK
-age >55
-abnormal LFTs
-CBD dilated

Question 23

how do you remove a CBD stone >1cm?

Answer 23

sphincterotomy and large balloon transpapillary dilation

Question 24

What is the rome criteria for sphincter of oddi dysfunction?

Answer 24

Need all 3
-biliary pain
-AST/ALT >3x ULN
-CBD>10
Perform sphincterotomy

suspected SOD
-biliary pain
-either increased LFTs or CBD dilation
controversial- ERCP +/- manometry

Question 25

What are the RF for shpincter of oddi dysfunction?

Answer 25

1. after cholecystecomy with ongoing biliary colic
2. recurrent idopathic pancreatitis
3. biliary pain in pt with GB intact and no gallstone (controversial)

Question 26

What is the typical presentation for choledochal cysts and what are they associated with?

Answer 26

jaundice, fever, pancreatitis, pain

associated with APBJ, cholangio, GB cancer, pancreatic cancer

Question 27

Describe the 5 types of choledochal cysts and how they are treated.

Answer 27

Type 3 can be treated with sphincterotomy, the rest need surgery

Question 28

What are the common causes of bile duct leak and how are they managed?

Answer 28

Large biloma needs PTC

post CCY- cystic duct stpump >ducts of lushka; Rx with plastic stent x 4 weeks, CHD injury = surgery

post OLT- plastic stent

trauma/liver injury

Question 29

How to manage hilar strictures?

Answer 29

Get MRI then EUS/FNA

don’t routinely stent with ERCP, just sent to surgery

Question 30

Answer 30

Type 3 choledochal cyst

Question 31

What is the most common GI manifestation in cystic fibrosis?

Answer 31

exocrine insufficiency

Question 32

What is a functional test for chronic pancreatitis?

Answer 32

Pancreatic function testing with secretin can assess pancreatic ductal function by measuring duodenal concentrations of bicarbonate after intravenous administration of secretin.

Question 33

pancreatic lesions in Von Hippel-Lindau disease

Answer 33

pancreatic abnormalities, with pancreatic cysts being the most common. These are most commonly serous cystadenomas and thus not at risk of malignant transformation.