Pancreas Flashcards
How is pancreas divisum diagnosed and treated?
- diagnose with MRCP and secretin
- treat with ERCP and sphincteroplasty of the minor papilla
When should you consider intervention for a pancreatic pseudocyst?
- most resolve spontaneously and can be managed expectantly
- can consider intervention if > 6cm or if symptomatic
What is the difference between a pancreatic pseudocyst and walled-off necrosis?
pancreatic pseudocyst results from non-necrotizing pancreatitis
When should necrotizing pancreatitis be treated with steroids? What is the agent of choice?
- only for signs of infectoin (gas in collection, fever, WBC)
- prefer to use imipenem
Describe the step up approach to necrotizing pancreatitis.
- start with supportive care
- can add antibiotics and perc drainage if necessary
- can then upsize drain
- would then consider video-assisted RP debridement
How do we define a post-operative pancreatic fistula?
when fluid has an amylase > 3 times serum
How are pancreatic fistulas classified?
- defined as fluid amylase > 3x serum
- biochemical leak
- grade B: persistent drainage x3 weeks requiring non-operative intervention
- grade C: leak requiring reoperation or with development of sepsis, organ failure, or death
What should you check to look for autoimmune pancreatitis?
IgG4
What are the non-operative management principles of chronic pancreatitis?
- pain control
- nutritional optimization
- EtOH avoidance
- pancreatic enzyme replacement
Describe a Puestow procedure. When should it be used?
- longitudinal pancreaticojejunostomy
- use for dilated pancreatic duct (>6mm) with normal pancreatic head
Describe a Frey procedure. When should it be used?
- excavation of the pancreatic head with lateral longitudinal pancreaticojejunostomy
- use for those with disease primarily in pancreatic head with duct dilatation
Describe the Beger procedure. When should it be used?
- resection of pancreatic head up to wall of duodenum with either end-to-end or side-to-side pancreaticojejunostomy
- use for those with disease primarily in the pancreatic head without duct dilatation
What surgery should you offer those with chronic pancreatitis with the following features:
- primarily head disease without duct dilatation
- primarily head disease with duct dilatation
- diffuse disease with duct dilatation
- duct stricture with normal head
- primarily head disease without duct dilatation: Beger
- primarily head disease with duct dilatation: Frey
- diffuse disease with duct dilatation: Puestow
- duct stricture with normal head: distal pancreatectomy
How should you managed minimal change chronic pancreatitis (small duct chronic pancreatitis)?
- resection and drainage procedures aren’t options
- denervation operation
- or total pancreatectomy with islet autotransplantation
How should CEA be interpreted for those with a pancreatic cyst?
CEA > 192 indicates a mucinous cyst
How should amylase be interpreted for those with a pancreatic cyst?
high amylase means its in communication with the pancreatic duct
What are the CEA and amylase for a serous cystadenoma of the pancreas?
low for both
What are the CEA and amylase for an IPMN?
both are elevated
What are teh CEA and amylase for a mucinous cystic neoplasm of the pancreas?
- CEA is elevated
- amylase is low
How should serous cystadenomas of the pancreas be managed?
resect if symptomatic, >4cm, or growing on surveillance
How should mucinous cystic neoplasms of the pancreas be managed?
resect all given their malignant potential
“patulous fish mouth with mucin secretions from the ampulla” is a pathognomonic endoscopic finding for those with what pancreatic disease?
a main duct IPMN
How should IPMNs be managed?
- resect main duct and mixed IPMNs
- less clear cut for branch duct IPMNs which can sometimes be watched
What are high risk features of branch duct IPMNs? Moderate risk?
high risk
- enhancing mural nodule > 5mm
- MPD > 10mm
- obstructive jaundice
moderate risk
- cyst > 3cm
- thickened/enhancing wall
- nodule < 5mm
- lymphadenopathy
- abrupt change in MPD size with atrophy of distal
- cyst growth > 5mm over 2 years
- acute pancreatitis
Are pancreatic neuroendocrine tumors usually function or not?
they are usually non-functional
Where are the various PNETs usually found in the pancreatic parenchyma?
- head: insulinoma or somatostatinoma
- body: insulinoma, VIPoma
- tail: insulinoma, VIPoma, glucagonoma
How should PNETs be managed?
those with locoregional disease should undergo resection given a significant portion are malignant
What are the most common functional PNET?
insulinoma
Describe the symptoms, workup, and management of insulinomas.
- present with fasting hypoglycemia, neuroglycopenic symptoms, and relief of symptoms with glucose
- should have elevated insulin and c-peptide and at least 25mg/dL increase in glucose after administration of glucagon
- localize with EUS/CT/MRI/selective intra-aterial calcium injection with hepatic venous sampling for insulin
- manage with formal resection, can consider enucleation if <2cm and more than 2mm from duct
Where is the gastrinoma triangle?
- junction of cystic duct and CBD
- junction of neck and body of pancreas
- junction of 2nd/3rd portions of duodenum
Describe the symptoms, workup, localization, and management of gastrinomas.
- presents with abdominal pain, diarrhea, and weight loss with multifocal PUD
- diagnose with fasting serum gastrin (>1000 diagnostic), can add secretin stim test if equivocal (>200 increase with secretin)
- localize with CT/MRI/EUS/somatostatin receptor scintigraphy, selective inrta-arterial calcium injection
management depends on location
- duodenal mucosa: enucleation
- noninvasive, <5cm in pancreatic head: enucleation
- invasive or >5cm in pancreatic head: whipple
- distal pancreas: distal pancreatectomy
Describe the symptoms, workup, localization, and management of glucagonomas.
- presents with dermatitis (necrolytic migratory erythema), diabetes, depression, and DVT (factor X-like antigen secretion)
- diagnose with fasting glucagon levels between 1000-5000
- localize with CT/MRI/somatostatin scintigraphy/selective aniogram/EUS
- manage with resection and lymphadenectomy and cholecystectomy
Describe the symptoms of a somatostatinoma.
cholecystitis, DM, malabsorption, and steatorrhea
What are the symptoms of VIPoma?
WDHA syndrome
- watery diarrhea
- hypokalemia
- achlorhydria
What is the most common pancreatic tumor?
non-functional PNET
Which pancreatic adenocarcinomas are borderline resectable?
<180 contact with SMA
<180 contact with celiac
contact of CHA without extension to bifurcation
>180 contact with or wall irregularity of PV/SMV but amenable to resection and reconstruction
Which pancreatic adenocarcinoma patients are candidates for neoadjuvant and adjuvant therapy?
- neoadjuvant: borderline resectable disease
- adjuvant: consider for all patients
Patient with history of multiple episodes of pancreatitis is now presenting with hematemesis what is the diagnosis and management?
gastric varices from splenic vein thrombosis, treat with splenectomy
What is the medical management of functional neuroendocrine tumors of the pancreas while awaiting resection?
octreotide works for all but insulinoma
What gene mutation is most common for those with hereditary pancreatitis?
PRSS1
What somatic mutations are associated with pancreatic adenocarcinoma?
KRAS and TP53
