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BTK Review 2024 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

How is pancreas divisum diagnosed and treated?

A
  • diagnose with MRCP and secretin
  • treat with ERCP and sphincteroplasty of the minor papilla
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2
Q

When should you consider intervention for a pancreatic pseudocyst?

A
  • most resolve spontaneously and can be managed expectantly
  • can consider intervention if > 6cm or if symptomatic
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3
Q

What is the difference between a pancreatic pseudocyst and walled-off necrosis?

A

pancreatic pseudocyst results from non-necrotizing pancreatitis

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4
Q

When should necrotizing pancreatitis be treated with steroids? What is the agent of choice?

A
  • only for signs of infectoin (gas in collection, fever, WBC)
  • prefer to use imipenem
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5
Q

Describe the step up approach to necrotizing pancreatitis.

A
  • start with supportive care
  • can add antibiotics and perc drainage if necessary
  • can then upsize drain
  • would then consider video-assisted RP debridement
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6
Q

How do we define a post-operative pancreatic fistula?

A

when fluid has an amylase > 3 times serum

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7
Q

How are pancreatic fistulas classified?

A
  • 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
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8
Q

What should you check to look for autoimmune pancreatitis?

A

IgG4

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9
Q

What are the non-operative management principles of chronic pancreatitis?

A
  • pain control
  • nutritional optimization
  • EtOH avoidance
  • pancreatic enzyme replacement
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10
Q

Describe a Puestow procedure. When should it be used?

A
  • longitudinal pancreaticojejunostomy
  • use for dilated pancreatic duct (>6mm) with normal pancreatic head
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11
Q

Describe a Frey procedure. When should it be used?

A
  • excavation of the pancreatic head with lateral longitudinal pancreaticojejunostomy
  • use for those with disease primarily in pancreatic head with duct dilatation
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12
Q

Describe the Beger procedure. When should it be used?

A
  • 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
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13
Q

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

A
  • 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
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14
Q

How should you managed minimal change chronic pancreatitis (small duct chronic pancreatitis)?

A
  • resection and drainage procedures aren’t options
  • denervation operation
  • or total pancreatectomy with islet autotransplantation
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15
Q

How should CEA be interpreted for those with a pancreatic cyst?

A

CEA > 192 indicates a mucinous cyst

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16
Q

How should amylase be interpreted for those with a pancreatic cyst?

A

high amylase means its in communication with the pancreatic duct

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17
Q

What are the CEA and amylase for a serous cystadenoma of the pancreas?

A

low for both

18
Q

What are the CEA and amylase for an IPMN?

A

both are elevated

19
Q

What are teh CEA and amylase for a mucinous cystic neoplasm of the pancreas?

A
  • CEA is elevated
  • amylase is low
20
Q

How should serous cystadenomas of the pancreas be managed?

A

resect if symptomatic, >4cm, or growing on surveillance

21
Q

How should mucinous cystic neoplasms of the pancreas be managed?

A

resect all given their malignant potential

22
Q

“patulous fish mouth with mucin secretions from the ampulla” is a pathognomonic endoscopic finding for those with what pancreatic disease?

A

a main duct IPMN

23
Q

How should IPMNs be managed?

A
  • resect main duct and mixed IPMNs
  • less clear cut for branch duct IPMNs which can sometimes be watched
24
Q

What are high risk features of branch duct IPMNs? Moderate risk?

A

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

25
Q

Are pancreatic neuroendocrine tumors usually function or not?

A

they are usually non-functional

26
Q

Where are the various PNETs usually found in the pancreatic parenchyma?

A
  • head: insulinoma or somatostatinoma
  • body: insulinoma, VIPoma
  • tail: insulinoma, VIPoma, glucagonoma
27
Q

How should PNETs be managed?

A

those with locoregional disease should undergo resection given a significant portion are malignant

28
Q

What are the most common functional PNET?

A

insulinoma

29
Q

Describe the symptoms, workup, and management of insulinomas.

A
  • 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
30
Q

Where is the gastrinoma triangle?

A
  • junction of cystic duct and CBD
  • junction of neck and body of pancreas
  • junction of 2nd/3rd portions of duodenum
31
Q

Describe the symptoms, workup, localization, and management of gastrinomas.

A
  • 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

32
Q

Describe the symptoms, workup, localization, and management of glucagonomas.

A
  • 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
33
Q

Describe the symptoms of a somatostatinoma.

A

cholecystitis, DM, malabsorption, and steatorrhea

34
Q

What are the symptoms of VIPoma?

A

WDHA syndrome
- watery diarrhea
- hypokalemia
- achlorhydria

35
Q

What is the most common pancreatic tumor?

A

non-functional PNET

36
Q

Which pancreatic adenocarcinomas are borderline resectable?

A

<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

37
Q

Which pancreatic adenocarcinoma patients are candidates for neoadjuvant and adjuvant therapy?

A
  • neoadjuvant: borderline resectable disease
  • adjuvant: consider for all patients
38
Q

Patient with history of multiple episodes of pancreatitis is now presenting with hematemesis what is the diagnosis and management?

A

gastric varices from splenic vein thrombosis, treat with splenectomy

39
Q

What is the medical management of functional neuroendocrine tumors of the pancreas while awaiting resection?

A

octreotide works for all but insulinoma

40
Q

What gene mutation is most common for those with hereditary pancreatitis?

A

PRSS1

41
Q

What somatic mutations are associated with pancreatic adenocarcinoma?

A

KRAS and TP53

42
Q
A

BTK Review 2024 (19 decks)

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