Pancreas

Question 1

What is the location of the pancreas uncinate process?

Answer 1

The pancreas uncinate process rests on the aorta, behind the SMA and SMV.

Question 2

What are the arterial supplies to the head of the pancreas?

Answer 2

The head is supplied by the superior pancreaticoduodenal artery (off GDA) and the inferior pancreaticoduodenal artery (off SMA).

Question 3

What arteries supply the body of the pancreas?

Answer 3

The body is supplied by the great, inferior, and caudal pancreatic arteries (off splenic artery).

Question 4

What arteries supply the tail of the pancreas?

Answer 4

The tail is supplied by the splenic dorsal arteries.

Question 5

What do ductal cells in the pancreas secrete?

Answer 5

Ductal cells secrete bicarbonate and have carbonic anhydrase. High flow leads to high bicarbonate and low chloride.

Question 6

What is the function of acinar cells in the pancreas?

Answer 6

Acinar cells (exocrine) secrete digestive enzymes.

Question 7

Which pancreatic enzyme is secreted in active form?

Answer 7

Amylase is the only pancreatic enzyme secreted in active form.

Question 8

What does the ventral pancreatic bud form?

Answer 8

The ventral pancreatic bud forms the uncinate and inferior portion of the head and contains the duct of Wirsung. Migrates posteriorly, to the right and clockwise to fuse with dorsal bud.

Question 9

What does the dorsal pancreatic bud form?

Answer 9

The dorsal pancreatic bud forms the body, tail, and superior portion of the head and has the duct of Santorini.

Question 10

What marks the transition from foregut to midgut?

Answer 10

The Sphincter of Oddi marks the transition of foregut to midgut, where celiac supply stops and SMA takes over.

Question 11

What is the most common diagnosis for annular pancreas?

Answer 11

Annular pancreas occurs with equal frequency in adults and children, with children most commonly diagnosed on prenatal US.
RF: Down’s syndrome. Tx: duodeno-jejunostomy. Pancreas not resected. If pancreatitis is the problem, ERCP and sphincteroplasty

Question 12

Pancreatic divisum

Answer 12

Pancreatic Divism: Most asymptomatic. Dx: MRCP is best to use first because less invasive, can also use ERCP. Minor papilla shows large duct of Santorini (Majority of pancreas is drained through duct of Santorini). Major papilla shows small duct of Wursung (Inferior portion of pancreatic head and uncinate drains through duct of Wursung).
- Tx: If symptomatic ERCP with sphincterotomy and stent placement in minor papilla (Santorini duct), open sphincteroplasty if fails

Question 13

What is the most common location for heterotopic pancreas?

Answer 13

The most common location of heterotopic pancreas is the duodenum.

Surgical resection if symptoms, otherwise no treatment

Question 14

What is Ranson’s Criteria used for?

Answer 14

Ranson’s Criteria with 3 or more points indicates severe pancreatitis, leading to ICU admission.

Question 15

Acute necrotic collection vs walled off necrosis vs pseudocyst

Answer 15

Acute necrotic collection - < 4 weeks
Walled off necrosis – takes 4 weeks to mature, has capsule, all have necrotic debris in collection = heterogenous, can be intra or extrapancreatic
Pseudocyst – takes 4 weeks to mature. Fluid collection is homogenous, no internal septa, usually extra pancreatic

-Antibiotics for necrotizing pancreatitis w signs of infection
-Clinical signs: fever, elevated WBC
-CT guided FNA with organisms
-Imipenem is antibiotic of choice

Question 16

Infected pancreatic necrosis, walled off collections or infected Pseudocyst

Answer 16

Infected pancreatic necrosis, walled off collections or infected Pseudocyst with no main duct disruptions
- Optimal timing for pancreatic intervention is >4 weeks after onset of pancreatitis
- Try to delay any intervention if possible unless you have positive gram stain on FNA or patient is getting unstable
- 1st step after failed medical management/more septic is: ALMOST ALWAYS START WITH drainage: CT guided retroperitoneal drain placement. Then wait 72 hours and can place more drains if more sick or collections are larger
- This can be followed by video assisted retroperitoneal debridement or endoscopic debridement (step up approach)
- Alternate first line therapy: endoscopic transmural drainage (needs to be 2 cm from stomach/duodenum)
- Otherwise percutaneous drains have fallen out of favor and endoscopic drainage is first choice and now preferred over drains
- Open debridement of the pancreas (last line) is only indicated for infected necrosis or abscess of pancreas, for which endoscopic measures have failed
RF for necrotizing pancreatitis: obesity

In necrotizing pancreatitis – enteral feeds decreased the rate of conversion to infected necrotizing pancreatitis

If you have a pancreatic pseudocyst and completely disrupted pancreatic duct  only real solution is surgery with lateral pancreaticojejunostomy

Prophylactic antibiotics should not be started if no signs of infection. If empiric antibiotics initiate: carapenem; or cefepime + metronidazole

Question 17

Pancreatic pseudocyst

Answer 17

Pancreatic pseudocyst FNA  No glycogen, no mucin, high amylase (>5000)
- EUS with FNA is only done if diagnosis of pseudocyst is not clear
- Patients who are symptomatic, have rapidly enlarging pseudocysts, or who have infected pseudocysts that do not improve with medical management endoscopic drainage through stomach or duodenum (NEED TO BE AT LEAST 2 CM AWAY or less)
- Open cyst gastrostomy – anterior gastrostomy  drain pseudocyst from posterior wall of stomach using linear stapler close anterior wall
- Cystduodenostomy  if near pancreatic head/duodenum
- Roux en y cystojejunostomy – if away from stomach and duodenum
- The only indication to place a percutaneous drain in a pseudocyst, is in an infected pseudocyst in a pt who cannot tolerated endoscopic or surgical intervention

Pseudocyst
-MC w chronic pancreatitis, than acute pancreatitis
-Resolve spontaneously; manage expectantly for at least 6 weeks (ideally 3mo). Also allows wall to mature. Consider intervention if >6cm or symptomatic.
-Need ERCP or MRCP prior to intervention
-Approaches: transpapillary endoscopic stenting, endoscopic transluminal drainage, open cystgastrostomy, laparoscopic cystgastrostomy

If you see “septations” in pancreatic cyst, this is a solid component concerning for malignancy NOT pseudocyst

Question 18

What is the characteristic finding in serous cystic neoplasms?

Answer 18

Serous Cystic Neoplasm (Serous Cystadenomas)
Benign
MC in pancreatic tail
MC women
No connection with pancreatic duct
Usually have numerous loculations
High in glycogen, low CEA
Present with abdominal pain, N/V, dyspepsia
CT: Shows:
- Classically will show a central scar (central calcification)
- Honeycomb pattern
Tx: Nothing, unless symptomatic or > 4 cm  resect

Question 19

What is the main characteristic of mucinous cystic neoplasms?

Answer 19

Mucinous Cystic Neoplasms
90% arise in body or tail
Female to male 9:1
Usually have single loculation
Premalignant lesions
Classically CT will show “peripheral egg-shell” = calcifications in the wall = diagnostic!!
Cyst FNA  low amylase, high CEA, KRAS positive, + mucin
Walls of the cyst contain “ovarian-type stroma” on path
THESE DO NOT COMMUINCATE WITH MAIN PANCREATIC DUCT  contrast to IPMN
ALL OF THESE Should be completely resected due to risk of CA
If found in distal pancreas  MC operation is laparoscopic spleen preserving distal pancreatectomy

Question 20

Intraductal papillary-mucinous neoplasm (IPMN)?

Answer 20

Intraductal papillary-mucinous neoplasm IPMN
-MRI is the preferred imaging
-Cyst FNA: High amylase, high CEA (> 200), KRAS positive, + Mucin
-On endoscopy the mucin will protrude through the ampulla and show a classic fish mouth appearance
-If main duct involved: chronic obstructive pancreatitis, pancreatic insufficiency (steatorrhea, diabetes, weight loss)

Main duct IPMN – 60% risk of malignancy
-Resection

Mixed type - very high risk of CA
-Resection

Branch duct IPMN – 25% malignancy
-Further imaging/EUS FNA vs straight to resection
-“High risk features” = straight to RESECTION: obstructive jaundice, enhancing solid component, main pancreatic duct > 1.0 cm
-“Worrisome features” (seen on MRI) = EUS WITH FNA; IPMN > 3 cm in size, thickened or enhancing cyst wall, non-enhancing mural nodule, main pancreatic duct dilation 0.5 cm – 0.9 cm, abrupt caliber change in the main pancreatic duct, symptoms (abdominal pain, pancreatitis)
-If any of these are found on EUS with FNA = RESECTION; mural nodules, thickened walls,+ Mucin, high CEA or + for KRAS

If the branch duct IPMN does not meet any of the above criteria  Follow up MRI/CT in 1 year

Question 21

Pancreatic fistula

Answer 21

Post-operative pancreatic fistula definition (all require amylase > 3 times upper limit of normal from drain)
- Biochemical leak – elevated amylase with no clinical implications  no change in vitals, no sepsis, no percutaneous/endoscopic drainage performed, < 3 weeks persistent drainage, no angiography performed for bleeding
- Grade B fistula – elevated amylase + any one of the above clinical implications
- Grade C fistula – elevated amylase + organ failure or reoperation or death
Management:
Any patient with abdominal fluid collection concerning for pancreatic leak and has symptoms requires a PC drain to be placed
1st start with if high output >400 cc then NPO and TPN. If low < 200 then okay to eat.
Octreotide (lowers pancreatic fistula output)
If it doesn’t resolve after 6-8 weeks  ERCP, sphincterotomy and stent placement
Need to wait at least 2-3 months before thinking of operating

Question 22

What is the treatment for pancreatic ascites and pleural effusion?

Answer 22

Caused by retroperitoneal leakage of pancreatic duct disruption or ruptured pseudocyst
Can occur after trauma
This is not a pancreatic pleural fistula
Majority close on their own
Dx: aspiration  high amylase and protein > 25
Tx: thoracentesis/paracentesis Then treat like fistula NPO, TPN, octreotide. ERCP with stent placement if that fails

Question 23

Chronic pancreatitis

Answer 23

Chronic pancreatitis – exocrine and endocrine function is decreased
Sx: Chronic pain, weight loss
Risk for pancreatic cancer with chronic pancreatitis
Tx and work up:
- Get CT if any abnormality found here  EUS with biopsy to rule out cancer
- If no mass seen on EUS, then do ERCP to look for strictures
- Tx: First line is diet modifications, DC alcohol. Analgesics and splanchnic nerve blocks
ERCP is the most sensitive test to Dx chronic pancreatitis
Surgical indications for chronic pancreatitis – (Only consider after all medical and endoscopic therapy have been maximized)
- Extreme pain, nutrition abnormalities, addiction to narcotics, biliary obstruction, can’t r/o CA

Question 24

Periampullary mass – 4 types of CA

Answer 24

Pancreatic ductal adenocarcinoma - #1 MC periampullary tumor
- 5YS 7%
Distal cholangiocarcinoma – 2nd MC periampullary tumor (10%)
- Cystic duct to ampulla, basically all of CBD
- 5YS 35%
Ampullary adenocarcinoma – 3rd MC periampullary tumor (8%)
- Ampulla of Vater
- 5YS 65%
Duodenal adenocarcinoma – 4th MC periampullary tumor 4%
- 5YS 50%
Tx: For resection, generally use pancreatic CA guidelines for contraindication etc

Question 25

Pancreatic ductal adenocarcinoma, pancreatic cancer

Answer 25

Lymphatic spread 1st
RF: # smoking, AGE (older), obesity, diabetes, family history of pancreatic CA, chronic pancreatitis, FAP, BRCA2, Peutz- Jegers,
Prognosis based on vascular and nodal invasion, and ability of R0 resection
KRAS2 – involved in 95% of pancreatic cancer. MC gene mutation.
BRCA2: associated with increased risk of pancreatic CA
CA 19-9: correlates with tumor burden. Higher level, higher tumor stage. If > 1000 then 95% chance it is unresectable.
- Used as marker to monitor response to therapy
Diagnosis:
- CT has 85% sensitivity to diagnose (best initial test),
- ERCP has 90% sensitivity (however should not be used routinely. Only for high suspicion and no mass on CT)
- PET is not recommended for staging
Chemo –
- Gemcitabine + Capecitabine 1st line
- FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) ONLY for highly functional patients. Actually has better survival when compared to gemcitabine
Adjuvant Chemotherapy: for ALL
If after obtained CT, vascular involvement is still not clear  Next step is EUS to check for resectability
Preoperative ERCP and stent placement for a patient with obstructive jaundice before a whipple increases risk of wound infection and pancreatic fistula. Should only be used in cholangitis or severe pruritus. Also dilated duct helps intra-op
If the patient presents with resectable tumor and has obstructive jaundice  next step is whipple not stent placement

Question 26

Palliative treatment of pancreatic CA

Answer 26

• Metal stents for biliary obstruction = longer patency rates.
• Plastic stents for biliary obstruction need to be exchanged q2-3 months, increased occlusion rates
• For GOO or duodenal obstruction – duodenal stent just as good as gastrojejunostomy. Endoscopic stents better if < 6 months life expectancy. > 6 months = gastroJ

Question 27

Pancreatic neuroendocrine tumors

Answer 27

2nd MC pancreatic tumor
20% associated with familial syndromes. Mostly sporadic
Most are non-functional
Biochemical workup must be done when found.
Workup:
- Obtain Chromogranin A level: elevated in 60% of functional and nonfunctional and Pancreatic polypeptide
- All need CT/MRI + a somatostatin localization study
- (CT can miss small tumors, especially duodenal gastrinoma)
- If above can’t find it, and especially for DUODENAL gastrinoma  EUS
- Can’t use somatostatin study for insulinoma
- Best imaging to localize: 68Ga somatostatin receptor positron emission tomography PET/PET-CT (DODATATE scan)
- However most hospitals don’t have it so use  octreotide scan
- All need EUS with FNA: Gives you information about whether its malignant AND if lymph nodes are involved

Question 28

Non-functional pancreatic neuroendocrine tumors

Answer 28

70% of PNET are non-functional
90% of non-functional tumors are malignant, and they are very aggressive. Most cases have metastatic disease when found
More indolent compared to adenocarcinoma
Tx:
- If < 2 cm, low grade, asymptomatic you can observe vs enucleation
- If > 2 cm, invasive, OR NODE POSITIVE  whipple or distal pancreatectomy with splenectomy. All need lymphadenectomy.
- Tumors that are small, not near pancreatic duct, and benign  Can enucleate
- OK to resect liver metastatic disease for cure

Question 29

Functional pancreatic neuroendocrine tumors

Answer 29

Functional pancreatic neuroendocrine tumors
30%
These are usually multifocal especially in MEN1
Octreotide for symptom palliation effective for all except somatostatinoma
MC in pancreatic head - gastrinoma and somatostatinoma

Non-functional > 2 cm, somatostatinoma, gastrinoma, VIPoma  all need formal resection with lymphadenectomy +/- splenectomy

Question 30

Insulinoma

Answer 30

Insulinoma – 90% benign. 99% found in pancreas. Evenly distributed in pancreas. MC to be solitary.
MC NET in pancreas
Sx: “Whipple Triad”= fasting hypoglycemia, neuroglycopenic sx (confusion, combativeness, seizures, visual changes, loss of consciousness), relief with glucose administration

Dx:
- Insulin to glucose ration > 0.3 after fasting
- High C peptide and insulin
- Fasting hypoglycemia <50 and fasting insulin > 24
- These are diagnostic
- Insulin to C-peptide ratio should be < 1.0 if it is more, than this is factitious
CT is the initial localization study
If above doesn’t localize then  MRI with DOTATE or endoscopic US
Octreotide scan does not work here for localization
Selective pancreatic arterial calcium stimulation with hepatic venous insulin sampling  BEST TEST to localize if can’t see on CT
- VERY INVASIVE, most likely you won’t use this
Treatment:
- <2 cm enucleate. > 2 cm formal resection (whipple or distal pancreatectomy)
Diazoxide – used preop to control hypoglycemia symptoms
Octreotide – also used preop to control symtpoms
Chemo: 5FU and streptazosin and debulking for recurrence or mets.

Question 31

Gastrinoma

Answer 31

70% found in the duodenum, 25% in pancreas
60% most are malignant and most commonly found in head of pancreas
Most are multifocal
75% sporadic 25% MENI

-Triad= abdominal pain, diarrhea, weight loss in the presence of PUD

Gastrinoma triangle (Passaro Triangle) – junction between cystic duct and CBD, Junction of neck and body of pancreas , 2nd and 3rd portion of duo
Will see prominent gastric folds
MC mets to liver (Strongest prognostic indicator)
Ulcers (MC proximal duodenum, can be found distally though) and DIARRHEA (even with fasting)
MC found in duodenum, MC 1st portion
All patients with suspected gastrinoma should be screened for MEN1
Work up: Genetic testing, gastrinoma level, CT abd, EUS, octreotide/DOTA scan
Dx (need both):
- 1st DC any PPI, H2 blocker
- Screening: 1st get fasting serum gastrin >100. If negative, excludes gastrinoma
- If positive, this is not diagnostic
- Confirming test: 24-hour stomach basal acid output > 15.
- Confirming test (MC used): Gastric pH <2 is consistent with gastrinoma. >3 excludes it
- Performed if above tests are unclear: Fasting Secretin test – Check gastrin before, at 5, 10, 15 minutes after secretin given
- Increase in gastrin > 120 above baseline = diagnostic.
Tx:
Medical: 1st give PPI
Surgical:
- If has MEN1, - Surgery usually not performed due to multifocality and metastatic disease spread
- Surgery only indicated here if gastrinoma is identifiable and > 2 cm
- Must do surgery for hyperparathyroidism 1st
- For sporadic cases – Perform surgery, if no evidence of metastatic disease
- Duodenal gastrinoma  resection with margins and lymphadenectomy
- 2nd portion  whipple
- Pancreatic gastrinoma – Mobilize pancreas, intra-op US, and palpation
- Neck/Body/tail distal pancreatectomy +/- splenectomy. Take peripancreatic nodes
- Head  enucleation if <2 cm. > 2 cm whipple. Both need periportal, peri-duodenal, perihepatic lymph node dissection
- Patients with liver mets can undergo surgery only if all of the tumor can be removed
Chemo: 5FU and streptazosin for malignant disease. Palliation is octreotide and PPI.
Mets disease and severe symptoms despite maximum medical tx  total gastrectomy. NO VAGOTOMY

Question 32

Glucagonoma

Answer 32

4 D’s - Diabetes, DVT, Depression, Dermatitis stomatitis, necrolytic migratory rash, anemia, weight loss
Most are malignant.
Most in distal pancreas
Dx: fasting glucagon level

Tx: whipple or distal pancreatectomy with splenectomy; removal of the body and tail of the pancrease to the left of the SMA and SMV. Do lymphadenectomy. Octreotide for symptoms, and zinc, amino acids and fatty acids for skin rash. Chemo same

Question 33

VIPoma

Answer 33

VIPoma (Verner-Morrison Syndrome)
Watery diarrhea with hypokalemia and achlorhydria (WDHA) or acidosis from diarrhea
Dx: exclude other causes of diarrhea and high VIP level
Most are malignant and distal pancreas.
Tx: resection. Octreotide for symptoms

Question 34

Somatostatinoma

Answer 34

Somatostatinoma – worst prognosis of all
Diabetes, gallstones, steatorrhea, hypochlorhydria
Most malignant, MC head, MC specific site in ampulla and periampullary area
Dx: fasting somatostatin level
Tx: cholecystectomy with resection. Chemo for malignant same

Question 35

Whipple performed for:

Answer 35

• Periampullary carcinoid
• Adenocarcinoma in 1st or 2nd portion of duodenum
• Neuroendocrine (gastrinoma, carcinoid, somatostatinoma), in 2nd portion of duodenum
• Distal cholangiocarcinoma (distal to cystic duct)
• Gastrinoma (sporadic) in 2nd portion of duodenum or > 2 cm in pancreatic head
• Pancreatic endocrine neoplasm (insulinoma) in head of pancreas > 2 cm
• Neuroendocrine (gastrinoma, carcinoid, somatostatinoma) > 2 cm in 2nd portion of duodenum

Whipple NOT performed for:
- Lymphoma in 1st or 2nd portion of duochemo-XRT
- Symptomatic duodenal diverticulitis in 2nd portion  if biliopancreatic sx:  ERCP, stent placement
- Crohn’s affecting duodenum  if stricture in 1st or if in 2nd portion  gastroJ with vagotomy

Question 36

Solid pseudopapillary epithelial neoplasm

Answer 36

• Occurs exclusively in young females
• Has some malignant potential
• Resect all of these

Question 37

Surgery for chronic pancreatitis:

Answer 37

Dilated pancreatic duct ≥ 6 mm = These patients NEED a procedure to drain the bile duct
* Peustow’s procedure: Roux en y Longitudinal pancreaticojejunostomy for diffusely dilated/strictured main pancreatic duct with no inflammation of pancreatic head
o Requires a minimum of 6 cm length of anastomosis to pancreatic duct
* Frey procedure (Peustow plus coring out head of pancreas), without transection of pancreatic neck): Duodenum preserving longitudinal Roux en y pancreaticojejunostomy with pancreatic head resection
o For isolated pancreatic head involvement and main duct dilation
o More commonly performed because technically easier to perform vs Beger
Non dilated pancreatic duct = These patients NEED resection, not drainage
* Beger procedure (duodenum preserving pancreatic head resection and Roux en y with two pancreaticojejunostomies using the same limb with pancreatic neck transection)
o for isolated pancreatic head involvement without ductal dilation
o Has more extensive vascular dissection of duodenum, can lead to duodenum necrosis

• Whipple - normal ducts, isolated pancreatic head, or salvage after other failed procedures
  o Worse quality of life when compared to pancreas preserving surgeries above
• Distal pancreatectomy - for normal ducts, but only distal gland affected
• Diabetes  long term complication after these surgeries
• Bilateral splanchnicectomy or celiac ganglionectomy  80% pain control
  Total pancreatectomy with auto islet transplantation for chronic pancreatitis, indicated for:
• Last resort
• Patients with small ducts and diffuse disease
• Minimal change chronic pancreatitis

Question 38

CBD stricture 2/2 to chronic pancreatitis:

Answer 38

CBD stricture 2/2 to chronic pancreatitis: Dx with MRCP. Do ERCP with brush biopsy if cannot rule out CA on MRCP. Tx: Choledocho-jejunostomy, NOT ERCP with stent

Question 39

Autoimmune pancreatitis

Answer 39

Autoimmune pancreatitis – pain, obstructive jaundice, Enlarged pancreas on imaging. Dx: Will see lymphocytes, elevated beta-globulin, and IgG-4. Tx: Steroids

Question 40

Pancreatic lymphoma

Answer 40

Pancreatic lymphoma
Will have B type symptoms, fevers, chills night sweats.
CT will show bulky lymphadenopathy!!!
Will not have weight loss, back pain, obstructive jaundice
Treatment: chemotherapy alone, cyclophosphamide, vincristine, Doxorubicin (Adriamycin), prednisone

Question 41

Secretin test

Answer 41

Pancreatic cancer - decreased volume, normal enzyme and bicarb
Chronic pancreatitis - Decreased bicarb, normal enzyme and volume
Zollinger-Ellison - Increased volume normal enzyme and bicarb
End stage pancreatitis - decreased everything
Malnutrition - decreased enzyme only

Question 42

Fecal fast test

Answer 42

<20 g of fecal fat is consistent with an intestinal etiology, whereas >20g of fecal fat is consistent with pancreatic insufficiency (after replacing enzymes)

Question 43

-Puestow Procedure vs Beger Procedure vs Frey procedure

Answer 43

-Puestow Procedure= Longitudinal pancreaticojejunostomy
-For dilated pancreatic duct (6mm or greater) would go with Peustow, so long as pancreatic head is normal
-Beger Procedure= Resection of pancreatic head up to wall of duodenum with either end to end or side to side pancreaticojejunostomy (Duodenum preserving pancreatic head resection)
-Frey Procedure= Lateral longitudinal pancreaticojejunostomy with an excavation of the pancreatic head (Core out head of pancreas but avoid pancreatic transection required of Beger procedure)
-If pancreatic head dominant disease with or without duct dilation= Frey procedure
-If distal pancreatic duct stricture with side branch changes and normal pancreatic head= distal pancreatectomy
-Minimal change pancreatitis- resection/ drainage will not help- denervation operation (bilateral thoracoscopic splanchnicectomy)

Question 44

Cystic neoplasms of pancreas

Answer 44

-MRCP better characterize duct anatomy (than abdominal CT)
-EUS allows for aspiration for cyst fluid analysis (CEA and Amylase)
-CEA >192 c/w mucinous cyst
-High amylase indicates ductal communication (pseudocyst or IPMN)

Question 45

Double duct sign on MRCP

Answer 45

simultaneous dilation of common bile duct/ billiard tree and pancreatic duct that suggests biliary obstruction; commonly associated with pancreatic head tumors, particularly periampullary tumors

Next step: ERCP for visualization of biliary tree & pancreatic ducts and bx/ brushings; can also place biliary stent

-Presents with…chronic alcohol use, abdominal pain, jaundice, unintentional weight loss, hepatomegaly, RUQ tenderness

Question 46

Pancreas cystic lesion flow chart

Answer 46

Question 47

Pancreatic unresectability

Answer 47

Any metastases, extension into the hepatoduodenal ligament, involvement of major arterial structures, inolvement of nodal or neural structures around the celiac or superior mesenteric artereries

Isolated involvement of the ssuperior mesenteric vein or portal vein can be resected in select patients

Question 48

Pancreas secretion physiologic control

Answer 48

-Cholecystokinin: pancreatic enzyme secretion
-Secretin: pancreatic fluid and bicarbonate secretion