pancreas Flashcards
From which embryological layer does the pancreas develop?
The pancreas develops from the foregut endoderm at the level of the duodenum.
What embryological buds form the pancreas?
The ventral bud and dorsal bud.
What does the ventral bud form in the pancreas?
It forms the uncinate process, inferior part of the head, and proximal part of the main pancreatic duct.
What does the dorsal bud form in the pancreas?
It forms the rest of the pancreas and rest of the pancreatic duct.
What is the most common congenital anomaly of the pancreas?
Pancreatic divisum.
What happens in pancreatic divisum?
The main pancreatic duct drains into the accessory duct, which is too small, causing the rest of the pancreas to drain into the minor papilla.
What condition may result from pancreatic divisum?
Chronic pancreatitis with acute or chronic episodes.
What is annular pancreas?
Malrotation of the ventral bud, resulting in a ring of pancreatic tissue encircling the duodenum.
What complication can annular pancreas cause?
Duodenal obstruction (differential diagnosis of duodenal atresia).
Is the pancreas intraperitoneal or retroperitoneal?
It is a retroperitoneal organ, except the tail, which is intraperitoneal (within the splenorenal ligament).
Where is the pancreas located anatomically?
Posterior to the stomach, between the duodenum (right) and the spleen (left).
What are the anatomical parts of the pancreas?
• Head & uncinate process (behind superior mesenteric vessels)
• Neck (overlies the superior mesenteric vessels)
• Body (overlies the superior mesenteric vessels)
• Tail (closely related to the spleen, contains many islets of Langerhans)
Where does the main pancreatic duct start and end?
It starts at the tail of the pancreas, runs through the parenchyma to the head, and merges with the bile duct to form the hepatopancreatic ampulla.
What does the accessory pancreatic duct drain?
It drains the uncinate process and inferior part of the head, opening into the minor duodenal papilla.
What is the hepatopancreatic ampulla?
A short, dilated channel where the main pancreatic duct and bile duct fuse, opening into the major duodenal papilla.
What is the arterial supply of the pancreas?
• Splenic artery (branch of celiac trunk)
• Anterior & posterior superior pancreatoduodenal arteries (from gastroduodenal artery)
• Anterior & posterior inferior pancreatoduodenal arteries (from superior mesenteric artery)
How is the pancreas drained venously?
Pancreatic veins drain into the splenic vein, which drains into the hepatic portal vein.
Name the endocrine functions of the pancreas.
• Insulin from beta cells
• Glucagon from alpha cells
• Somatostatin from delta cells
• Also secretes VIP (vasoactive intestinal peptide)
What are the exocrine enzymes produced by the pancreas?
Lipase, amylase, trypsin, and proteases
How are pancreatic exocrine enzymes activated?
They are secreted in an inactive form and activated by enterokinase in the duodenum.
What is the definition of acute pancreatitis?
It is auto-digestion of the pancreas due to premature activation of pancreatic enzymes.
What is the mnemonic for causes of acute pancreatitis?
“I GET SMASHED”
Name 5 common causes of acute pancreatitis.
• Idiopathic
• Gallstones blocking the ampulla of Vater (~40%)
• Ethanol (alcohol) abuse (~40%)
• Trauma (especially in children)
• Drugs (e.g., NRTIs, valproate)
What happens in the pathophysiology of acute pancreatitis?
–>Premature enzyme activation leads to:
• Auto-digestion of pancreatic tissue
• Fat necrosis from lipase activity
• Saponification (fat + calcium = hypocalcemia)
• Enzyme-mediated cytokine release, damaging vessels and tissues
What are key symptoms of acute pancreatitis?
• Severe epigastric pain radiating to the back
• Worsens when supine or after meals
• Relieved by sitting or leaning forward
• Nausea, vomiting, anorexia
What are important signs of acute pancreatitis on examination?
• Low-grade fever
• Epigastric tenderness, possibly with guarding
• Abdominal distention
• Absent bowel sounds
What signs suggest severe acute pancreatitis?
• Hypovolemic shock: tachycardia, tachypnea, hypotension
• SIRS (systemic inflammatory response syndrome): shock + fever
What are the hemorrhagic signs seen in pancreatitis?
• Cullen sign: periumbilical ecchymosis
• Grey-Turner sign: flank ecchymosis
• Fox sign: ecchymosis of the inguinal ligament
What are the extra-intestinal manifestations of acute pancreatitis?
• Uveitis
• Pleural effusion or ARDS
• Shock
What are 5 differential diagnoses (DDx) of acute pancreatitis?
- Perforated duodenal ulcer
- Acute mesenteric ischemia
- Cholangitis or cholecystitis
- Abdominal aortic aneurysm (AAA) rupture
- Inferior wall myocardial infarction (MI)
What does a CBC reveal in acute pancreatitis?
Leukocytosis and possibly low hemoglobin in hemorrhagic pancreatitis.
What are key points about amylase and lipase in pancreatitis?
• Both are elevated (>3× normal limit)
• Lipase is more specific, rises earlier, and lasts longer
• High amylase can also be seen in other conditions (e.g., perforated GI viscus, ectopic pregnancy, renal failure, DKA)
What electrolyte abnormalities are seen in acute pancreatitis?
Hypocalcemia, acidosis, and low magnesium (especially in alcohol-related cases)
Why is glucose measured in acute pancreatitis?
To assess for hyperglycemia or hypoglycemia.
What lab abnormalities may be found in renal and liver function tests in pancreatitis?
• High BUN due to hypovolemia (from renal function tests)
• Elevated AST (from liver function tests)
What is the significance of CRP in pancreatitis?
If CRP >150 mg/L after 48 hours, it indicates poor prognosis.
What are the imaging options and their roles in acute pancreatitis?
• Abdominal US: First choice for uncomplicated cases, good for detecting gallstones
• Supine & Erect AXR: Rule out perforation, show signs like sentinel loop or colon cut-off
• CT with contrast: Best for complicated/unstable cases, shows severity and complications (e.g., necrosis, fluid collection)
What are Ranson’s criteria used for in pancreatitis?
To predict severity and prognosis.
• >3: Needs ICU admission
• 0–2: <5% mortality
• 3–4: ~15% mortality
• 5–6: ~40% mortality
• >7: ~100% mortality
What are Ranson’s criteria at admission?
GA LAW (georgia law) pancreas doesnt mess w georgia law
• Glucose >200 mg/dL
• AST >250 IU/L
• LDH >350 IU/L
• Age >55
• WBC >16,000/mm³
Think A is before L so 250 before 350
What are Ranson’s criteria in the first 48 hours?
HOBBS
• Hypocalcemia
• Hematocrit drop >10%
• O2 sat <60 mmHg
• BUN increase >5 mg/dL
• Base deficit >4 mEq/L
• Fluid sequestration >6L
what is the eitology of hypocalcemina in pancreatitis
fat saponification. fat necrosis binds to calcium
what is the least common cause of acute pancreatitis
scorpion bite
what complication is associated with splenic vein thrombosis
gastric varices (tx splenectomy)
What is the main goal of bowel rest (NPO) in mild acute pancreatitis?
To rest the pancreas and reduce enzyme secretion. Oral feeding can be resumed within 24 hours in mild cases.
Which opioids are preferred for pain control in acute pancreatitis, and why?
Fentanyl and meperidine are preferred over morphine because they do not increase sphincter of Oddi pressure.
Why is aggressive IV fluid resuscitation important in acute pancreatitis?
correct severe intravascular volume depletion due to vomiting and third-spacing.
Which IV fluid is preferred in acute pancreatitis and why?
Lactated Ringer’s solution is preferred over normal saline, as saline can cause hyperchloremic metabolic acidosis, worsening pancreatic stimulation.
When are antibiotics indicated in acute pancreatitis?
Only in infected necrotizing pancreatitis or if >30% of pancreas is necrosed.
What is the recommended nutritional support in severe pancreatitis?
• Early enteral nutrition via nasojejunal tube within 72 hours
• If not tolerated, use supplemental parenteral nutrition
What is the approach to cholecystectomy in gallstone pancreatitis?
• In mild cases: done during same admission
• In severe cases: delayed as interval cholecystectomy (after ~6 weeks)
When is debridement surgery indicated in acute pancreatitis?
• Hemorrhagic pancreatitis
• Infected necrotizing pancreatitis (fever, unresolved symptoms, sepsis)
• Complicated pseudocysts (e.g., rupture, hemorrhage, infection, gastric outlet obstruction)
What is a pancreatic pseudocyst?
An encapsulated fluid collection (without epithelial lining) that forms weeks after acute pancreatitis or trauma.
What are common causes of pancreatic pseudocysts?
• Acute pancreatitis
• Chronic pancreatitis
• Trauma
What are the clinical features of pancreatic pseudocyst?
• Unresolved epigastric pain or mass
• Features of obstructive jaundice
• Features of gastric outlet obstruction
How is a pancreatic pseudocyst diagnosed?
With CT scan or ultrasound.
How are pancreatic pseudocysts managed based on size and symptoms?
• <5 cm: Observation only
• >5 cm or symptomatic: Drainage (percutaneous or surgical)
Why should you wait 6 weeks before draining a pseudocyst?
To allow the cyst wall to mature and strengthen for safer drainage.
What are complications of untreated pancreatic pseudocysts?
• Rupture, fistula, infection
• Gastric outlet obstruction
• Hemorrhage into cyst
• Pancreatic ascites
What are common causes of a pancreatic abscess?
Gram-negative organisms like E. coli, Klebsiella, and Proteus.
What are signs of a pancreatic abscess?
Persistent fever and epigastric mass.
How is a pancreatic abscess diagnosed and managed?
• Diagnosis: CT scan, fine needle aspiration for culture
• Management:
• IV broad-spectrum antibiotics (e.g., cephalosporins + metronidazole)
• CT/US-guided drainage or surgical drainage
What is sterile pancreatic necrosis and how is it managed?
• Non-infected necrosis (50% resolve spontaneously)
• Monitor; may need CT-guided aspiration if infection is suspected
What is infected pancreatic necrosis?
• Severe form leading to multiple organ failure in 50% of cases
• Requires surgical debridement and antibiotics
Name other systemic complications of acute pancreatitis.
• ARDS (from inflammatory mediators and trypsin)
• DIC (due to coagulation cascade activation)
• Pleural effusion
• Pancreatic ascites
