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*OldSurgery > Pancreas > Flashcards

Pancreas Flashcards

1
Q

where is the pancreas?

A

retroperitoneal

behind posterior peritoneal membrane at level of L2

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2
Q

where does the head of the pancreas sit?

A

the duodenal C loop

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3
Q

where does the neck of the pancreas sit

A

over the superior mesenteric vein

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4
Q

where is the body of the pancreas?

A

left of the SMV

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5
Q

where is the tail of the pancreas

A

the distal-most portion and abuts the splenic hilum

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6
Q

_____ descends in the posterior surface of the pancreatic head to join the main pancreatic duct at the ampulla of Vater which is surrounded by the sphincter of Oddi

A

CBD

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7
Q

main pancreatic duct

A

Duct of Wirsung

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8
Q

lesser duct that drains the superior portion of the head through the lesser papilla

A

Duct of Santorini

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9
Q

what supplies the arterial supply of the head of the pancreas

A

Celiac trunk to the hepatic artery to the GDA to the superior pancreaticoduodenal artery
SMA to the inferior pancreaticoduodenal artery

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10
Q

what blood supply goes to the body and tail of the pancreas

A

Celiac trunk to the splenic artery

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11
Q

where do the veins of the pancreas drain?

A

portal vein

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12
Q

likely responsible for high incidence of metastases with pancreatic cancer

A

abundant and diffuse lymphatic drainage of the pancreas

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13
Q

what is 80-90% of the pancreatic mass?

A 
exocrine 
Amylases
Lipases
proteases
Secrete fluid and electrolytes and bicarbonate
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14
Q

what are the endocrine portions of the pancreas

A

Islets of Langerhans - secretes hormones that control glucose homeostasis

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15
Q

2 main causes of acute pancreatitis?

A

alcohol

gallstones

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16
Q

what cells are injuired in acute pancreatitis

A

acinar cell injury

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17
Q

____________ tends to have a higher mortality rate than alcoholic pancreatitis

A

biliary pancreatitis

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18
Q

the beta cells of the pancreas secrete what?

A

insulin and amylin

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19
Q

the delta cells of the pancreas secrete what?

A

somatostatin

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20
Q

what is the Ddx for acute pancreatitis?

A 
Acute cholecystitis
Ascending cholangitis
Perforated peptic ulcer
Mesenteric ischemia
Esophageal perforation
MI
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21
Q

what bite can cause acute pancreatitis?

A

scorpion bites

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22
Q

what happens w/ amylase and lipase levels w/ pancreatitis?

A

will go up then back down

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23
Q

location of acute pancreatitis pain

A

Epigastric. May radiate to back, LUQ or RUQ

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24
Q

character of acute pancreatitis pain

A

Dull, boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until reaching a constant ache. Severity varies

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25
Q

associated symptoms w/ acute pancreatitis

A

N/V. Hematemesis or melena if severe

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26
Q

precipitating factors w/ acute pancreatitis

A

Large fatty meal if GS pancreatitis. Alcohol ingestion if EtOH pancreatitis

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27
Q

alleviating factors w/ acute pancreatitis?

A

sitting or standing

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28
Q

if acute pancreatitis is severe what 2 signs can you see?

A

grey turner’s sign

cullen’s sign

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29
Q

blood around flank (pancreatitis)

A

grey turner’s signs

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30
Q

what will the abdominal exam look like w/ acute pancreatitis

A

Upper abdominal tenderness with distention +/- guarding and rebound

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31
Q

blood around umbilicus (pancreatitis)

A

cullen’s sign

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32
Q

if there a correlation w/ amylase and lipase levels w/ severity of acute pancreatitis

A

no

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33
Q

what will you often see on ABG w/ acute pancreatitis

A

metabolic acidiosis

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34
Q

What are the criteria for Ranson’s for acute pancreatitis (on admission)

A 
Age		>55 years
WBC 	>16,000/µL
Blood glucose level  >200 mg/dL
Serum LDH level 	>350 IU/L
AST level 	>250 IU/L
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35
Q

If the Ranson score is greater than what pancreatitis is likely?

A

equal to or greater than 3

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36
Q

what is the CT grade for a normal pancreas

A

Grade A

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37
Q

what grade on a CT scan is “Inflammation of pancreas or peipancreatic fat”

A

Grade C

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38
Q

grade of pancreas on CT with “Focal or diffuse gland enlargement”

A

Grade B

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39
Q

Grade on CT scan with “Single ill-defined collection or phlegmon”

A

Grade D

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40
Q

Grade of pancreatitis with “Two or more ill-defined collections or the presence of gas in or nearby the pancreas”

A

Grade E

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41
Q

what causes gas near or by the pancreas

A

gas forming bacteria

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42
Q

what are some signs w/ pancratitis on x-ray

A

sentienel loop

cut off sign

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43
Q

what is the tx for mild pancreatitis

A 
most will resolve on own
make NPO
IVF
Analgesics
NO ABX
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44
Q

if a patient has gallstone pancreatitis what should you do?

A

cholecystectomy same admission

after pancreatitis resolves but before they go home

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45
Q

how do you determine if pancreatitis is resolved?

A

based on patient
pain better, no nausea
then you can start feeding them

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46
Q

complications that can occur w/ severe pancreatitis

A 
shock
pulmonary failure
renal failure
GI bleed
MOS failure
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47
Q

for severe pancreatitis what do you need to monitor?

A

Folye catheter
Central venous catheter
PA catheter (fluid levels)

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48
Q

how do you tx severe pancreatitis?

A

agressive fluid resuscitation

may need pharmacologic assistance

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49
Q

how do you monitor respiratory for severe pancreatitis

A

pulse ox

ABG

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50
Q

what is one of the main causes of ARDS?

A

acute pancreatitis

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51
Q

when should you only give antibiotics for pancreatitis?

A

if you suspect infection

don’t prophylaxis

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52
Q

how can you determine infection w/ pancreatitis?

A

gas on CT scan

CT guided fine needle aspiration to get a culture

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53
Q

tx for severe pancreatitis?

A

NGT and antiemetics for N/V prn
prophylaxis for gastritis and PUD
prophylaxis for DVT
Nasojejunal feeding past LOT (TPN is second choice)

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54
Q

when does infected pancreatitis occur?

A

2-3 weeks into pancreatitis

55
Q

if pancreatic infection is confirmed what do you do?

A

necrosectomy- agressive surgical debridement to remove dead tissue (usually multiple OR trips)
drainage
ABX

56
Q

A collection of pus adjacent to the pancreas without necrosis

A

pancreatic abscess

57
Q

how do you tx a pancreatic abscess?

A 
external drainage (CT guided) or operative drainage 
ABX
58
Q

a cyst has what?

A

epithelial cell wall

59
Q

what is the most common complication of acute pancreatitis?

A

Peripancreatic fluid collections

60
Q

do you treat most Peripancreatic fluid collections?

A

no they resolve spontaneously- if not they are a pseudocyst

61
Q

what can a pancreatic pseudocyst cause?

A

May cause abdominal pain, N/V, early satiety, jaundice

62
Q

how do you drain a non-communicated Pancreatic pseudocyst?

A

externally

63
Q

how do you drain a communicated Pancreatic pseudocyst?

A

drained internally (can have it drain into stomach)

64
Q

what is caused by chronic, irreversible inflammation that leads to fibrosis with calcification?

A

chronic pancreatitis

65
Q

what will someone w/ chronic pancreatitits have?

A

Chronic abdominal pain and normal or mildly elevated pancreatic enzyme levels

66
Q

when do endocrine and exocrine insufficiencies occur w/ chornic pancreatitis?

A

When 90% of gland is replaced with scar

67
Q

what occur when endocrine and exocrine insufficiencies occur ?

A

DM and steatorrhea

68
Q

most common cause of chronic pancreatitis?

A

excessive alcohol consumption

69
Q

location of pain w/ chronic pancreatitis and character of pain

A

epigastric can radiate to back

dull character

70
Q

associated symptoms w/ chronic pancreatitis?

A

steatorrhea and weight loss

DM

71
Q

duration of pain w/ chronic pancreatitis?

A

Initially intermittent lasting hours to days

Becomes constant and unrelenting

72
Q

precipitating factors for chronic pancreatitis?

A

supine position

food and ETOH

73
Q

alleviating factors w/ chronic pancreatitis

A

leaning forward

74
Q

in advanced chronic pancreatitis how will patients look?

A

decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition

75
Q

what will the abdominal exam be like w/ chronic pancreatitis?

A

Upper abdominal tenderness

Fullness or mass in epigastrium

76
Q

what is seen on radiography w/ chronic pancreatitis?

A

Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases

77
Q

if pain relieved w/ chronic pancreatitis?

A

rarely

78
Q

what replacements do those w/ chronic pancreatitis need?

A

enzyme replacement

insulin

79
Q

how can you allieve pain w/ chronic pancreatitis?

A

Analgesics

Celiac plexus blockade

80
Q

what is endoscopic tx for chronic pancreatitis (rarely helps w/ pain)

A

Decompressing an obstructed pancreatic duct

81
Q

procedure to drain the pancreatic duct
can only do w/ a dilated pancreatic duct
pain relief in 42%

A

pancreaticojejunostomy (Puestow procedure)

82
Q

for unresectable pancreatic cancer what is the median survival?

A

6 months

83
Q

risks for pancreatitic cancer

A

smoking and smokeless tobacco
long standing DM
chronic pancreatitis

84
Q

what type are more pancreatitic cancer?

A

adenocaricoma

3/4 are in head or neck

85
Q

most people with pancreatic cancer present how?

A

painless jaundice due to obstruction of common bile duct

86
Q

what are associated symptoms w/ pancreatic cancer?

A 
Significant weight loss
Anorexia
Malaise 
Fatigue
Nausea
87
Q

if someone presents w/ painless jaundice and signs of malnourishment?

A

pancreatic cancer

88
Q

courvoisier’s sign- will see on someone w/ pancreatic cancer

A 
palpable gallbladder (non tender)
feels like a balloon
89
Q

how will someone w/ advanced pancreatic cancer present?

A

Ascites, palpable abdominal mass, hepatomegaly, splenomegaly
Sister Mary Joseph nodule
Blumer’s shelf ()
Virchow’s node

90
Q

Sister Mary Joseph nodule

A

nodule at belly button)

91
Q

what is a Blumer’s shelf?

A

palpable ridge on rectal exam

92
Q

what is virchow’s node

A

(suprclavicular) node

93
Q

what labs will be elevated with pancreatic cancer?

A

Elevation of total and direct bilirubin, alk phos and g-GGT
Mild elevation of transaminases (low hundreds)
Preoperative CA19-9 levels may be of prognostic value with high levels indicating poorer outcome and less chance of being resectable
CEA elevated in 40 – 45%

94
Q

what does an US allow you to see w/ pancreatic cancer?

A

dilated ductal system

needs to be followed up

95
Q

mainstay for initial diagnostic modality for pancreatic cancer

A

CT

may miss small tumors

96
Q

Patient requires conscious sedation
Better than CT at detecting small tumors (in the right hands)
FNA
Can’t detect distant metastases

A

EUS

97
Q 
diagnostic for pancreatic cancer 
More invasive
Can do brush cytology and forcep biopsy
Therapeutic palliation
Can’t detect distant metastases
A

ERCP

98
Q

what can be used to stage pancreatic cancer that is a sx procdure?

A

Preoperative staging laparoscopy

99
Q

surgical procedure of tumors at head of pancreas

A

Pancreaticoduodenectomy (Whipple procedure)

100
Q

what is the dread complication of a whipple?

A

pancreatic leak

101
Q

surgery for for tumor at the body or tail of the pancreas

A

distal pancreatectomy

102
Q

after surgical resection for pancreatic cancer what is done?

A

chemo/ radiation

103
Q

palliative treatment for pancreatic cancer?

A 
narcotic analgesics
tricyclic antidepressants 
antiemetics
celiac axis neurolysis
RT  or chemo
104
Q

palliative tx for jaundice w/ pancreatic cancer

A

endoscopic or percutaneous stent placement

operative biliary decompression at time of operation for resectability assessment

105
Q

for a duodenal obstruction w/ pancreatic cancer what can be done?

A

gastrojejunostomy

endoscopic stenting of duodenal obstruction

106
Q

Usually large (avg 10cm) and well-circumscribed
Frequently at body or tail
Women > men, > 50yo
Abdominal mass or pain or incidental
Benign
Most removed for symptoms or to differentiate from other tumors

A

Serous cystadenoma

107
Q

is the serous cystadenoma multiloculated or not?

A

Multiloculated w/ clear and serous fluid

108
Q

potentially lethal pancreatic neoplasm
contain at least a focal area of atypia
unilocaular w/ thick mucous

A

Mucinous cystadenoma or cystadenocarcinoma

109
Q

how will mucinous cystadenoma or cystadenocarcinoma present?

A

abdominal pain or mass

110
Q

what are the 2 other names for pancreatic endocrine tumors

A

Pancreatic islet cell tumors

Pancreatic neuroendocrine neoplasms

111
Q

how to dx a pancreatic endocrine tumor

A

CT or MRI
visceral angiography
endoscopic US
octreotide scan (nuclear medicine)
Transhepatic portal venous hormone sampling
Surgical exploration with intraoperative US

112
Q

most common pancreatic endocrine tumor

A

insulinoma

113
Q

what is the whipple triad w/ insulinoma

A

Symptoms of hypoglycemia during fasting
Documentation of hypoglycemia with serum glucose < 50 mg/dL
Relief of hypoglycemic symptoms with exogenous glucose

114
Q

what must there be an absence of in the urine to diagnose insulinoma?

A

sulfonylurea in plasma and/or urine

from exogenous insulin of DM meds

115
Q

what labs are needed for a biochemica diagnosis of insulinoma

A

Blood glucose < 40 mg/dl
Concominent serum insulin ≥ 10 uU/L
C-peptide levels > 2.5 mg/dL
Serum proinsulin levels > 25% normal (nl < 2 ng/mL)

116
Q

diagnosis for insulinoma

A

monitored fast checking serum insulin:glucose ratio q 4 – 6 hr

117
Q

treament fo rinsulinoma

A

surgery

debulk if there is metastatiic dz

118
Q

what drugs can be used for non-surgical canidates w/ an insulinoma

A

Octreotide and diazoxide

119
Q

what syndrome is caused by gastrinoma?

A

zollinger and ellison

120
Q

where are gastrinomas found

A

found within the gastrinoma triangle

121
Q

what diagnoses gastrinoma

A

Fasting gastrin level > 1000 pg/mL while gastric pH < 2

122
Q

tx for non-surgical canidats for gastinoma

A

PPI
CT (mets and non-surgical canidates)
excision

123
Q

how will people w/ gastrinoma present?

A

bad peptic ulcers
Severe esophagitis
Severe diarrhea

124
Q

tx for gastinoma

A

surgical excision

125
Q

how will someone w/ a glucagonoma present

A

Weight loss, diarrhea, stomatitis, necrolytic migratory erythema, DVT, psychiatric disorders, cachexia, anemia

126
Q

diagnosis for glucagonoma

A

Elevated fasting serum glucagon levels (500 – 1000 pg/dL)

127
Q

where are most glucagonomas?

A

body or tail

128
Q

tx for glucagonoma

A

resection/debulking and octreotide (unresectable).

129
Q

presents with WDHA (watery diarrhea, hypokalemia and achlorhydria)
will ahve meatbolic acidosis

A

VIPoma (Verner-Morrison syndrome)

130
Q

Seen in Pancreas, ampulla, duodenum, jejunum, cystic duct or rectum
Present w/ Steatorrhea, diabetes, hypochlorhydria and cholelethiasis

A

somatostatinoma

131
Q

diagnosis for stomatostatinoma

A

Diagnosis with fasting serum somatostatin levels (>160 pg/mL) and imaging as above

132
Q

where are most stomatostatinomas located?

A

head of pancreas

133
Q

is surgery for cure common w/ stomatostatinomas?

A

No, often have debulking

*OldSurgery (22 decks)

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