Pancreas Flashcards
1
Q
where is the pancreas?
A
retroperitoneal
behind posterior peritoneal membrane at level of L2
2
Q
where does the head of the pancreas sit?
A
the duodenal C loop
3
Q
where does the neck of the pancreas sit
A
over the superior mesenteric vein
4
Q
where is the body of the pancreas?
A
left of the SMV
5
Q
where is the tail of the pancreas
A
the distal-most portion and abuts the splenic hilum
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
7
Q
main pancreatic duct
A
Duct of Wirsung
8
Q
lesser duct that drains the superior portion of the head through the lesser papilla
A
Duct of Santorini
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
10
Q
what blood supply goes to the body and tail of the pancreas
A
Celiac trunk to the splenic artery
11
Q
where do the veins of the pancreas drain?
A
portal vein
12
Q
likely responsible for high incidence of metastases with pancreatic cancer
A
abundant and diffuse lymphatic drainage of the pancreas
13
Q
what is 80-90% of the pancreatic mass?
A
exocrine Amylases Lipases proteases Secrete fluid and electrolytes and bicarbonate
14
Q
what are the endocrine portions of the pancreas
A
Islets of Langerhans - secretes hormones that control glucose homeostasis
15
Q
2 main causes of acute pancreatitis?
A
alcohol
gallstones
16
Q
what cells are injuired in acute pancreatitis
A
acinar cell injury
17
Q
____________ tends to have a higher mortality rate than alcoholic pancreatitis
A
biliary pancreatitis
18
Q
the beta cells of the pancreas secrete what?
A
insulin and amylin
19
Q
the delta cells of the pancreas secrete what?
A
somatostatin
20
Q
what is the Ddx for acute pancreatitis?
A
Acute cholecystitis Ascending cholangitis Perforated peptic ulcer Mesenteric ischemia Esophageal perforation MI
21
Q
what bite can cause acute pancreatitis?
A
scorpion bites
22
Q
what happens w/ amylase and lipase levels w/ pancreatitis?
A
will go up then back down
23
Q
location of acute pancreatitis pain
A
Epigastric. May radiate to back, LUQ or RUQ
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
25
associated symptoms w/ acute pancreatitis
N/V. Hematemesis or melena if severe
26
precipitating factors w/ acute pancreatitis
Large fatty meal if GS pancreatitis. Alcohol ingestion if EtOH pancreatitis
27
alleviating factors w/ acute pancreatitis?
sitting or standing
28
if acute pancreatitis is severe what 2 signs can you see?
grey turner's sign
| cullen's sign
29
blood around flank (pancreatitis)
grey turner's signs
30
what will the abdominal exam look like w/ acute pancreatitis
Upper abdominal tenderness with distention +/- guarding and rebound
31
blood around umbilicus (pancreatitis)
cullen's sign
32
if there a correlation w/ amylase and lipase levels w/ severity of acute pancreatitis
no
33
what will you often see on ABG w/ acute pancreatitis
metabolic acidiosis
34
What are the criteria for Ranson's for acute pancreatitis (on admission)
```
Age >55 years
WBC >16,000/µL
Blood glucose level >200 mg/dL
Serum LDH level >350 IU/L
AST level >250 IU/L
```
35
If the Ranson score is greater than what pancreatitis is likely?
equal to or greater than 3
36
what is the CT grade for a normal pancreas
Grade A
37
what grade on a CT scan is "Inflammation of pancreas or peipancreatic fat"
Grade C
38
grade of pancreas on CT with "Focal or diffuse gland enlargement"
Grade B
39
Grade on CT scan with "Single ill-defined collection or phlegmon"
Grade D
40
Grade of pancreatitis with "Two or more ill-defined collections or the presence of gas in or nearby the pancreas"
Grade E
41
what causes gas near or by the pancreas
gas forming bacteria
42
what are some signs w/ pancratitis on x-ray
sentienel loop
| cut off sign
43
what is the tx for mild pancreatitis
```
most will resolve on own
make NPO
IVF
Analgesics
NO ABX
```
44
if a patient has gallstone pancreatitis what should you do?
cholecystectomy same admission
| after pancreatitis resolves but before they go home
45
how do you determine if pancreatitis is resolved?
based on patient
pain better, no nausea
then you can start feeding them
46
complications that can occur w/ severe pancreatitis
```
shock
pulmonary failure
renal failure
GI bleed
MOS failure
```
47
for severe pancreatitis what do you need to monitor?
Folye catheter
Central venous catheter
PA catheter (fluid levels)
48
how do you tx severe pancreatitis?
agressive fluid resuscitation
| may need pharmacologic assistance
49
how do you monitor respiratory for severe pancreatitis
pulse ox
| ABG
50
what is one of the main causes of ARDS?
acute pancreatitis
51
when should you only give antibiotics for pancreatitis?
if you suspect infection
| don't prophylaxis
52
how can you determine infection w/ pancreatitis?
gas on CT scan
| CT guided fine needle aspiration to get a culture
53
tx for severe pancreatitis?
NGT and antiemetics for N/V prn
prophylaxis for gastritis and PUD
prophylaxis for DVT
Nasojejunal feeding past LOT (TPN is second choice)
54
when does infected pancreatitis occur?
2-3 weeks into pancreatitis
55
if pancreatic infection is confirmed what do you do?
necrosectomy- agressive surgical debridement to remove dead tissue (usually multiple OR trips)
drainage
ABX
56
A collection of pus adjacent to the pancreas without necrosis
pancreatic abscess
57
how do you tx a pancreatic abscess?
```
external drainage (CT guided) or operative drainage
ABX
```
58
a cyst has what?
epithelial cell wall
59
what is the most common complication of acute pancreatitis?
Peripancreatic fluid collections
60
do you treat most Peripancreatic fluid collections?
no they resolve spontaneously- if not they are a pseudocyst
61
what can a pancreatic pseudocyst cause?
May cause abdominal pain, N/V, early satiety, jaundice
62
how do you drain a non-communicated Pancreatic pseudocyst?
externally
63
how do you drain a communicated Pancreatic pseudocyst?
drained internally (can have it drain into stomach)
64
what is caused by chronic, irreversible inflammation that leads to fibrosis with calcification?
chronic pancreatitis
65
what will someone w/ chronic pancreatitits have?
Chronic abdominal pain and normal or mildly elevated pancreatic enzyme levels
66
when do endocrine and exocrine insufficiencies occur w/ chornic pancreatitis?
When 90% of gland is replaced with scar
67
what occur when endocrine and exocrine insufficiencies occur ?
DM and steatorrhea
68
most common cause of chronic pancreatitis?
excessive alcohol consumption
69
location of pain w/ chronic pancreatitis and character of pain
epigastric can radiate to back
| dull character
70
associated symptoms w/ chronic pancreatitis?
steatorrhea and weight loss
| DM
71
duration of pain w/ chronic pancreatitis?
Initially intermittent lasting hours to days
| Becomes constant and unrelenting
72
precipitating factors for chronic pancreatitis?
supine position
| food and ETOH
73
alleviating factors w/ chronic pancreatitis
leaning forward
74
in advanced chronic pancreatitis how will patients look?
decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition
75
what will the abdominal exam be like w/ chronic pancreatitis?
Upper abdominal tenderness
| Fullness or mass in epigastrium
76
what is seen on radiography w/ chronic pancreatitis?
Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases
77
if pain relieved w/ chronic pancreatitis?
rarely
78
what replacements do those w/ chronic pancreatitis need?
enzyme replacement
| insulin
79
how can you allieve pain w/ chronic pancreatitis?
Analgesics
| Celiac plexus blockade
80
what is endoscopic tx for chronic pancreatitis (rarely helps w/ pain)
Decompressing an obstructed pancreatic duct
81
procedure to drain the pancreatic duct
can only do w/ a dilated pancreatic duct
pain relief in 42%
pancreaticojejunostomy (Puestow procedure)
82
for unresectable pancreatic cancer what is the median survival?
6 months
83
risks for pancreatitic cancer
smoking and smokeless tobacco
long standing DM
chronic pancreatitis
84
what type are more pancreatitic cancer?
adenocaricoma
| 3/4 are in head or neck
85
most people with pancreatic cancer present how?
painless jaundice due to obstruction of common bile duct
86
what are associated symptoms w/ pancreatic cancer?
```
Significant weight loss
Anorexia
Malaise
Fatigue
Nausea
```
87
if someone presents w/ painless jaundice and signs of malnourishment?
pancreatic cancer
88
courvoisier's sign- will see on someone w/ pancreatic cancer
```
palpable gallbladder (non tender)
feels like a balloon
```
89
how will someone w/ advanced pancreatic cancer present?
Ascites, palpable abdominal mass, hepatomegaly, splenomegaly
Sister Mary Joseph nodule
Blumer’s shelf ()
Virchow’s node
90
Sister Mary Joseph nodule
nodule at belly button)
91
what is a Blumer’s shelf?
palpable ridge on rectal exam
92
what is virchow's node
(suprclavicular) node
93
what labs will be elevated with pancreatic cancer?
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
what does an US allow you to see w/ pancreatic cancer?
dilated ductal system
| needs to be followed up
95
mainstay for initial diagnostic modality for pancreatic cancer
CT
| may miss small tumors
96
Patient requires conscious sedation
Better than CT at detecting small tumors (in the right hands)
FNA
Can’t detect distant metastases
EUS
97
```
diagnostic for pancreatic cancer
More invasive
Can do brush cytology and forcep biopsy
Therapeutic palliation
Can’t detect distant metastases
```
ERCP
98
what can be used to stage pancreatic cancer that is a sx procdure?
Preoperative staging laparoscopy
99
surgical procedure of tumors at head of pancreas
Pancreaticoduodenectomy (Whipple procedure)
100
what is the dread complication of a whipple?
pancreatic leak
101
surgery for for tumor at the body or tail of the pancreas
distal pancreatectomy
102
after surgical resection for pancreatic cancer what is done?
chemo/ radiation
103
palliative treatment for pancreatic cancer?
```
narcotic analgesics
tricyclic antidepressants
antiemetics
celiac axis neurolysis
RT or chemo
```
104
palliative tx for jaundice w/ pancreatic cancer
endoscopic or percutaneous stent placement
| operative biliary decompression at time of operation for resectability assessment
105
for a duodenal obstruction w/ pancreatic cancer what can be done?
gastrojejunostomy
| endoscopic stenting of duodenal obstruction
106
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
Serous cystadenoma
107
is the serous cystadenoma multiloculated or not?
Multiloculated w/ clear and serous fluid
108
potentially lethal pancreatic neoplasm
contain at least a focal area of atypia
unilocaular w/ thick mucous
Mucinous cystadenoma or cystadenocarcinoma
109
how will mucinous cystadenoma or cystadenocarcinoma present?
abdominal pain or mass
110
what are the 2 other names for pancreatic endocrine tumors
Pancreatic islet cell tumors
| Pancreatic neuroendocrine neoplasms
111
how to dx a pancreatic endocrine tumor
CT or MRI
visceral angiography
endoscopic US
octreotide scan (nuclear medicine)
Transhepatic portal venous hormone sampling
Surgical exploration with intraoperative US
112
most common pancreatic endocrine tumor
insulinoma
113
what is the whipple triad w/ insulinoma
Symptoms of hypoglycemia during fasting
Documentation of hypoglycemia with serum glucose < 50 mg/dL
Relief of hypoglycemic symptoms with exogenous glucose
114
what must there be an absence of in the urine to diagnose insulinoma?
sulfonylurea in plasma and/or urine
| from exogenous insulin of DM meds
115
what labs are needed for a biochemica diagnosis of insulinoma
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
diagnosis for insulinoma
monitored fast checking serum insulin:glucose ratio q 4 – 6 hr
117
treament fo rinsulinoma
surgery
| debulk if there is metastatiic dz
118
what drugs can be used for non-surgical canidates w/ an insulinoma
Octreotide and diazoxide
119
what syndrome is caused by gastrinoma?
zollinger and ellison
120
where are gastrinomas found
found within the gastrinoma triangle
121
what diagnoses gastrinoma
Fasting gastrin level > 1000 pg/mL while gastric pH < 2
122
tx for non-surgical canidats for gastinoma
PPI
CT (mets and non-surgical canidates)
excision
123
how will people w/ gastrinoma present?
bad peptic ulcers
Severe esophagitis
Severe diarrhea
124
tx for gastinoma
surgical excision
125
how will someone w/ a glucagonoma present
Weight loss, diarrhea, stomatitis, necrolytic migratory erythema, DVT, psychiatric disorders, cachexia, anemia
126
diagnosis for glucagonoma
Elevated fasting serum glucagon levels (500 – 1000 pg/dL)
127
where are most glucagonomas?
body or tail
128
tx for glucagonoma
resection/debulking and octreotide (unresectable).
129
presents with WDHA (watery diarrhea, hypokalemia and achlorhydria)
will ahve meatbolic acidosis
VIPoma (Verner-Morrison syndrome)
130
Seen in Pancreas, ampulla, duodenum, jejunum, cystic duct or rectum
Present w/ Steatorrhea, diabetes, hypochlorhydria and cholelethiasis
somatostatinoma
131
diagnosis for stomatostatinoma
Diagnosis with fasting serum somatostatin levels (>160 pg/mL) and imaging as above
132
where are most stomatostatinomas located?
head of pancreas
133
is surgery for cure common w/ stomatostatinomas?
No, often have debulking
