Pancreas Flashcards
Is the pancreas intraparitoneal or retroperitoneal?
Retroperitoneal
The pancreas lies behind what membrane at what level?
Behind the posterior peritoneal membrane at the level of L2
Where is the head of the pancreas?
in the duodenal C loop
Where is the neck of the pancreas?
lies over the superior mesenteric vein
Where is the body of the pancreas?
left of the SMV
Where is the tail of the pancreas?
The tail is the distal-most portion and abuts the splenic hilum
Where is the CBD in relation to the pancreas?
CBD descends in the posterior surface of the pancreatic head
What duct does the CBD join and where?
the main pancreatic duct at the ampulla of Vater
What is the ampulla surrounded by?
The sphincter of Oddi
What is the Duct of Wirsung?
main pancreatic duct
What is the Duct of Santorini?
lesser duct that drains the superior portion of the head through the lesser papilla
What artery supplies the head of the pancreas?
- Celiac trunk to the hepatic artery to the GDA (Gastroduodenal artery) to the superior pancreaticoduodenal artery
- SMA (Superior mesenteric artery) to the inferior pancreaticoduodenal artery
What artery supplies the body and tail of the pancreas?
Celiac trunk to the splenic artery
Where does venous drainage from the pancreas empty?
portal vein
What percentage of the pancreas mass is exocrine?
80-90%
What do acinar cells do?
Secrete enzymes responsible for digestion
Secrete fluid and electrolytes and bicarbonate
What enzymes to acinar cells secrete?
Amylases
Lipases
proteases
What is the function of bicarb?
buffer
What is bicarbonates stimulus and when is it released?
secretin which is released due to low duodenal pH
What do the islets of Langerhans do?
secretes hormones that control glucose homeostasis
What do alpha cells secrete?
Glucagon
What do beta cells secrete?
Insulin and amylin
What do delta cells secrete?
Somatostatin
What do PP or F cells secrete?
Pancreatic polypeptide
What is the pathophys of pancreatitis?
An acute inflammatory process in which pancreatic enzymes autodigest the gland
Pancreatitis is a malfunction of what?
exocrine secretion
What process allows activation of pancreatic enzymes outside the pancreatic ducts and GI tract?
Acinar cell injury
What is the initiating event in acute pancreatitis?
anything that injures the acinar cell and impairs the secretion of zymogen granules, such as alcohol use, gallstones, and certain drugs
What is the overall mortality rate of patients with acute pancreatitis?
10-15%
Does biliary or alcoholic pancreatitis have a higher mortality rate?
Biliary>alcoholic
What percentage of biliary tract disease is caused by alcohol?
85%
What are other causes of pancreatitis?
Post-ERCP Drugs Tumors Trauma Hypertriglyceridemia Developmental abnormalities of the pancreas – pancreas divisum
What is on the ddx for acute pancreatitis?
Acute cholecystitis Ascending cholangitis Perforated peptic ulcer Mesenteric ischemia Esophageal perforation MI
How would acute cholecystitis present?
Gall stones, gallbladder wall thickening, pericholecystic fluid, nl amylase and lipase
How would ascending cholangitis present?
Jaundice, CBD dilation, nl amylase and lipase, Charcot’s triad, Reynold’s pentad
Perforated peptic ulcer
Free air
How would mesenteric ischemia present?
Thickened bowel wall, pneumatosis intestinalis
How would esophageal perforation present?
Air in mediastinum, pnuemothx, pleural effusion, nl amylase and lipase
How does an MI present?
Abnl cardiac nz’s and EKG, nl amylase and lipase
Where is pain located in acute pancreatitis?
Epigastric. May radiate to back, LUQ or RUQ
What are the characteristics of pain in acute pancreatitis?
Dull, boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until reaching a constant ache. Severity varies
What are the associated sx with acute pancreatitis?
N/V. Hematemesis or melena if severe
What are the precipitating factors of pancreatitis?
Large fatty meal if GS pancreatitis. Alcohol ingestion if EtOH pancreatitis
What are the alleviating factors for acute pancreatitis?
Sitting or standing
What is the general survey of acute pancreatitis?
Varies: Uncomfortable to motionless. NAD to toxic (pale, diaphoretic, and listless)
Respiratory distress if severe
Jaundice if GS pancreatitis
What will vitals show for acute pancreatitis?
Normal to fever, tachycardia, hypotension and hypoxic if severe
What will abdominal exam show for acute pancreatitis?
Upper abdominal tenderness with distention +/- guarding and rebound
Severe – Grey Turner’s sign or Cullen’s sign
What is the Grey Turner’s sign?
Bruising of the flank
What is the cullen’s sign
Bruising around umbilicus
What will labs show for acute pancreatitis?
CBC w/diff – leukocytosis with left shift
Amylase elevation ~ 2.5 x normal
Lipase elevation 5 x normal
The level of elevation not related to severity of disease
Elevated bili and alk phos if GS pancreatitis
ABGs if patient is dyspneic
What is part of Ranson’s Criteria 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
What is part of Ranson’s Criteria during first 48 hrs?
Hematocrit fall >10%
BUN level increase >5 mg/dL
Serum calcium level 4 mEq/L
Fluid sequestration >600 mL
What does a ranson’s score of >/= 3 indicate?
Severe pancreatitis likely
What does a Ranson’s score of <3 indicate?
Severe pancreatitis unlikely
What mortality is associated with a Ranson’s score of 0-2
2%
What mortality is associated with a Ranson’s score of 3-4?
15%
What mortality is associated with a Ranson’s score of 5-6?
40%
What mortality is associated with a Ranson’s score of 7-8?
100%
When should a CRP be drawn for pancreatitis?
24-48 hrs after presentation
What levels of CRP indicates severe pancreatitis?
> 6 mg/dL at 24 hour and > 7 mg/dL at 48 hours strongly indicates severe pancreatitis
What BUN level indicates severe pancreatitis?
Elevated BUN at admission
What is Grade A severity on CT?
Normal pancreas
What is Grade B severity on CT?
Focal or diffuse gland enlargement
What is Grade C severity on CT?
Inflammation of pancreas or peipancreatic fat
What is Grade D severity on CT?
Single ill-defined collection or phlegmon
What is Grade E severity on CT?
Two or more ill-defined collections or the presence of gas in or nearby the pancreas
What would CXR show for acute pancreatitis?
R/O free air. Pleural effusions, hemidiaphragm elevation
What would abd films show for acute pancreatitis?
ileus, sentinel loop, cutoff sign
What would CT show for acute pancreatitis?
pancreatic edema, peripancreatic fluid, necrosis of the gland
What would US show for acute pancreatitis?
gallstones, CBD enlargement
What is the treatment for acute pancreatitis that will spontaneously resolve?
NPO
IVF
Analgesics
No ABX
If gallstone – cholecystectomy when pancreatitis resolves (same admission)
Resolution based on symptoms, not amylase and lipase levels
Feed as pain and tenderness resolve and WBC return to normal
What complications are associates with pancreatitis?
Shock, pulmonary failure, renal failure, GI bleed, MOS failure
When should a patient with acute pancreatitis be admitted to ICU?
CV issues
Respiratory issues
How are CV issues managed with acute pancreatitis?
Monitor CV status Foley catheter Central venous catheter PA catheter Treat with Aggressive fluid resuscitation May need pharmacologic assistance
How is respiratory status monitored?
Pulse ox
ABG
What is impairment of oxygenation caused by with acute pancreatitis?
Sympathetic pleural effusions
ARDs
Fluid overload
How are respiratory issues managed?
O2
May need intubation with aggressive vent settings
How should fluids be managed with acute pancreatitis?
NPO and require aggressive intravenous hydration
Initial several liter fluid bolus followed by 250-500 cc/h continuous infusion
What is the abx protocol for acute pancreatitis?
As prophylaxis against infection in severe acute pancreatitis is not recommended
Should be used in any case of pancreatitis complicated by infected pancreatic necrosis
What GI measures should be taken with a patient with AP?
NGT and antiemetics for nausea and emesis prn
Prophylaxis for gastritis and PUD
What is the nutrition protocol for AP?
Early initiation of enteral nutritional supplementation maintenance of a positive nitrogen balance nasojejunal feeding – past the LOT
TPN second choice
What surgery is indicated when the etiology is gallstones?
Cholecystectomy
What it the protocol for cholecystectomy for mild pancreatitis?
+/- ERCP for sphincterotomy and stone extraction pre-op
Cholecystectomy prior to d/c
What is the protocol for cholecystectomy for severe pancreatitis?
ERCP for sphincterotomy and stone extraction if stone impacted at ampulla of Vater
Cholecystectomy after recovery
What percentage of mortality is associated with infected pancreatic necrosis?
40%
At what point of acute pancreatitis does infected pancreatic necrosis occur?
2-3 weeks
What does worsening organ disfunction signify?
infected pancreatic necrosis
What will be on CT that signifies infected pancreatic necrosis?
Air on CT
What test is done if there is no air on CT but there is high suspicion of infected necrosis?
CT guided needle aspiration for C&S
What is done for an infected pancrease?
Necrostomy
Drainage
ABX
What is a necrosectomy?
aggressive surgical debridement to remove dead tissue and to clear the infection – usually requires multiple trips to the OR
What is a pancreatic abscess?
A collection of pus adjacent to the pancreas without necrosis
How is a pancreatic abscess treated?
External drainage (Operative or Percutaneous) ABX
What is the most common complication of acute pancreatitis?
Peripancreatic fluid collections
What causes peripancreatic fluid collections?
disruption of pancreatic duct
What is a persistent peripancreatic fluid collection called?
Pseudocyst
How are peripancreatic fluid collections treated?
Usually respond spontaneously
What is a pancreatic pseudocyst?
Collection of peripancreatic fluid that is walled into a cyst like structure
What is it called when the pseudocyst contacts the pancreatic duct and shares fluid?
Communicating
How long does it take for the wall of the pseudocyst to mature and therefore be treated surgically?
4-6 weeks
What are symptoms of pseudocyst?
May cause abdominal pain, N/V, early satiety, jaundice
What imaging is used for a pseudocyst?
CT
How are non-communicating pseudocysts drained?
externally
How are communicating pseudocysts drained?
Internally
What is the process of chronic pancreatitis?
Chronic, irreversible inflammation that leads to fibrosis with calcification
What are the sx for chronic pancreatitis?
Chronic abdominal pain and normal or mildly elevated pancreatic enzyme levels
How much of the pancreas must be replaced with scar tissue before exocrine insufficiencies occur?
90%
What occurs with endocrine and exocrine insufficiencies?
DM
Statorrhea
What is the most common cause of chronic pancreatitis?
Excessive alcohol consumption, 60% of all cases
What are other causes of chronic pancreatitis?
Obstruction of pancreatic juice Cystic fibrosis Hyperlipidemia Hypercalcemia medications
What is the location of pain in chronic pancreatitis?
Epigastric. May radiate to back
What are the characteristics of pain with chronic pancreatitis?
Dull
What symptoms are associated with chronic pancreatitis?
Steatorrhea and weight loss, DM
What is the duration of pain with chronic pancreatitis?
Initially intermittent lasting hours to days
Becomes constant and unrelenting
What are the precipitating factors of chronic pancreatitis?
Supine position
Food and EtOH
What are the alleviating factors of pancreatitis?
Leaning forward
What is seen in general survey for chronic pancreatitis?
Uncomfortable
Advanced disease - decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition
What will vitals show with chronic pancreatitis?
Normal
What will be found on abdominal exam with chronic pancreatitis?
Upper abdominal tenderness
Fullness or mass in epigastrium
What will labs show for chronic pancreatitis?
Serum amylase and lipase levels may be slightly elevated or not elevated at all
Pancreatic function tests
Glucose
What will show on abd radiography for chronic pancreatitis?
Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases
What provides the most accurate visualization of the pancreatic ductal system?
ERCP/MRCP
What imaging should be done for chronic pancreatitis and will diagnose most cases?
CT of abdomen
How is pain treated with chronic pancreatitis?
Rarely treated
What digestive therapy is given with chronic pancreatitis?
Pancreatic enzyme replacement
Insulin
How is abdominal pain alleviated with chronic pancreatitis?
Analgesics
Celiac plexus blockade
How is an obstructed pancreatic duct treated?
Endoscopic decompression
What is the Puestow procedure?
Pancreaticojejunostomy or pancreatic duct drainage
attach jejunum to pancreatic duct
What are the surgical treatments to relieve pain in chronic pancreatits?
Pancreaticojejnostomy (puestow)
Pancreatic resection
Sphincteroplasty
What percentage of pancreatic cancers will die?
98%
What is the median survival for unresectable pancreatic cancer
6 mo
What percentage diagnosed with pancreatic cancer are candidates for resection?
20%
What are risk factors for pancreatic cancer?
Black males in US Tobacco obesity red meats DM Hereditary Chronic pancreatitis
What is the most common type of pancreatic cancer?
Adenocarcinoma (90%)
Where do adenocarcinomas of the pancreas originate?
From ductal epithelium
What are the types of pancreatic cancers?
Adenocarcinoma Islet cell tumors Lymphomas Mucinous cystic neoplasms Metastatic lesions
What proportion of pancreatic cancers are in the head or neck?
3/4
What percentage of pancreatic cancers are in the body?
15-20%
What percentage of cancers are in the tail?
5-10%
How many pts have pain with pancreatic cancers at the head of the pancreas?
1/3 – no pain, 1/3 – mild pain, 1/3 severe pain
When does the patient experience pain with pancreatic cancer in the head of the pancreas?
Nighttime
What is the quality of pain with a patient with pancreatic cancer in the head of the pancreas?
Unrelenting, mid-epigastric, radiates to the mid- or lower back (what can radiating to the back signify)
What is a large indicator of pancreatic cancer?
Painless jaundice*****
What are associated sx with pancreatic cancer?
Significant weight loss Anorexia Malaise Fatigue Nausea
What is the duration of pain with pancreatic cancer?
Slow and progressive
What is the general survey for adenocarcinoma of the pancreas?
Thin/muscle wasting
Jaundiced
What does abdominal exam show for adenocarcinoma of the pancreas?
Courvoisier’s sign Ascites, palpable abdominal mass, hepatomegaly, splenomegaly Sister Mary Joseph nodule Blumer’s shelf Virchow’s node
What is Courvoiseier’s sign?
enlarged palpable gallbladder in patients with obstructive jaundice caused by tumors of biliary tree or pancreatic head tumors. This kind of biliary obstruction envolves slowly, then envolves dilated gallbladder with thin wall.
What is a Sister Mary Joseph nodule?
palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen
What is a blumers shelf?
inding felt in rectal examination that indicates that a tumor has metastasized to the Pouch of Douglas.
What is a virchows node?
lymph node in the left supraclavicular fossa (the area above the left clavicle)
What will labs show for adenocarcinoma of the pancrease?
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%
What does ultrasound (screening) show for pancreatic cancer?
Dilated ductal system
Can only detect 60 – 70% pancreatic lesions
What is the mainstay of diagnostic modality?
CT
What shows on CT for pancreatic cancer?
Small tumors can be missed
Can help direct FNA
90% accuracy to determine respectability
What is better than CT at detecting small tumors in the pancreas?
esophageal US
What can be done with an esophageal ultrasound with pancreatic cancer?
FNA
What is a disadvantage of esophageal US in pancreatic cancer?
Can’t detect distant metastases
What are advantages of ERCP with pancreatic CA?
Can do brush cytology and forcep biopsy
Therapeutic palliation
What are disadvantages of ERCP with pancreatic cancer?
More invasive
Can’t detect distant metastases
What diagnostic method for pancreatic CA prevents 20% of attempted resection?
Preoperative staging laparoscopy
What procedure is used for tumors at the head of the pancreas?
Pancreaticoduodenectomy (Whipple procedure)
What is the “dreaded”complication of whipple procedure?
Pancreatic leak
What procedure is used for tumor at the body or tail of the pancreas?
Distal pancreatectomy
What follows a distal pancreatectomy?
Adjuvant chemotherapy +/- RT
What is a Whipple procedure?
Tumor resected, cut bowel after stomach, attach stomach to sm bowel and pancreas stub to sm bowel
What is given for palliative care for pancreatic cancer?
CT and/or RT Narcotic analgesics Tricyclic antidepressants Antiemetics Celiac axis neurolysis RT
What is done to relieve jaundice with pancreatic cancer?
Endoscopic or percutaneous stent placement
Operative biliary decompression at time of operation for resectability assessment
What is done to relieve duodenal obstruction with pancreatic CA?
Gastrojejunostomy
What can be done to relieve duodenal obstruction in pancreatic cancer if pt is a poor candidate for surgery?
Endoscopic stenting of duodenal obstruction
What size is a serous cystadenoma?
10 cm
What a serous systadenoma?
Usually large (avg 10cm) and well-circumscribed
Multiloculated w/ clear and serous fluid
Benign
Where are serous cystadenomas usually found?
Frequently at body or tail
What demographic are serous cystadenomas usually found?
Women > men, > 50yo
How is a serous cystadenoma usually found?
Abdominal mass or pain or incidental
Why are serous cystadenomas removed?
for symptoms or to differentiate from other tumors
What are mucinous cystadenoma or cystadenocarcinoma?
Potentially lethal
Large (avg 10cm) soft and irregular
Unilocular with thick mucous
Why are mucinous cystadenoma or cystadenocarcinoma potentially lethal?
Most contain at least focal areas of atypia or frank carcinomatous transformations
Who are mucinous cystadenoma or cystadenocarcinomas usually seen in?
Women»_space; men
How are mucinous cystadenoma or cystadenocarcinomas usually found?
Abdominal pain or mass
How are mucinous cystadenoma or cystadenocarcinomas treated?
Aggressive surgical excision
What are tests that can diagnose pancreatic endocrine tumors (6)?
CT or MRI
Visceral angiography
EUS
Octreotide scan
Transhepatic portal venous hormone sampling
Surgical exploration with intraoperative US
What is the most common pancreatic endocrine tumor?
Insulinoma
What percentage of pancreatic endocrine tumors are malignant?
10%
Are pancreatic endocrine tumors solitary?
Most are solitary
What size are pancreatic endocrine tumors?
<2cm
How are pancreatic endocrine tumors often diagnosed?
with psychiatric conditions
What is the Whipple triad?
- Symptoms of hypoglycemia during fasting
- Documentation of hypoglycemia with serum glucose < 50 mg/dL
- Relief of hypoglycemic symptoms with exogenous glucose
What does the whipple triad indicate?
Insulinoma
How is insulinoma diagnosed?
monitored fast checking serum insulin:glucose ratio q 4 – 6 hr
What is the biochemical diagnosis for 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)
Absence of sulfonylurea in plasma and/or urine
What is the treatment for insulinoma?
Excision
What is the treatment for insulinoma for metastatic disease?
Debulk
What is the treatment for insulinoma for non-surgical candidates?
Octreotide and diazoxide
How is gastrinoma diagnised?
- Fasting gastrin level > 1000 pg/mL while gastric pH < 2
- If gastrin level > 200 pg/mL but < 1000 pg/mL, must have basal acid output ≥ 15 mEq/hr and a + secretin stimulation test
What is the treatment for gastrinoma?
PPI, CT (mets and non-surgical candidates), excision
What are the symptoms of a gastrinoma?
Intractable abdominal pain (PUD)
Severe esophagitis
Severe diarrhea
Where are most gastrinomas found?
60 – 90% found within the gastrinoma triangle
What are the symptoms of a glucagonoma?
Weight loss, diarrhea, stomatitis, necrolytic migratory erythema, DVT, psychiatric disorders, cachexia, anemia
How is glucagonoma diagnosed?
Elevated fasting serum glucagon levels (500 – 1000 pg/dL)
Where are most glucagonomas found?
Most at body or tail
What phase are glucagonomas when they present?
Usually large at presentation
Most have metastasized
What is the treatment for glucagonoma?
Treatment is resection/debulking and octreotide (unresectable). CT
What is WDHA?
watery diarrhea, hypokalemia and achlorhydria
What is WDHA associated with?
VIPoma (Verner-Morrison syndrome)
What are the symptoms of VIPoma (Verner-Morrison syndrome)?
Symptoms – watery diarrhea, weakness, lethargy and nausea
How is VIPoma (Verner-Morrison syndrome) diagnosed?
serum VIP level (>75 – 100 pg/dL). Also - hypokalemia, achlorhydria, metabolic acidosis and and imaging
What is the treatment for VIPoma (Verner-Morrison syndrome)?
Treatment surgical excision or octreotide (if unresectable). CT
What is a VIPoma?
Secretes vasoactive intestinal peptide
What is achlorhydria?
No gastric acid in stomach
What is a somatostatinoma?
Release somatostatin which inhibits pancreatic and GI secretions
Where are somatostatinomas found?
Pancreas, ampulla, duodenum, jejunum, cystic duct or rectum
What are the sx of somatostatinomas?
Steatorrhea, diabetes, hypochlorhydria and cholelethiasis
How are somatostatinomas diagnosed?
fasting serum somatostatin levels (>160 pg/mL) and imaging
Where are most somatostatinomas found in the pancreas?
Most in head of the pancreas
How are somatostatinomas treated?
Surgery
debulking indicated
CT
How common is cure for somatostatinoma?
cure rare b/c mets
