PANCREAS

Question 1

most common cause of acute pancreatitis

Answer 1

cholelithiasis - most common cause in the Western world

alcohol - second most common cause

Question 2

Ranson criteria

Answer 2

admission GA LAW

 Glucose  200
 AST 250 ( careful NOT amylase)

LDH 350
Age 55
WBC greater than 16

48 hr C HOBBS

Calcium < 8

 Hemoglobin < 10
 Oxygen paO2  less than 60
 BUN  increase by 5
 Base deficit < 4
 sequestration >6 L

Question 3

initial management of pancreatitis with NG tube

Answer 3

NG tube decompression not mandatory

Useful if ileus risks aspiration

Question 4

feeding acute pancreatitis patient

Answer 4

enteral nutrition if tolerated recommended

Question 5

what percentage of patients progress to infected necrosis who began with pancreatic necrosis

Answer 5

30-50%

Question 6

operation for pancreatic necrosis

Answer 6

only if infected

Morbidity mortality are decreased by not intervening early and less infected

Question 7

time course to intervene on pancreatic necrosis when not infected

Answer 7

3-4 weeks! Her graft allows for demarcation of necrosis

Question 8

gold standard 2 diagnosis pancreatic infected necrosis

Answer 8

CT-guided fine needle aspiration

Question 9

If patient is stable initial treatment of infected pancreatic necrosis

Answer 9

catheter drainage antibiotics

gold standard remains open surgical debridement!

Question 10

What abdominal planes does infected pancreatic necrosis tract in

Answer 10

its gastrocolic omentum

retroperitoneal flanks

Question 11

patient presents with jaundice fever and increased total bilirubin was the management

Answer 11

resuscitation and antibiotics

ERCP not urgent - and should be performed after resuscitation

Question 12

efficacy of studies to diagnose choledocholithiasis

Answer 12

ultrasound has a sensitivity of 40-60%
(95% sensitivity diagnosis stones in the gallbladder)

CT scan more helpful if with gallstone pancreatitis-75-95% sensitivity of common bile duct stones or dilated common bile duct

Question 13

Pancreas protocol CT scan

Answer 13

IV contrast during the pancreatic phase
arterial phase
Additional images after venous phase

Venous phase helps identified and evaluate superior mesenteric artery, superior mesenteric vein, portal vein, splenic veins

Question 14

signs of superinfection of gallstone pancreatitis on CT scan

Answer 14

air bubbles

Hounsfield units 30 or less during arterial or pancreatic phase

Question 15

difference between Ranson’s criteria used for pancreatic necrosis versus gallstone pancreatitis

Answer 15

gallstone pancreatitis he uses:
Increased age of 70
Increased white blood cell count 18

Decreased BUN
No at PaO2

Question 16

gallstone pancreatitis

Answer 16

cholecystectomy same hospitalization

Question 17

recurrence rate of gallstone pancreatitis if cholecystectomy is not performed

Answer 17

90%!

90 day risk of recurrence is 50%

Question 18

Timing of cholecystectomy for gallstone pancreatitis

Answer 18

Wait until evidence of peripancreatic inflammation improving measured by resolving epigastric pain

This is typically 48-72 hours for mild disease

patient with acute cholangitis should undergo ERCP

Question 19

One is the time to do ERCP for decompressive drainage for acute cholangitis

Answer 19

if patient fails to respond to aggressive resuscitation in the first 24 hours

Patient shows signs of SIRS

persistent or worsening epigastric pain or elevated bilirubin or signs concerning for an impacted stone

Question 20

Was performed at the same time as ERCP for acute cholangitis

Answer 20

sphincterotomy

Question 21

Antibiotics for gallstone pancreatitis

Answer 21

No consent cysts for prophylactic antibiotic administration

Question 22

normal segments that the major pancreatic duct drains

Answer 22

Duct of Wirsung

drains inferior pancreatic head, uncinate process body and tail

( everything except the superior head and neck drained by Sanorini) a

Question 23

when does pancreatic divisum usually present

Answer 23

30s and 40s the

Question 24

percentage of patients who was symptomatic with pancreatic divisum

Answer 24

5%!

Question 25

Diagnosis of pancreatic divisum

Answer 25

ERCP is the gold standard and

other studies can be very useful:
EUS, MRCP with secretary and stimulation, CT scan

Question 26

treatment of pancreatic divisum

Answer 26

minor papilla sphincterotomy can be curative

(NOT balloon dilatation)

Endoscopic versus open

Question 27

how was a minor papilla sphincterotomy performed open

Answer 27

Upper midline incision
Right colon rotation
kocherized maneuver

Longitudinal duodenotomy

sphincterotomy performed - Superior medial lip

Dorsal duct fold over reapproximated duodenum

The 5 French pediatric feeding tube retrograde third portion duodenum removed 2-3 weeks

Question 28

Chronic pancreatitis sphincter stenosis after failed sphincterotomy for pancreatic divisum was the treatment

Answer 28

pylorus-preserving Whipple-type procedure - pancreatic head resection

If the dorsal duct dilatation:
Puestow-type
or
Frey-type

Question 29

imaging study of choice for pancreatic pseudocyst

Answer 29

CT scan contrast-enhanced is Amerge as the primary test of choice cystic lesions of the pancreas

Ultrasound is low cost that limited in its evaluation of pancreas and retroperitoneum

Question 30

management of pancreatic pseudocyst

Answer 30

asymptomatic observe and follow

a laparoscopic surgical drainage method of choice

Cyst gastrostomy if: collection of abuts gastric wall ( send this portion of tissue to rule out malignancy of gastric wall)

Roux-en-Y jejunum drainage if: - the cyst wall does not directly adherent to stomach

performed with 40-60 cm limb and anastomosed to the opening of the cyst.

The cyst duodenostomy if: - used if pseudocyst is in the head of the pancreas and adherent to the medial wall of the duodenum. Must safeguard sphincter of Odie and intrapancreatic portion of common bile duct

Distal pancreatectomy if: cysts is in the tail reserve for unusual settings-hemorrhage from pseudoaneurysm-preoperatively embolized

Question 31

approach is contraindicated for pseudocyst management

Answer 31

DO NOT perform simple drainage of pseudocyst and splenic hilum or beneath the splenic capsule-significant hemorrhage may result

Percutaneous drainage best avoided the

Question 32

Contraindications endoscopic intervention for her pseudocyst

Answer 32

Extensive necrotic material her graft thinner immature wall

The adjacent pseudoaneurysm or other vascular structure next feels the

Question 33

Infected pseudocyst

Answer 33

Traditionally all infected cysts were treated external drainage

This is the management of choice in this setting of sepsis

bacterial colonize cysts can be drained into the stomach with endoscopic or surgical approach!

Question 34

when his early intervention indicated for pseudocyst

Answer 34

presence of a documented infection demonstrated by either presence of gas or FNA will