PANCREAS Flashcards
most common cause of acute pancreatitis
cholelithiasis - most common cause in the Western world
alcohol - second most common cause
Ranson criteria
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
initial management of pancreatitis with NG tube
NG tube decompression not mandatory
Useful if ileus risks aspiration
feeding acute pancreatitis patient
enteral nutrition if tolerated recommended
what percentage of patients progress to infected necrosis who began with pancreatic necrosis
30-50%
operation for pancreatic necrosis
only if infected
Morbidity mortality are decreased by not intervening early and less infected
time course to intervene on pancreatic necrosis when not infected
3-4 weeks! Her graft allows for demarcation of necrosis
gold standard 2 diagnosis pancreatic infected necrosis
CT-guided fine needle aspiration
If patient is stable initial treatment of infected pancreatic necrosis
catheter drainage antibiotics
gold standard remains open surgical debridement!
What abdominal planes does infected pancreatic necrosis tract in
its gastrocolic omentum
retroperitoneal flanks
patient presents with jaundice fever and increased total bilirubin was the management
resuscitation and antibiotics
ERCP not urgent - and should be performed after resuscitation
efficacy of studies to diagnose choledocholithiasis
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
Pancreas protocol CT scan
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
signs of superinfection of gallstone pancreatitis on CT scan
air bubbles
Hounsfield units 30 or less during arterial or pancreatic phase
difference between Ranson’s criteria used for pancreatic necrosis versus gallstone pancreatitis
gallstone pancreatitis he uses:
Increased age of 70
Increased white blood cell count 18
Decreased BUN
No at PaO2
gallstone pancreatitis
cholecystectomy same hospitalization
recurrence rate of gallstone pancreatitis if cholecystectomy is not performed
90%!
90 day risk of recurrence is 50%
Timing of cholecystectomy for gallstone pancreatitis
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
One is the time to do ERCP for decompressive drainage for acute cholangitis
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
Was performed at the same time as ERCP for acute cholangitis
sphincterotomy
Antibiotics for gallstone pancreatitis
No consent cysts for prophylactic antibiotic administration
normal segments that the major pancreatic duct drains
Duct of Wirsung
drains inferior pancreatic head, uncinate process body and tail
( everything except the superior head and neck drained by Sanorini) a
when does pancreatic divisum usually present
30s and 40s the
percentage of patients who was symptomatic with pancreatic divisum
5%!
Diagnosis of pancreatic divisum
ERCP is the gold standard and
other studies can be very useful:
EUS, MRCP with secretary and stimulation, CT scan
treatment of pancreatic divisum
minor papilla sphincterotomy can be curative
(NOT balloon dilatation)
Endoscopic versus open
how was a minor papilla sphincterotomy performed open
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
Chronic pancreatitis sphincter stenosis after failed sphincterotomy for pancreatic divisum was the treatment
pylorus-preserving Whipple-type procedure - pancreatic head resection
If the dorsal duct dilatation:
Puestow-type
or
Frey-type
imaging study of choice for pancreatic pseudocyst
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
management of pancreatic pseudocyst
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
approach is contraindicated for pseudocyst management
DO NOT perform simple drainage of pseudocyst and splenic hilum or beneath the splenic capsule-significant hemorrhage may result
Percutaneous drainage best avoided the
Contraindications endoscopic intervention for her pseudocyst
Extensive necrotic material her graft thinner immature wall
The adjacent pseudoaneurysm or other vascular structure next feels the
Infected pseudocyst
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!
when his early intervention indicated for pseudocyst
presence of a documented infection demonstrated by either presence of gas or FNA will
