Pancreas Flashcards
What structure is the tail of the pancreas said to “tickle”?
Spleen
What are the 2 pancreatic ducts?
- Wirsung duct
2. Santorini duct
Which duct is the main duct?
Wirsung duct (Mnemonic: Santorini = Small)
How is the blood supplied to the head of the pancreas?
- Celiac –> gastroduodenal –> anterior and posterior superior pancreaticoduodenal
- SMA –> anterior and posterior inferior pancreaticoduodenal
- Splenic –> dorsal pancreatic
Why must the duodenum be removed if the head of the pancreas is removed?
They share the same blood supply (gastroduodenal)
What is the endocrine portion of the pancreas?
Islets of Langerhans
What is the exocrine function of the pancreas?
Digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase
What maneuver is used to mobilize the duodenum and pancreas and evaluate the entire pancreas?
Kocher maneuver: Incise the lateral attachments of the duodenum and then lift the pancreas to examine the posterior surface
What is acute pancreatitis?
Inflammation of the pancreas
What are the most common etiologies of acute pancreatitis in the US?
- Alcohol abuse
- Gallstones
- Idiopathic
What is the acronym to remember all the causes of pancreatitis?
I GET SMASHED:
Idiopathic, Gallstones, Ethanol, Trauma, Scorpion bite, Mumps (viruses), Autoimmune, Steroids, Hyperlipidemia, ERCP, Drugs
What are the symptoms of acute pancreatitis?
Epigastric pain (frequently radiating to the back), N/V
What are the signs of pancreatitis?
Epigastric tenderness, diffuse abdominal tenderness, decreased bowel sounds (adynamic ileus), fever, dehydration, shock
What is the differential diagnosis of acute pancreatitis?
Gastritis, PUD, perforated viscus, acute cholecystitis, SBO, mesenteric ischemia, ruptured AAA, biliary colic, inferior MI, pneumonia
What lab tests should be ordered for acute pancreatitis?
CBC, LFT, amylase/lipase, T&C, ABG, Ca, coags, serum lipids
What are the associated diagnostic findings for acute pancreatitis?
Lab: high amylase, lipase, WBC
AXR: sentinel loop, colon cutoff, possibly gallstones
U/S: phlegmon, cholelithiasis
CT: phlegmon, pancreatic necrosis
What is the most common sign of pancreatitis on AXR?
Sentinel loops
What is the treatment for acute pancreatitis?
NPO, IVF, NGT if vomiting, +/- TPN vs. post-pyloric tube feeds, H2 blocker, PPI, analgesia (Demerol), correction of coags/electrolytes, +/- alcohol withdrawal prophylaxis
What are the possible complications of acute pancreatitis?
Pseudocyst, abscess/infection, pancreatic necrosis, splenic/mesenteric/portal vessel rupture or thrombosis, pancreatic ascites/pleural effusion, diabetes, ARDS, sepsis, MOF, coagulopathy, DIC, encephalopathy, severe hypocalcemia
What is the prognosis of acute pancreatitis?
Based on Ranson’s criteria
Are post-pyloric tube feeds safe in acute pancreatitis?
Yes
What are Ranson’s criteria at presentation for acute pancreatitis?
- Age > 55
- WBC > 16,000
- Glucose > 200
- AST > 250
- LDH > 350
What are Ranson’s criteria during the initial 48 hours of acute pancreatitis?
- Base deficit > 4
- BUN increase > 5 mg/dL
- Fluid sequestration > 6 L
- Serum Ca < 8
- Hct decrease > 10%
- PO2 < 60 mmHg
How can the admission Ranson criteria be remembered?
GA LAW: Glucose > 200 Age > 55 LDH > 350 AST > 250 WBC > 16,000
How can the Ranson’s criteria at less than 48 hours be remembered?
C HOBBS: Calcium < 8 mg/dL Hct drop > 10% O2 < 60 Base deficit > 4 BUN > 5 increase Sequestration > 6L
How can the AST vs. LDH values in Ranson’s criteria be remembered?
A before L and 250 before 350
What is the etiology of hypocalcemia with pancreatitis?
Fat saponification: fat necrosis binds to calcium
What complication is associated with splenic vein thrombosis?
Gastric varices (treat with splenectomy)
Can TPN with lipids be given to a patient with pancreatitis?
Yes, if the patient does not suffer from hyperlipidemia
What is the least common cause of acute pancreatitis?
Scorpion bite (from Trinidad)
What is chronic pancreatitis?
Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine function
What are the subtypes of chronic pancreatitis?
- Chronic calcific pancreatitis
2. Chronic obstructive pancreatitis
What are the causes of chronic pancreatitis?
Alcohol abuse, idiopathic, hypercalcemia (hyperparathyroidism), hyperlipidemia, familial, trauma, iatrogenic, gallstones
What are the symptoms of chronic pancreatitis?
Epigastric and/or back pain, weight loss, steatorrhea
What are the associated signs of chronic pancreatitis?
Type 1 diabetes, steatorrhea, weight loss
What are the signs of pancreatic exocrine insufficiency?
Steatorrhea (fat malabsorption from lipase insufficiency), malnutrition
What are the signs of pancreatic endocrine insufficiency?
Diabetes (glucose intolerance)
What are the common pain patterns of chronic pancreatitis?
Unrelenting pain, recurrent pain
What is the differential diagnosis for chronic pancreatitis?
PUD, biliary tract disease, AAA, pancreatic cancer, angina
What percentage of patients with chronic pancreatitis have or will develop pancreatic cancer?
2%
What are the appropriate lab tests for chronic pancreatitis?
Amylase/lipase, 72-hr fecal fat analysis, glucose tolerance test
Why may amylase/lipase be normal in a patient with chronic pancreatitis?
Because of extensive pancreatic tissue loss
What radiographic tests should be performed for chronic pancreatitis?
CT: gland enlargement or atrophy, pseudocysts, calcifications, masses
KUB: calcifications
ERCP: ductal irregularities with dilation and stenosis, pseudocysts
What is the medical treatment for chronic pancreatitis?
D/c alcohol use, insulin, pancreatic enzyme replacement, narcotics
What is the surgical treatment for chronic pancreatitis?
Puestow (longitudinal pancreaticojejunostomy); Duval (distal pancreaticojejunostomy); near-total pancreatectomy
What is the Frey procedure?
Longitudinal pancreaticojejunostomy with core resection of the pancreatic head
What is the indication for surgical treatment of chronic pancreatitis?
Severe, prolonged or refractory pain
What are the possible complications of chronic pancreatitis?
Insulin-dependent diabetes, steatorrhea, malnutrition, biliary obstruction, splenic vein thrombosis, gastric varices, pancreatic pseudocyst, abscess, narcotic addiction, pancreatic ascites/pleural effusion, splenic artery aneurysm
What is gallstone pancreatitis?
Acute pancreatitis from a gallstone in or passing through the ampulla of Vater
How is the diagnosis of gallstone pancreatitis made?
Acute pancreatitis and cholelithiasis and/or choledocholithiasis and no other cause of pancreatitis
What radiologic tests should be performed for gallstone pancreatitis?
U/S: look for gallstones
CT: look at pancreas, if symptoms are severe
What is the treatment for gallstone pancreatitis?
Conservative measures and early interval cholecystectomy, IOC after pancreatic inflammation resolves
Why should early interval cholecystectomy be performed on patients with gallstone pancreatitis?
Pancreatitis will recur in 33% of patients within 8 weeks
What is the role of ERCP?
- Cholangitis
2. Refractory choledocholithiasis
What is hemorrhagic pancreatitis?
Bleeding into the parenchyma and retroperitoneal structures with extensive pancreatic necrosis
What are the signs of hemorrhagic pancreatitis?
Abdominal pain, shock, ARDS, Cullen’s sign, Grey-Turner’s sign, Fox’s sign
What is Cullen’s sign?
Bluish discoloration of the periumbilical are from retroperitoneal hemorrhage tracking around to the anterior abdominal wall through fascial planes
What is Grey-Turner’s sign?
Ecchymosis or discoloration of the flank in patients with retroperitoneal hemorrhage from dissecting blood from the retroperitoneum
(Grey TURNer = TURN side to side = flank)
What is Fox’s sign?
Ecchymosis of the inguinal ligament from blood tracking from the retroperitoneum and collecting at the inguinal ligament
What are the significant lab values for hemorrhagic pancreatitis?
Increased amylase/lipase, decreased Hct, decreased Ca
What radiologic test should be performed for hemorrhagic pancreatitis?
CT with IV contrast
What is a pancreatic abscess?
Infected peripancreatic purulent fluid collection
What are the signs and symptoms of pancreatic abscesses?
Fever, unresolving pancreatitis, epigastric mass
What radiographic test should be performed for pancreatic abscesses?
Abdominal CT with needle aspiration (Gram stain and culture)
What are the associated lab findings for pancreatic abscesses?
Positive Gram stain and culture of bacteria
Which organisms are found in pancreatic abscesses?
Gram negative (E. coli, Pseudomonas, Klebsiella) Gram positive (Staph) Candida
What is the treatment for pancreatic abscesses?
Antibiotics and percutaneous drain placement; or operative debridement and placement of drains
What is pancreatic necrosis?
Dead pancreatic tissue, usually following acute pancreatitis
How is the diagnosis of pancreatic necrosis made?
Abdominal CT with IV contrast: dead pancreatic tissue does not take up contrast
What is the treatment for sterile pancreatic necrosis?
Medical management
What is the treatment for pancreatic necrosis suspicious of infection?
CT-guided FNA
What is the treatment for toxic, hypotensive pancreatic necrosis?
Operative debridement
What is a pancreatic pseudocyst?
Encapsulated collection of pancreatic fluid
What makes a pancreatic pseudocyst “pseudo”?
Wall is formed by inflammatory fibrosis, not epithelial cell lining
What is the incidence of pancreatic pseudocyst?
10% after alcoholic pancreatitis
What are the associated risk factors for pancreatic pseudocysts?
Chronic > acute pancreatitis
What is the most common cause of pancreatic pseudocyst in the US?
Chronic alcohol pancreatitis
What are the symptoms of pancreatic pseudocysts?
Epigastric pain/mass, vomiting, mild fever, weight loss
What are the signs of pancreatic pseudocyst?
Palpable epigastric mass, epigastric tenderness, ileus
What lab tests should be performed for pancreatic pseudocyst?
Amylase/lipase, bilirubin, CBC
What are the diagnostic findings for pancreatic pseudocyst?
Labs: high amylase, bilirubin (if obstruction), leukocytosis
U/S: fluid-filled mass
CT: fluid-filled mass
ERCP: radiopaque contrast material fills cyst if there is a communicating pseudocyst
What is the differential diagnosis of a pancreatic pseudocyst?
Cystadenocarcinoma, cystadenoma
What are the possible complications of a pancreatic pseudocyst?
Infection, bleeding into cyst, fistula, pancreatic ascites, gastric outlet obstruction, SBO, biliary obstruction
What is the treatment for pancreatic pseudocyst?
Drainage of cyst or observation
What is the waiting period before a pancreatic pseudocyst should be drained?
It takes 6 weeks for pseudocyst walls to become firm enough to hold sutures and most will resolve in this period of time if they are going to
What percentage of pancreatic pseudocysts resolve spontaneously?
50%
What is the treatment for pancreatic pseudocyst with bleeding into cyst?
Angiogram and embolization
What is the treatment for pancreatic pseudocyst with infection?
Percutaneous external drainage and IV antibiotics
What size pancreatic pseudocyst should be drained?
Over 5 cm (or if the cyst walls are thick or calcified)
What are the three treatment options for pancreatic pseudocyst?
- Percutaneous aspiration/drainage
- Operative drainage
- Transpapillary stent via ERCP (must have communicating pancreatic duct)
What are the surgical options for pancreatic pseudocyst adherent to the stomach?
Cystogastrostomy (drain into stomach)
What are the surgical options for pancreatic pseudocyst adherent to the duodenum?
Cystoduodenostomy (drain into duodenum)
What are the surgical options for pancreatic pseudocyst not adherent to the stomach or duodenum?
Roux-en-Y cystojejunostomy (drain into the Roux limb of the jejunum)
What are the surgical options for pancreatic pseudocyst in the tail of the pancreas?
Resection of the pancreatic tail
What is an endoscopic option for drainage of a pancreatic pseudocyst?
Endoscopic cystogastrostomy
What must be done during a surgical drainage procedure for a pancreatic pseudocyst?
Biopsy of the cyst wall to rule out a cystadenocarcinoma.
What is the most common cause of death due to pancreatic pseudocyst?
Massive hemorrhage into the pseudocyst
What is the most common pancreatic cancer?
Adenocarcinoma arising from duct cells
What are the associated risk factors for pancreatic cancer?
Smoking, diabetes, heavy alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy
What is the average age of presentation with pancreatic cancer?
> 60 yo
What are the different types of pancreatic cancer?
Duct cell adenocarcinoma, cystadenocarcinoma, acinar cell carcinoma
What percentage of pancreatic cancers arise in the pancreatic head?
66%
Why are most pancreatic cancers in the tail non-resectable?
There tumors grow without symptoms until it’s too late and they have metastasized
What are signs and symptoms of pancreatic cancers in the head of the pancreas?
Jaundice (from obstruction of bile duct), weight loss, abdominal pain, back pain, weakness, pruritus, anorexia, Courvoisier’s sign, acholic stools, dark urine, diabetes
What are the signs and symptoms of pancreatic cancers in the body or tail?
Weight loss, pain, migratory thrombophlebitis, jaundice, N/V, fatigue
What are the most common symptoms of cancer of the pancreatic head?
- Weight loss
- Pain
- Jaundice
What is Courvoisier’s sign?
Palpable, non-tender, distended gallbladder
What percentage of patients with cancers of the pancreatic head have Courvoisier’s sign?
33%
What is the classic presentation of pancreatic cancer in the head of the pancreas?
Painless jaundice
What metastatic lymph nodes described classically for gastric cancer can be found with metastatic pancreatic cancer?
Virchow’s node; Sister Mary Joseph’s nodule
What are the associated lab findings of pancreatic cancer?
Increased direct bilirubin, alkaline phosphatase (biliary obstruction), LFTs, pancreatic tumor markers
Which tumor markers are associated with pancreatic cancer?
CA-19-9
What does CA-19-9 stand for?
Carbohydrate Antigen 19-9
What diagnostic studies are performed for pancreatic cancer?
Abdominal CT, U/S, cholangiography (ERCP to r/o choledocholithiasis and cell brushings), endoscopic U/S with biopsy
What is stage I pancreatic cancer?
Tumor is limited to pancreas
What is stage II pancreatic cancer?
Tumor extends into bile duct, peripancreatic tissues or duodenum
What is stage III pancreatic cancer?
Stage II plus positive nodes or celiac/SMA involvement
What is stage IVA pancreatic cancer?
Tumor extends to stomach, colon, spleen, or major vessels
What is stage IVB pancreatic cancer?
Distant metastases
What is the treatment for pancreatic cancer of the head?
Whipple procedure (pancreaticoduodenectomy)
What is the treatment for pancreatic cancer of the body or tail?
Distal resection
What factors signify inoperability of pancreatic cancer?
Vascular encasement (SMA, hepatic artery), liver mets, peritoneal implants, distant mets, malignant ascites
Is portal vein or SMV involvement an absolute contraindication for resection of pancreatic cancer?
No, can be resected and reconstructed with vein interposition graft at some centers
Should patients undergo preoperative biliary drainage (e.g. ERCP)?
No
What is the Whipple procedure?
Cholecystectomy, truncal vagotomy, antrectomy, pancreaticoduodenectomy, choledochojejunostomy, pancreaticojejunostomy, gastrojejunostomy
What is the complication rate after a Whipple procedure?
25%
What mortality rate is associated with a Whipple procedure?
< 5%
What is the pylorus-preserving Whipple?
No antrectomy; anastomose duodenum to jejunum
What are the possible complications of a Whipple procedure?
Delayed gastric emptying, anastomotic leak, pancreatic/biliary fistula, wound infection, post-gastrectomy syndromes, sepsis, pancreatitis
What is the postoperative adjuvant therapy for a Whipple procedure?
Chemotherapy +/- XRT
What is the palliative treatment for pancreatic cancer if the tumor is inoperable and biliary obstruction is present?
PTC or ERCP and placement of stent across obstruction
What is the prognosis at 1-year after diagnosis of pancreatic cancer?
Dismal: 10%
What is the 5-year survival rate for operable pancreatic cancer?
20%
What is an annular pancreas?
Pancreas encircling the duodenum
What is pancreatic divisum?
Failure of the 2 pancreatic ducts to fuse; duct of Santorini usually acts as the main duct in such situations
What is heterotopic pancreatic tissue?
Pancreatic tissue usually found in the stomach or small bowel
What is a Puestow procedure?
Longitudinal filleting of the pancreas/pancreatic duct with a side-to-side anastomosis with the small bowel
What medication decreases output from a pancreatic fistula?
Somatostatin
Which has a longer half-life: amylase or lipase?
Lipase
What is the WDHA syndrome?
Pancreatic VIPoma (Vasoactive Intestinal Polypeptide tumor). Causes: Watery Diarrhea, Hypokalemia, Achlorhydria
What is the Whipple triad of pancreatic insulinoma?
- Hypoglycemia (< 50)
- Symptoms of hypoglycemia: MSC, vasomotor instability
- Relief of symptoms with administration of glucose
What is the most common islet cell tumor?
Insulinoma
What pancreatic cancer is associated with gallstone formation?
Somatostatinoma (inhibits gallbladder contraction)
What is the triad found with pancreatic somatostatinoma tumors?
- Gallstones
- Diabetes
- Steatorrhea
What are the two classic findings with pancreatic glucagonoma tumors?
- Diabetes
2. Dermatitis/rash (necrotizing migratory erythema)
