Pancreas Flashcards
What is the balthazar system?
Staging of pancreatitis
a - normal
b - focal/diffuse enlargement
c - intrinsic pancreatic abnl with peripancreatic inflammation
d - fluid collection/phlegmon
e - 2 or more large phlegmonous collections or peripancreatic gas
What are the two main appearances of pancreatitis
Diffuse gland enlargement
Normal sized gland with peripancreatic fluid
What is the diagnostic key for pancreatic parenchymal necrosis?
Nonperfusion of a pancreatic segment
Which part of the pancreas is most susceptible to necrosis?
The body - doesnt have dedicated blood supply
What is the natural progression of peripancreatic fluid collections?
Most resorp in 2-3 weeks
What is a pseudocyst? What does it indicate?
A peripancreatic fluid collection with a thick fibrous wall lasting more than 6 weeks
Persistent communication with the pancreatic duct
When are pseudocysts usually drained?
4cm
Irregular fluid collection within a fluid collection surrounding pancreas suggestS?
Pseudoaneurysm
What causes the colon cutoff sign with regards to pancreatitis?
Pancreatic inflammatory fluid occupies the left pararenal space and causes colonic spasm
What are the helpful signs that distinguish IPMN and chronic pancreatitis?
IPMN will have mainly ductal dilation
Chronic pancreatitis will have parenchymal atrophy
What percentage of pancreatic parenchymal loss must occur for pancreatic insufficiency?
90%
Chain of lakes appearance of the pancreatic ducts is seen with what
chronic pancreatitis
What are the two types of familial pancreatitis
1) familial occurence associated with hyperlipidemia, hyperparathyroidism, CF, cholelithiasis
2) AD inherited syndrome
What is hereditary pancreatitis?
AD inherited
early bouts of pancreatitis as a kid, increased risk of pancreatic cnacncer
Subtype of pancreatitis seen in older men, milder symptoms. What is the marker?
Autoimmune pancreatitis
IgG4
How are most pancreatic cancers on CT?
hypoattenuating mass
What US finding is specific for ductal adenocarcinoma?
Ductal dilation
What are the two important phases in detection of pancreatic tumors?
Pancreatic phase (45 seconds) - will have maximal contrast between hypoattenuating mass and parenchyma
Portal venous - detects hepatic mets and lymphadenoapthy
How do most pancreatic tumors present on MRI?
Hypo in T1 and hyper on T2
What does obliteration of the pancreatic - SMA fat plane suggest?
Pancreatic mass
What are the causes of nonresectibility in pancreatic cancer?
Arterial invasion - celiac or SMA
Venous invasion - *limited involvement of SMV and portal can be resected
Regional lymphadenopathy with metastatic tumor
Distant mets
Multiple collateral vessels in the upper abdomen in a patient with pancreatic cancer should prompt search for what?
splenic/mesenteric vein occlusion
What 3 features help distinguish islet cells tumors?
Hypervascularity
Lack of vascular encasement
Propensity to calcify
What are the common hyperfunctioning islet cell tumors?
Insulinoma and gastrinoma
Which type of islet cell tumor are worse?
Nonfunctioning because they dont have symptoms and can grow to big sizes before detection
What is the gastrinoma triad?
Location of half of gastrinomas (arise out of pancreas)
Amuplla vater, junction of cystic duct and CBD, and junction of neck and body of pancreas
Gastrinomas are associated with what syndrome?
MEN I
What percentage of gastrinoma are malignant?
75%
What NM test can detect gastrinoma? Why?
Octreotide scintigraphy
High concentration of somatostatin receptiors
What is the US difference between primary and metastatic islet cell tumor? Between cavernous hemangioma?
PRimary - hypoechoic
Metastatic - hyperechoic with posterior acoustinc shadowing
Hemangioma - no shadowing
What is the difference between islet cell tumors associated with MEN and those that arise sporadically?
MEN I - tend to be small, multiple, and biologically less aggressive
What are the symptoms with glucagonoma
necrolytic erythema migrans, diarrhea, diabetes, glossitis
What is unique about hepatic mets in hypervascular primary tumors, such as islet cell?
Can contain fluid air level
Intratumoral calcification with solid and cystic elements in a young african woman
Solid and papillary epithelial neoplasm
What is the treatment of SPEN
total cure with resection
What are the unique features of acinar neoplasm?
Larger than ductal
Encapsulated
Has metastatic fat necrosis due to systemic release of lipase
What tumor causes metastatic fat necrosis
Acinar cell carcinoma
Most common met to the pancreas?
Renal cell
What are the two main types of cystic pancreatic masses? Which are benign?
Serous - benign
Mucinous - pre/malignant
Honeycombed appearance, many (>6) small (
Serous “Serous has Several”
Few large cysts
Mucinous
What is the main differential for a mucinous cystadenoma
Pseudocyst - will have history of pancreatitis
What are malignant features of mucinous neoplasms
Thick septation
mural nodules
Mucin eminating from the papilla of vater is pathognomonic for what
IMPN
What is the imaging in IPMN
pancreatic ductal dilation with filing defects
Identification of a dilated side branch is suggestive of what diagnosis?
side branch IPMN
What is the size cutoff for resection of side branch IPMN
3cm
What is the grandma tumor? mother tumor? daughter tumor?
Grandma - serous
Mother - “M”ucinous
Daughter - SPEN
What are the pancreatic manifestations of VHL?
Numerous cysts
Serous cystadenoma
Islet cell tumor
Where do pancreatic lacerations most often occur
Between the neck and body
What is pancreatic divisum?What are the drainage pathways?
Failure of the dorsal and ventral portions of the pancreas to fuse
The duct of santorini empties via the accessory papilla
What are the two theories of pancreatic annulus forms?
Failure of pancreatic atrophy
Ventral portion adheres to duodenum and stretches around it as it rotates into position
Calcifications in the pancreas that are not intraductal and without ductal dilation?
Sarcoidosis
Where are the calcifications with chronic pancreatitis seen
Intraductal
What does a sausage shaped and with an apparent hypoattenuating halo surrounding an enlarged pancreas suggest?
Autoimmune pancreatitis
