pancreas Flashcards
what is the main pancreatic duct
duct of Wirsung - typically forms a common channel w the common bile duct and enters the duodenum at the ampulla of Vater and sphincter of Oddi
where is the prox and distal pancreatic duct located
prox is in pancreatic tail and distal is near duodenum in head of pancreas
pancreas divisum
majority of the dorsal pancreas empties into duodenum via duct of Santorini and portion of pancreatic head and uncinate process empties via the major papilla
what does the celiac artery trifurcate into
left gastric, splenic, and common hepatic
two pancreatic ducts
wirsung duct and santorini duct
how is blood supplied to head of pancreas
- celiac trunk-gastroduodenal-ant sup pancreaticoduodenal artery/post sup pancdu artery
- sup mesenteric artery-ant inf pandu art/post inf pandu artery
- splenic artery-dorsal pancreatic artery
why must the duodenum be removed if the head of the pancreas is removed
share same blood supply-gastroduodenal artery
endocrine function of pancreas
- control glucose hemeostasis w feedback mechanism based upon glucose levels
- islets of langerhans: alpha cells (glucagon) and beta cells (insulin)
- delta (somatostatin): strong inhibitor of pancreatic exocrine secretion
exocrine function of pancreas
digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase
what is the only enzyme secreted in active form
amylase
result from a malfunction in exocrine secretion
acute pancreatitis
what is acute pancreatitis assoc w in terms of elevated levels
pancreatic enzyme levels in blood/urine
acute inflammatory process of the pancreas w variable involvement of other regional tissues or remote organ systems
acute pancreatitis
assoc w minimal organ dysfunction and uneventful recovery; normal enhancement of pancreatic parenchyma on contrast enhanced computed tomography
mild acute pancreatitis
assoc w organ failure and or local complications such as necrosis, abscess or pseudocyst
severe acute pancreatitis
occur early in the course of acute pancreatitis, are located in or near the pancreas and always lack a wall of granulation of fibrous tissue
acute fluid collection
pancreatic necrosis
Diffuse or focal area(s) of nonviable pancreatic parenchyma typically associated with peripancreatic fat necrosis Nonenhanced pancreatic parenchyma >3 cm or involving more than 30% of the area of the pancreas
acute pseudocyst
Collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a result of acute pancreatitis, pancreatic trauma or chronic pancreatitis, occurring at least 4 weeks after the onset of symptoms, is round or ovoid and most often sterile; when pus is present, the lesion is termed a “pancreatic abscess
pancreatic abscess
Circumscribed, intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis or pancreatic trauma
Often 4 weeks or more after onset
Pancreatic abscess and infected pancreatic necrosis differ in clinical expression and extent of associated necrosis
what is acute pancreatitis due to
acinar cell injury which allows activation of pancreatic enzymes outside of the pancreatic ducts and digestive tract which results in destruction of pancreatic and peripancreatic tissue
mc cause of acute pancreatitis
alcohol ingestion and biliary calculi
in pts w pancreatitis related to alcohol consumption, the first episode is usually preceded by
6-8yrs of heavy alcohol ingestion
how does chronic pancreatitis dev from alcohol consumption
pts experience recurring acute attacks which are freq related to continued alcohol consumption; after multiple attacks of acute pancreatitis, the pancreatic ductal system becomes permanently damaged leading to chronic
mc mechanical cause of pancreatitis
gallstones
pt w noncrampy, epigastric pain alleviated by sitting/standing that radiated to left/right upper quadrant and back along with n/v
acute pancreatitis
pe with fever, tachycardia, upper abd tenderness with guarding +/- abd distention
acute pancreatitis
what two pe signs may indicate severe acute pancreatitis
- grey turns: flank hematoma
- cullens: falciform ligament resulting in periumbilical ecchymosis
lab values assoc w acute pancreatitis
- elev serum amylase/lipase
- amylase rises quickly within the first 12 hours after admission and usually returns to normal after 3-5days
imaging acute pancreatitis
- CXR to look for sympathetic pleural effusions, atelectasis or hemidiaphragm elevation, exclude free air
- plain/upright AXR for calcifications, gallstones, ileus, or cutoff sign
- US for gallstones, duct dilation, pancreatic enlargement, peripancreatic fluid collections
- CT for fluid, edema, necrosis
- MRCP
mc sign of pancreatitis on axr
sentinel loop
tx acute pancreatitis
- npo
- ivf
- ngt if vomiting
- H2 blocker/PPI
- analgesia (demerol)
- correction of coags/electrolytes
- +/- alcohol withdrawal prophylaxis
ranson’s criteria at presentation
- age >55
- wbc >16000
- glc>200
- ast >250
- ldh >350
“GA law”
ranson’s criteria during initial 48hrs
- base deficit >4
- BUN inc >5mg/dL
- fluid sequestration >6L
- serum Ca 10%
- po2 (abg)
cause of hypocalcemia w pancreatitis
fat saponification: fat necrosis binds to calcium
complication assoc w splenic vein thrombosis
gastric varices (tx w splenectomy)
chronic pancreatitis
chronic inflam of pancreas region causing destruction of parenchyma, fibrosis, and calcification resulting in loss of endocrine/exocrine tissue
2 subtypes of chronic pancreatitis
- chronic calcific pancreatitis
2. chronic obstructive pancreatitis
s/sx chronic pancreatitis
dull epigastric/back pain, wl, steatorrhea, dm1
signs of pancreatic exocrine insuff
steatorrhea and malnutrition
labs chronic pancreatitis
- amylase/lipase
- 72hr fecal fat analysis
- g1c tolerance test
amylase/lipase level chronic pancreatitis
normal because of extensive pancreatic tissue loss
imaging chronic pancreatitis
- ct
- kub
- ercp ductal irreg w dilation and stenosis (chain of lakes), pseudocysts
- mrcp
tx chronic pancreatitis
- discont alcohol
- insulin for dm1
- pancreatic enzyme replacement
- narcotics for pain
surgery for chronic pancreatitis
- puestow: longitudinal pancreaticojejunostomy (pancreatic duct must be dilated);drainage
- duval: distal panjej near total pancreatectomy
frey procedure
long panjej w core resection of pancreatic head
gallstone pancreatitis
acute pancreatitis from gallstone in or passing through the ampulla of vater
imaging gallstone pancreatitis
- us gallstones
- ct for pancreas
tx gallstone pancreatitis
conservative measures and early interval cholecystectomy and intraop cholangioggram 3-5d after pancreatic inflam resolves
role of ercp
- cholangitis
2. refractory choledochlithiasis
What is the APACHE 2 score of 8 or greater mean
severe acute pancreatitis
CT grading system for acute pancreatitis
a: normal pancreas
b: pancreatic enlargement
c: pancreatic inflammation/peripancreatic fat
d: single peripancreatic fluid collection
e: two or more fluid collections/ retroperitoneal air
mc complications of acute pancreatitis
- peripancreatic fluid collections
- pseudocysts
- infected pancreatic necrosis
what is diagnostic of infected pancreatic necrosis
ct scan with retroperitoneal air or air within the lesser sac
cause of peripancreatic fluid
disruption of pancreatic duct; enzymatic fluid collects around the pancreas and is walled off by surrounding viscera
what do fluid collections that persist become
pseudocysts- collection of peripancreatic fluid contained in cyst like structure without an epithelial lining
s/sx of pseudocyst
epigastric pain, n/v, early satiety from compression of stomach, duodenum, or common bile duct
best imaging study for pseudocyst
ct scan
tx of noncommunicating pseudocyst
aspirated or drained percutaneously
tx of communicating pseudocyst
internal drainage into stomach, duodenum or roux limb
internal drainage by sewing cyst wall directly to draining organ
mc cause of chronic pancreatitis
alcohol consumption
mc pancreatic carcinoma
pancreatic adenocarcinoma
principal risk factors of developing pancreatic cancer
inc age and smoking
3 main genetic abnorm leading to pancreatic cancer
- oncogene activation
- tumor suppressor gene inactivation
- over expression of growth factors or their receptors
mc expressed genetic mutation in malignant pancreatic neoplasms
Kirsten rat sarcoma oncogene (K-ras)- ras gene encodes GTP binding protein that is involved in growth signal transduction and when mutated aids in transforming cells
most important gene in hereditary pancreatic cancer
BRCA2
what kind of surgery is for pancreatic head or peiampullary lesions
pancreaticoduodenectomy (whipple)
what kind of surgery is for pancreatic body and tail lesions
distal pancreatectomy that usually includes a splenectomy
whipple procedure
-removal of the head of the pancreas, duodenum, and distal common bile duct; performed for carcinoma of the pancreas, duodenum, or distal common bile duct, and for trauma.
Reconstruction includes a choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy
highest rate of anastomoses leakage from whipple is assoc with
pancreaticojejunostomy
prognosis of pancreatic cancer
- unresectable has median survival of approx 6m even w chemo
- resection approx 19m
poor prognostic indicators of pancreatic cancer
- lymph node metastasis
- tumor size >3cm
- perineural invasion
other names for pancreatic endocrine tumors (PETs)
pancreatic islet cell tumors and pancreatic neuroendocrine neoplasms
most common functional PET
insulinomas- majority are benign
-solitary,
dx of insulinoma
-monitored 72hr fast
whipples triad
- symptoms of hypoglycemia
- low blood glucose (40-50mg/dL)
- relief of symptoms following iv glucose
suggests insulinoma
if results of 72hr fast for insulinoma is indeterminate then what test
secretin injection test- won’t release insulin in response to secretin and inhibit normal response of beta cells to secretin
gastrinoma triangle
- junction of common bile/cystic ducts
- neck/body of pancreas
- second/third portion of duodenum
abd pain, severe esophagitis, persistent diarrhea
gastric acid hyper secretion
gastrinoma
what is diagnostic for a gastrinoma
- gastrin levels >1000pg.mL in pt w gastric pH of 200, basal acid output >15mEq/hr and positive secretin stimulation test >200pg/mL inc in gastrin after injection of secretin
where do glucagonomas arise from
pancreatic alpha cells- located in body or tail
mild glucose intolerance and necrolytic migratory erythema skin rash
glucagonoma
dx of glucagonoma
serum glucagon level of 500-1000pg/mL
watery diarrhea, hypokalemia, and hypochlorhydria
VIPomas
triad known as WDHA syndrome/ watery diarrhea syndrome/pancreatic cholera syndrome/endocrine cholera/verner-morrison syndrome
dx of VIPoma
serum VIP level >75-150pg/mL
somatostatinoma
somatostatin inhibits production of variety of hormones including growth hormone, gastrin, insulin, and glucagon; also inhibits intestinal absorption, gastrointestinal motility, and gallbladder contraction
dx of somatostatinomas
fasting somatostatin level >160pg/mL and pancreatic/duodenal mass
eval of PETs
- CT or MRI
- ASVS if others aren’t able to localize the lesion
- somatostatin scintigraphy (Octreoscan)
tx PETs
- complete surgical extirpation of primary and all metastatic ds; controlled preop by somatostatin analogues and PPI
- nonop palliative tx symptom control and ablative modalities
WHO classification for PETs
- Well-differentiated neuroendocrine tumor
• Benign: confined to pancreas, 2 mitoses/HPF, >2% KI-67-positlve cells, or angloinvaslve
ο Functioning: gastrinoma, insulinoma, VIPoma, glucagonoma, somatostatinoma, or ectopic hormonal syndrome
ο Nonfunctioning
- Well-differentiated neuroendocrine carcinoma
• Low grade malignant: invasion of adjacent organs and/or metastases
ο Functioning: gastrinoma, insulinoma, glucagonoma, VIPoma, somatostatinoma or ectopic hormonal syndrome
ο Nonfunctioning
- Poorly differentiated neuroendocrine carcinoma
• High grade malignant
TNM classification of PETs
T-primary Tumor
TX:Primary tumor cannot be assessed
TO:No evidence of primary tumor
T1:Tumor limited to the pancreas and size 4 cm or invading duodenum or bile duct
T4:Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or superior mesenteric artery);For anyT, add (m) for multiple tumors
N-regional Lymph Nodes
NX:Regional lymph node cannot be assessed
NO:No regional lymph node metastasis
N1:Regional lymph node metastasis
M-distant Metastases
MX:Distant melaslasis cannot be assessed
MO:No distant metastases
M1a: Distant metastasis
Disease Stages
Stage I: T1,NO,MO
Stage IIa:T2,NO,MO
IIb:T3,NO,MO
Stage Illa:T4,NO,MO
lllb: Any T,N1,MO
Stage IV:Any T, Any N,M1
A 20-year-old man comes to the emergency department with severe epigastric pain. He has a history of pancreatitis 8 months ago, but no cause was identified. He has otherwise been healthy. He does not smoke or drink alcohol. He takes no medications. His vital signs are temperature—38°C, blood pressure (BP)—130/80 mm Hg, pulse—110/minute, and respirations—18/minute. He has severe epigastric tenderness with guarding. There Is no scleral icterus. An ultrasound does not show gallstones. The bile ducts are not dilated. Laboratory studies show:
Lipase—20,000 units
Total bilirubin—0.9 mg/dL
Calcium—9/0 mg/dL
Which of the following additional findings Is most likely to support the diagnosis of pancreas divisum?
- separate dorsal and ventral ducts
Pancreatic divisum generally encompasses a variety of anatomic abnormalities whereby the majority of the dorsal pancreas empties Into the duodenum via the duct of Santorini and a portion of the pancreatic head and uncinate empty via the major papilla. The abnormalities can include an absent duct of Wirsung and separate dorsal and ventral ducts that do not fuse as well as a filamentous connection between the dorsal and ventral ducts. In the absence of divisum, that Is, in the normal state, the dorsal and ventral ducts join and the majority of secretions enter the duodenum via the duct of Wirsung through the major papilla. The common bile duct Is separate from the pancreatic duct until they merge at near the ampulla. .
A 50-year-old woman has severe gallstone pancreatitis. She is receiving IV fluid and is receiving nothing by mouth In an effort to slow pancreatic secretion to decrease the amount of active pancreatic enzyme leaking Into the disrupted glandular tissue. Which of the following enzymes Is produced by the pancreas and secreted in its active form?
-amylase
The pancreas secretes a variety of digestive enzymes Including amylases, lipases, and proteases. The majority of enzymes Including trypsin and chymotrypsln are secreted in their inactive form (trypslnogen and chymotrypsinogen). Amylase Is secreted In Its active form. Cholecystoklnin (CCK) is secreted by the duodenum and leads to the secretion of several pancreatic enzymes, while gastrin is a hormone primarily produced In the antrum.
A 42-year-old man comes to the emergency department with severe abdominal pain. He takes no medications. He drinks a quart of vodka daily and smokes one to two packs of cigarettes dally. Temperature is 38°C, BP is 110/90, pulse Is 20/minute, and respirations are 24/minute. He has severe epigastric tenderness. Which of the following variables Is included In Ranson’s criteria on admission to predict the severity of this patient’s Illness?
-wbc
Ranson’s criteria is one of the grading systems for the severity of pancreatitis that relies on clinical and laboratory values on admission and during the Initial 48 hours. On admission, the criteria Include age, WBC, serum glucose, serum LDH, and SGOT. Arterial PO2, calcium, and base deficit are three of six criteria measured during the Initial 48 hours. Total bilirubin, although often measured, is not part of the criteria.
A 70-year-old woman is brought to the clinic by her family because of jaundice. She has also had a 20-pound weight loss over the past few months and has recently noticed very dark urine and light-colored stools. She does not have any pain. She Is thin. There is a nontender, globular mass in the right upper quadrant. An ultrasound shows dilated intrahepatic and extrahepatic bile ducts with a dilated pancreatic duct and a mass In the head of the pancreas. Mutations In which of the following Is most likely associated with this patient’s diagnosis?
-k ras
The most commonly expressed genetic mutation in pancreatic cancer occurs in the K-ras oncogene. It Is present in at least 75% of pancreatic carcinomas. Mutations In the p53 tumor suppressor gene are the second most common mutation In pancreatic cancer and the most common genetic event in all human cancers. Mutations in other genes Including p16, the retinoblastoma gene, and in the DNA mismatch repair genes also occur but are less common.
A 66-year-old man presented to the clinic with painless jaundice. Further evaluation with CT imaging and endoscopic ultrasonography (EUS) showed a small resectable tumor In the head of the pancreas and no evidence of metastatic disease. EUS-gulded biopsy confirmed the diagnosis of pancreatic adenocarcinoma. Pancreaticoduodenectomy is planned. Which of the following statements regarding the role of adjuvant or neoadjuvant therapy for this patient Is true?
-adjuvant and neoadjuvant strategies can include radiation/chemo
Unfortunately, even after successful surgical resection, the majority of patients with pancreatic cancer will develop recurrence of their disease—both locally and systemically. Due to the high recurrence rates, efforts aimed at developing adjuvant and neoadjuvant strategies have been pursued. Treatment can consist of either chemotherapy alone or with radiation. Treatment can be given preoperatively (neoadjuvant) or postoperatively (adjuvant). Although there are several theoretical advantages of neoadjuvant strategies with promising results, no randomized comparisons have been done versus adjuvant therapy.
what is the waiting period before a pseudocyst should be drained
6weeks for pseudocyst walls to mature or become firm enough to hold sutures
mc symptoms assoc w cancer of pancreatic head
wl, pain, jaundice
tumor markers assoc w pancreatic cancer
ca-19-9
stage 1 cancer
tumor limited to pancreas w no nodes or metastases
stage 2 cancer
tumor extends into bille duct, peripancreatic tissues, or duodenum; no node or metastases
stage 3 cancer
same stage 2 but with positive node, celiac, or sma involvement
stage 4a cancer
tumor extends to stomach, colon, spleen, or major vessels, w any nodal status and no distant metastases
stage 4b cancer
distant metastases
