Pancreas Flashcards
What is the brightest T1 organ in the body
Pancreas
What is pancreatic parenchymal phase?
Late arterial (~40 seconds)
Maximal size of pancreatic duct in adults and elderly?
3 mm and 5 mm.
3 categories of pancreatic neoplasms
Solid epithelial (2). Cystic epithelial (4). Endocrine neoplasms (5)
Solid epithelial neoplasms of pancreas (2)
Ductal adenocarcinoma (most common). Acinar cell carcinoma (rare, aggressive, can cause fat necrosis)
Cystic epithelial neoplasms of pancreas(4)
Serous cystic, mucinous cystic (PMCN), Solid Papillary Epithelial neoplasm (SPEN), Intraductal paillary neoplasm (IPMN)
Endocrine neoplasms of pancreas (5) + nonfunctioning Islet cell
Insulinoma, gastrinoma, glucagonoma, VIPoma, Somatostatinoma
Ductal Adenocarcinoma of pancreas: Demographics, risk factors
Age>60. Slightly more in males. Smoking, alcohol, pancreatitis.
Ductal Adenocarcinoma of pancreas: imaging (CT phase, T1, enhancement.
Panc head. Late arterial phase hypoenhancing tumor against backgound enhancing pancreas. Hypodense CT. T1 Hypointense. Ill-defined. Hypovascualr. Double duct sign
Unresectable pancreatic cancer factors?
Vascular encasement (SMA or Celiac). Direct invasion of adjacent organs. Liver metastasis. Adenopathy. Ascites (peritoneal spread).
5 vessels that matter for surgical resection of pancreas
Celiac, SMA, Hepatic artery, SMV, Portal vein.
Trousseau’s sign
spontaneous venous thrombosis in pancreatic adenocarcinoma
Normal size of duodenal papilla?
Less than 1.5 cm.
Acinar Cell carcinoma of pancreas (demographics, clinical triad of lipase hypersecretion syndrome)
Elderly males. Lipase excretion causes; subcu fat necrosis, bone infarcts causing polyarthralgias, eosinophila
DDx for pancreatic mass w/ no ductal dilatation (8)
Autoimmune pancreatitis, groove pancreatitis, cystic pancreatic tumor, neuroendocrine tumor, Duodenal GIST, lymph node, mets, lymphoma
Pancreatic Mucinous Cystic Neoplasm features. Location, Ductal communication. calcifications
Mother tumor. Malignant potential. No ductal communication. Peripheral calcifications. 80& in the tail. Few large lesions (<6 cysts that are over 2 cm)
Serous cystadenoma. Ductal communication, calcification, vascularity
Grandma tumor, benign, no ductal communication, central calcifications (central stellate calcification), variable location. Many cysts (>6 cysts that are <2cm). Hypervascular.
Classic features of Serous Cystadenoma. (Vascularity? associated syndrome? calcs?)
Hypervascular. A/w VHL. Central calcification and scar
IPMN
Grandfather tumor, Ductal Communication. Can be aggressive.
IPMN should be resected if..
Over 3 cm in size. Mural nodule, pancreatic duct >10mm. Arising from main branch
IPMN Side branch vs. main branch. which is worse?
Main branch is worse. It should be resected.
IPMN classic appearance on endoscopy
Fish mouth papilla pouring out mucin.
Solid and Papilary endothelial neoplasm (SPEN). Appearance. Malignant potential?
“Daughtor tumor” Always in Asians or black girls. Low malignant potential. Large/heterogenous. Hemorrhagic. SPEN has a capsule (like Mother like daughter)
Differential for Solid mass in the tail of the pancreas (2)
Spen. Accessory spleen (1-3 cm, will follow spleen on all phases).
How to differentiate SPEN from Spleen on Nuc Med Scan
Heated tracer RBC scan or Sulfur colloid scan.
Which 2 pancreatic cystic tumors have capsules?
SPEN and Mucinous cystic (like mother like daughter)
Differential for something enhancing in pancreas (2)
Islet cell tumor. Splenic artery Pseudoaneurysm.
Of the 6 islet cell tumors, which are the important 2, and the other 4?
- Insulinoma (mostly benign, the rest are more malignant), Gastrinoma 2. Nonfunctioning, glucagonoma, VIPoma, somatostatinoma
Insulinoma (most common). What’s whipple’s triad? AKA what is hypoglycemia?
90% benign. Whipple’s triad (hypoglycemia, symptoms of hypoglycemia, relief w/ IV glucose) of Small, difficult to see.
Gastrinoma (2nd most common Islet cell tumor). (where do they originate from? How often malignant?)
Most originate from duodenum (gastrinoma triangle). 60% malignant.
Gastrinoma triangle and association.
CBD, duodenum, and neck/body of pancreas. Major cause of Zollinger-Ellison syndrome, leading to Jejunal ulcer. A/w MEN-1
Nonfunctioning islet cell tumor (3rd most common IC tumor)
Big and Bad. Malignant and larger. Necrotic on imaging studies.
Glucagonoma facts High rate of malignancy. 5 D’s
Diabetes, dermatitis, DVT, Depression, Death (most are malignant)
VIPoma facts? WDHA?
Vasoactive intestinal peptide. WDHA (Watery Diarrhea, Hypokalemia, Achlorhydria). Variable malignancy.
Somatostatinoma facts
Rare. A/w NF1
3 congenital pancreatic anomalies
Divisum, annular pancreas, common channel syndrome/pancreaticobiliary maljunction.
Normal pancreatic duct drainage
Main pancreatic duct drains to major papilla (ampulla of Vater) through the duct of Wirsung. Duct of Santorini drains to the minor papilla. (Santori is Superior and drains to the Small)
Pancreatic duct anatomy that is constant, regardless of anomaly (3)
CBD always drains to the major papilla where it meets duct of Wirsung. Main PD always drains the tail. Duct of Santori always drains to Minor papilla.
Pancreatic divisum duct drainage
Dorsal (main PD) drains into small (minor) papilla. Ventral duct of Wirsung drains into major papilla
Pancreatic divisum is in ____ % of population and is a risk factor for ____
15%, pancreatitis
Pancreatic divisum (most common congenital anomaly caused by
Failure of fusion of ventral and dorsal pancreatic ducts.
What is a Santorinicile? (pancreatic divisum problem)
Focal dilatation of termial duct of santorini. May cause pancreatitis due to obstruction of minor papilla
What is crossing sign in pancreati divisum
CBD crossing over the main duct to join the duct of Wirsung
Annular pancreas complication in kids vs. Adults
Kids - obstruction. Adults, pancreatitis, duodenal ulcer disease.
Annular pancreas is a/w ___ syndrome
Down’s syndrome
Annular pancraes is due to
incomplete rotation of the ventral pancreatic bud
Common channel syndrome/pancreaticobiliary maljunction.
Normally CBD and duct of wirsung both drain in major papilla, but are seprated by a septum. In Common channel syndrome, there is no septum, allowing reflux b/w the systems.
Common channel syndrome is on spectrum of __. May predispose to __
choledocal cyst. May predispose to cholangiocarcinoma, but this is controvertial.
Systemic diseases that affect pancreas (4)
VHL, CF, Schwachman diamond, Obesity/steroid use (causes fatty atrophy)
VHL association (3 letters = 3 categories). (3 in pancreas, 3 in other belly, 3 in CNS) + epidydimal cysts.
Serous Cystadenoma, regular cysts, islet cell tumors. Preo, RCC (younger age/clear cell), Renal cysts. Hemangioblastoma in brain, hemangiomioblastoma in spine, Endolymphatic sac tumor.
2 most common causes of pancreatic insufficiency in children
- CF (Most common by far. Causes faty atrophy and cystosis.) 2. Shwachman-Diamond Syndrome (SDS)
Intestinal obstruction syndrome in CF patients
DIOS (Distal Intestinal Obstruction Syndrome))
Distal Intestinal obstruction syndrome (CF complications). Etiology, classic scenario
Thick bowel secrections leading to obstruction. Poor compliance with diet enzymes. (Classic scenario is if a CF patient got a lung transplant and stopped taking medications)
Shwachman-Diamond syndrome factoids
Pancreas can look like CF. exocrine dysfunction, bony replacement, neutropenia. 2nd most common cause of pancreatic insufficiency in children. Patients are mostly dwarves or have short stature.
Checklist for abdoimnal cornal CT (things that are better tested on cornoal studies)
Bile duct, spleen, kidneys, bowel
Dorsal agenesis of the pancreas. Associated with?
A/w high blood sugards, diabetes
Pancreatitis (4 types)
acute, chronic, autoimmune, groove
Acute pancreatitis. 2 most common causes. 2 grading systems and difference b/w them
alcohol, gallstone. Balthazare, CT severity index. The CT severity index uses the balthazar system and adds level of necrosis.
Balthazar grading system (A-E). Mortality is 14% for D, 54% for E
A. Normal. B. enlargement. C. Inflammatory changes. D. Single fluid collection . E. 2 or more collections
CT severity index scoring (CTSI). (0-3 has 8% mortality. 7-10 has 92% mortality)
Assigns 0-4 for A-E on Balthazar. Adds: 2 poings for <30% necrosis. 4 points for 30-50. 6 points for >50.
What is most important factor for outcome factors for survival in pseudocysts
Necrosis.
Pseudocyst
No ductal dilatation. 4 weeks to develop. Collection of pancreatic enzymes and fluid.
Pseudocyst terminology: No necrosis (over/under 4 wks). w/ necrosis (over/under 4 wks)
No necrosis <4wks = “acute peripancreatic fluid collection”. > 4 = psuedocyst. W/ necrosis <4 = acute necrotic collection. >4 = walled-off necrosis.
Factors that distinguish a pancreatic abscess from pseudocyst?
Abscess (forms earlier after pancreatitis, days to weeks, high HU 20-50, may contain air).
Pancreatitis complications Checklist (3 categories)
necrosis, fluid collections, vascular stigmata. Bowel involvement (tranverse), perihilar renal inflammation leading to venous compression or thrombosis.
Vascular stigmata of pancreatitis
Portal vein thrombosis. Splenic vein thrombosis. Slenic artery Psa, GDA Psa.
MCC of pancreatits in kids
Trauma. (seat belt or bike handles). Also should consider Nonaccidental trauma, if patient can’t ride a bike. May also have duodenal hematoma.
Chronic pancreatitis. Causes, pathognomonic finding
MCC is long term alcohol use. Divisum is a less common cause. Calcifications along pancreatic duct are pathogneumonic.
autoimune pancreatitis imaging
Sausage pancreas. Skinny duct. No inflammation. DDx may include lymphoma.
Autoimmune pancreatitis caused by __ and a/w __, __
inflammatory lymphoplasmcitic infiltrate. A/w Sjorden and IgG4 related sclerosing disease
IgG4 related sclerosiiong disease (5 things)
Autoimmune pancreatitis, retroperitoneal/mediastinal fibrosis, tubulointerstitial nephritis, sclerosing cholangitis, Riedels Thyroiditis.pseudotumor cerebri
Groove pancreatitis. Rare. Affects young men who drink. Describe it
focal pancreatitis at grove b/w head of pancreas and duodenum. Can cause varying levels of dupdenal stenosis or cystic change of duodenal wall. Differential includes adenocarcinoma.
Common sites of ectopic pancreatic tissue?
walls of stomach, duodenum, and Meckel diverticulum.
Fatty replacement of the pancreas is common in?
diabetes. obesity. elderly. Cystic fibrosis.
Low attenuation pancreatic mass with dilated loops of bowel?
VIPoma.
MEN-1 (PPP)
Pancreatic islet cell (Gastrinoma), pituitary adenoma, parathryoid adenoma.
MEN2A (MPP)
Medullary thyroid cancer, pheo, parathyroid adenoma
MEN2B (MPN)
Medullary thyroid. Pheo, neuromas
Jejunal ulcer is usually caused by what syndrome?
Zollinger Ellison Syndrome (too much gastrin)
