Pancreas Flashcards
Pancreas ducts
Santorini = small duct Wirsung = major duct
Pancreas divisum
failure of fusion
5% of population
Prone to pancreatitis
Santorini is major duct
Annular pancreas sign
double bubble on XRay
tx: obstruction w/duodenojejunostomy. Do not resect pancreas.
Celiac plexus block
50% EtOH on both sides of aorta near celiac
effective pain relief for non-resectable CA
Pancreatic pseudocysts tx
expectant management if asymptomatic and not enlarging up until ~12 wks after episode of acute pancreatitis. 85% of pseudocysts resolve on their own
Complications of untreated pseudocyst
bleeding, infection, rupture, obstruction of CBD or duodenum
recurrence - 10%, much higher with EXTERNAL drainage
Tx of persistent pseudocyst
INTERNAL drainage - cyst-gastrostomy, =-duodeostomy, -jejunostomy
Insulinoma
#1 islet cell tumor overall. Insulin to glucose ratio > 0.4. Incr C peptide (as with parathyroid hormone, C terminal of hormone is inactive). 90% benign Rx = enucleation
Gastrinoma
#1 islet cell tumor in MEN (MEN I). 60% malignant, 50% are multiple. 90% are in gastrinoma triangle: 1. cystic/CBD junction 2. pancreas neck 3. 3rd part of duodenum Gastrin level > 1000, do secretin stimluation test (normal pts will decr gastrin) Severe ulcer disease, diarrhea (due to lipase destruction by acid, malabsorption, and incr secretion) NGT and H2 blockers help diarrhea
Somatostainoma
gallstones, steatorrhea, pancreatitis, diabetes
Glucogonoma
diabetes, glossitis, stomatitis, migratory necrolytic erythema, streptozocin and octreotide help
VIP-oma
WDHA syndrome = Watery Diarrhea Hypokalemia Achlohydria
Diarrhea does not improve with NGT or H2 blockers
Fluid collection in pancreas, what is it?
Necrotizing pancreatitis
- >4 week -> WON
- <4 week: acute pancreatic fluid collection
Non-necrotizing pancreatitis
- >4 week -> pseudocyst
- <4 week: acute pancreatic fluid collection
Next step for pseudocyst management after 6 weeks?
Image the duct FIRST with MRCP or ERCP
Tx of pseudocysts
- transpapillary endoscopic stenting
- endoscopic transluminal drainage
- open cyst-gastrostomy
- lap cyst-gastrostomy
Unresectable pancreatic tumor criteria
Tumor abutting the celiac artery/trunk, hepatic artery, or SMA by more than 180 degrees
Encasement/occlusion of the SMV/portal vein
Borderline resectability of pancreatic tumors
Tumors that cause venous distortion of the SMV/portal vein axis
Encasement of GDA up to the hepatic artery
Less than 180 degree abutment of the SMA
Mucinous cystic pancreatic neoplasm
- age
- sex
- location
- contour
- wall
- calcification present?
- pancreatic duct communication
- malignant potential
- imaging characteristics
- cyst fluid analysis: amylase/CEA/KRAS
- Treatment
- recurrence
- associated malignancy
- 4th-5th decade of life
- female
- > 95% body, tail
- round, oval, macrocystic 2-6 cm
- yes, central thickening
- yes, central
- no
- moderate 12-20%
- solid areas, peripheral calcifications
- low to none/>192 ng/mL/present
- resection
- no
- no
Main duct/mixed type IPMN
- age
- sex
- location
- contour
- wall
- calcification present?
- pancreatic duct communication
- malignant potential
- imaging characteristics
- cyst fluid analysis: amylase/CEA/KRAS
- Treatment
- recurrence
- associated malignancy
- 6-7th decade of life
- male > female
- head (70%), body, tail
- main duct dilatation
- absent
- uncommon
- NA
- high
- > 10 mm nodules
- high/>192 ng/mL/present
- resection
- yes, up to 10% - lifelong surveillance required
- yes - other GI cancers, skin, breast, prostate
Branch duct IPMN
- age
- sex
- location
- contour
- wall
- calcification present?
- pancreatic duct communication
- malignant potential
- imaging characteristics
- cyst fluid analysis: amylase/CEA/KRAS
- Treatment
- recurrence
- associated malignancy
- 6-7th decade of life
- male > female
- head (60%), body, tail
- grape cluster
- yes
- uncommon
- yes
- low to moderate
- > 3 cm, main duct >6 mm, irregular wall, mural nodules
- high/>192 ng/mL/present
- resection for high risk stigmata and worrisome features; surveillance with MRI/EUS every 6 months otherwise
- yes, up to 10% - lifelong surveillance required
- yes - other GI cancers, skin, breast, prostate
Tx of low grade, small PNET tumors
Enucleation
