Pancreas Flashcards
MC cause acute panc
alcohol gallstones
Gallstone Panc tx
Clear duct - ERCP, IC
Cholecystectomy in same admission
Atlanta classification
Non-nec: < 4 wks (acute peri-panc fluid collection), > 4 wks (pancreatic pseudocyst)
Nec: < 4 wks (acute nec collection, > 4 wks (walled off necrosis)
Nec panc tx with abx or not
No, only if have subsequent infection
F, Inc WBC, CT guided FNA
What abx for infected nec panc
Imipenem
Step up approach
1) Admit to ICU: Fluids, nutrition, support
2) Abx and percutaneous drain
3) Upsize drain
4) Video assisted retroperitoneal drainage
MC cause chronic panc
Alcohol
Biliary tract disease
Autoimmune
Idiopathic
S/S of chronic panc
Persistent abd pain
Weightloss
Malabsorption/steatorrhea/DM
>= 1 bout of acute panc
Dx: CT
Fibrosis, atrophy, calcification of gland
Chronic pain inc risk of cancer?
Yes
Tx
Non op mgmt
Abstain from alcohol
Panc enzyme replacement
Surgical mgmt of chronic pain
Decompress duct: Puestow
Resection of dz tissue: Beggar, Fray
Puestow
Longitudinal pancreaticojejunostomy
Large duct pancreatitis > 6 mm duct
W/ Normal panc head
Beggar
Resection of pancreatic head, pancreaticojejunostomy
Panc head dominant pancreatitis
Fray
Lat longitudinal pancreaticojejunostomy, core out head of panc
Distal panc
For mostly distal strictured disease
Minimal change panc
Resection/drainage won’t help
Need denervation
Bilateral thoracoscopic splantenectomy
Panc pseudocyst
Non nec > 4 wks
More common in chronic panc patients
Manage expectantly for 6 wks -> mature or resolve
If enlarging, symptomatic or > 6 cm then intervene
Panc pseudocyst surgical intervention
1st: Pre-op ERCP or MRCP to assess duct
2nd: Transpapillary endoscopic stenting, Endoscopic transluminal drainage, Open cystgastromstomy, Lap cystgastrostomy
PNETs
Most found incidentally on CT, then need panc triple phase CT or MRI
EUS -> FNA -> Analyze for CEA and amylase levels
Mucinous cyst
CEA > 190
Pseudocyst
Amylase high -> ductal communication
Serocystadenoma
Low CEA
Benign
Well circumscribed, central stellate scar
Do not need resection
Mucinous cystic neoplasm
Malignant potential Thick walled Cyst with internal septations CEA > 190, mucin in aspirate Tx: Must resect
IPMN
3 groups
Main duct
Branch duct
Mixed type
Main duct IPMN
Higher risk of malignancy
Fishmouth papilla on endoscopy
Must resect
Tx mixed type the same
Branch duct IPMN
Lower risk of malignancy
Decision to resect: Fitness of patient, Cyst > 3 cm, Thickened wall, non-enhancing mural nodules, lymphadenopathy, main duct > 10 cm
Daughter
Mother
Grandaughter
Daughter: Solid pseudopapillary
Mother: Mucinous
Grandmother: Serous
MC PNET
Non functional tumor
MC functional PNET
Insulinoma
Non function PNET
Malignant
Discovered late due to asymptomatic
Usually large, in head of panc and having some mass effect when found
Insulinoma
Benign
Throughout panc - even distribution
Whipple’s triad
Whipple’s triad
Neuroglycopenic symptoms
High insulin
Resolution of symptoms with administration of glucose
Dx of insulinoma
S/S Insulin > 18 Glucose < 55 C-peptide > 6 B hydroxy biutyrate < 2.7 Inc plasma glucose by 25 with glucagon Negative urine test for oral hypoglycemic
Tx:
Localize: Triphasic panc CT or MRI, EUS, or if cannot localize -> Intrarterial Ca injection and hepatic vein sampling.
Somatostatin scintography is not helpful
Solitary/Benign -> enucleate
Distal -> Distal panc/splenectomy
Gastrinom
Mostly malignant
In gastrinoma triangle
