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PANCREAS > PANCREAS > Flashcards

PANCREAS Flashcards

1
Q

relationship of the duodenum to the pancreas

A

head of the pancreas is surrounded by loop of the duodenum

Retroperitoneal

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2
Q

Relationship of pancreas to vasculature

A

Head of the pancreas extends to be right of the superior mesenteric VEIN
Anterior to this is gastroduodenal artery

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3
Q

Origin and course of gastroduodenal artery

A

Common HEPATIC artery
junction marked the beginning of the PROPER hepatic artery
gastroduodenal artery runs posterior to duodenum (massive bleeding)
Divides to form posterior superior pancreaticoduodenal arteries
Anastomosis with anterior and posterior INFERIOR pancreaticoduodenal arteries (these arise from superior mesenteric artery)

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4
Q

list right to left vascular structures related to the pancreas

A

far right: superior mesenteric vein
2 the left colon
at neck-the superior mesenteric artery
Cephalad at tail-splenic artery
Caudad at tail-dorsal pancreatic artery
Posterior and longitudinal 2 tail- splenic vein
Cephalad at head-gastroduodenal artery and superior anterior pancreaticoduodenal artery and superior posterior pancreaticoduodenal artery
Caudad at head-inferior anterior pancreaticoduodenal artery

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5
Q

pancreatic divisum

A

dorsal and ventral blood filter fuse the duct causing separate ductal drainage into duodenum
The accessory duct of Santorini drains through minor papilla
The major ampulla always drains the common bile duct and duct Wirsung

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6
Q

Normal pancreatic duct anatomy

A

Duct of Wirsung - major duct-major papilla (“ ampula of Vater”)-second portion of the duodenum-common bile duct off informs common channel with the main pancreatic duct before it enters the ampulla and sphincter of Oddi

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7
Q

Venous drainage of pancreas

A

Anterior venous arcade drains into superior mesenteric vein

Posterior venous arteriogram into portal vein

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8
Q

Enzymes is agreed to by the pancreas as inactive precursor

A

Trypsinogen
Chymotrypsinogen
activated by duodenum

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9
Q

alpha cells

A

Glucagon

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10
Q

Beta cells

A

Insulin

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11
Q

Delta cells

A

Somatostatin

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12
Q

Most common cause of pancreatitis

A

Cholelithiasis

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13
Q

List causes of pancreatitis

A 
Cholelithiasis
Alcohol
Hyperlipoproteinemia/hypercalcemia
Duodenal obstruction
Cardiopulmonary bypass (ischemia)-this is most common abdominal  problem post bypass
Mumps
Coxsackie B.
Cytomegalovirus
Cryptococcus
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14
Q

Drugs that cause pancreatitis

A 
Steroids
Dyazide
Furosemide
Estrogen
Azathioprine
Dideoxyinosine
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15
Q

Most common cause of mechanical etiology acute pancreatitis

A

gallstones

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16
Q

Gray Turner sign

A

Flank

TURN on side

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17
Q

Cullen sign

A

periumbilical ecchymosis

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18
Q

Fox sign

A

inguinal

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19
Q

Ranson criteria On admission

A 
GA  LAW
 glucose greater than 200 and
AST greater than 250
LDH greater than 350
Age greater than 55
White count greater than 16
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20
Q

Ranson criteria at 48 hours after admission

A 
C HOBBS
 calcium greater than 8
Hematocrit more than 10 point decrease
PaO2 less than 60 on room air
BUN greater than 5
Base deficit less than for
Sec restoration greater than 6 L
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21
Q

Clinical management based on ransom criteria

A

3 or greater criteria ICU
3 or greater criteria 15% mortality
Ranson criteria not used for gallstone pancreatitis

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22
Q

Management of common duct stone

A

MRCP 90% negative and stone-little utility
do not perform early ERCP
cholecystectomy same hospital admission with intraoperative cholangiogram-try to flush/glucagon
If still stuck postoperative ERCP
Do not wait for amylase/lipase normalized

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23
Q

Antibiotics for pancreatitis

A

Imipenem

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24
Q

management of pancreatic pseudocyst

A

Majority resolved spontaneously
Pancreatic rest
TPN and avoid oral intake that stimulates pancreatic secretion
a does not resolve within 4-6 weeks and still symptomatic pseudocyst that communicate with the pancreatic duct on ERCP should be drained surgically
The pseudocyst does not communicate with the pancreatic duct Endoscopic Cyst Gastrostomy
Alternative pseudocyst anastomosis to limb of jejunum and Roux-en-Y cyst jejunostomy

External drainage: Offer require a second operation because of pancreatic fistula
BIOPSY cyst wall
AVOID external drainage-fistula infection

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25
Q

Pulmonary disease or causes pancreatitis

A

cystic fibrosis

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26
Q

The splenic vein thrombosis

A

-year-old bleed with erosion in the splenic artery
cannot band
Cannot decompress with tips (independent of portal vein flow)
SPLENECTOMY

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27
Q

chain of lakes

A

segmental ductal obstruction and alternating areas of obstruction and dilation
Best treated with lateral pancreaticojejunostomy or modified Puestow

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28
Q

utility of celiac block for chronic pancreatitis pain

A

not very helpful

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29
Q

risk factors for pancreatic adenocarcinoma

A

Age
Smoking double the risk
Possible diabetes/alcohol
most common site head

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30
Q

Most common cancer of the pancreas

A

Adenocarcinoma with ductal epithelium origin

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31
Q

Other cancer the pancreas beside adenocarcinoma

A

Islet cell tumor
Cystadenocarcinoma
Lymphoma- rare-treated with chemotherapy and radiation!

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32
Q

what is expected mortality from Whipple

A

2-4% based on hospital volume

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33
Q

advantage of pylorus preserving Whipple

A

no survival advantage

May decrease dumping

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34
Q

utility of neoadjuvant chemotherapy for adenocarcinoma of the pancreas

A

no survival advantage

May improve resectability

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35
Q

workup for adenocarcinoma pancreas

A

preoperative CTA

DO NOT BIOPSY preop

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36
Q

procedures performed during a Whipple

A 
#1 pancreaticoduodenectomy
#2 antrectomy (is not pylorus-preserving)  with vagotomy  (to avoid acid from burning the bowel)
#3 cholecystectomy
#4 distal common bile duct resection
#5  pancreaticojejunostomy
 #6 choledochojejunostomy 
#7 gastroenterostomy
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37
Q

Gastrinoma triangle

A 
#1 common bile duct
#2 portion the duodenum
#3 pancreatic neck
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38
Q

What is considered incurable disease with adenocarcinoma pancreas

A

Liver metastases
Peritoneal seeding
Invasion of mesenteric root, celiac axis, mesenteric vessels

39
Q

Treatment of unresectable pancreatic adenocarcinoma

A

Papillae with biliary drainage endoscopic stenting in most cases
Gastric outlet obstruction management gastrojejunostomy
Back pain is improved with the celiac axis block

40
Q

Management of pancreaticojejunostomy leak after Whipple

A

Amylase rich drainage or abscess formation
Adequate drainage of secretions
Nutrition often TPN
Nonoperative therapy

41
Q

Most common cystic tumor of the pancreas

A

Cystadenoma-
Serous
or
mucinous -more common

42
Q

mucinous cystic neoplasm of the pancreas

A 
Women
Early age-50
Tall columnar cell
Treatment WHIPPLE!
Better prognosis than adenocarcinoma 50% 5 year survival rate
43
Q

Cystic papillary neoplasm of the pancreas

A

Young women in their 20s

Resection!

44
Q

islet cell tumor of the pancreas

A 
Includes:
 insulinoma
Gastrinoma
Glucagon,
Somatostatin,
VIP,
N
45
Q

Most common eyelid cell tumor of the pancreas

A

NON-functional

46
Q

Insulinoma

A

90% benign
Distended throughout pancreas
Diagnosis is confirmed out of proportion with glucose ratio
Whipple’s triad:

Symptoms known or likely to be caused by hypoglycemia
A low plasma glucose measured at the time of the symptoms
Relief of symptoms when the glucose is raised to normal
47
Q

Treatment of insulinoma

A

ENUCLEATION

If patient not a candidate they alleviate with streptozotocin or diazoxide

48
Q

Zollinger-Ellison syndrome

A

Peptic ulcer disease caused by gastrin secreting islet cell tumor
ulcers in unusual locations distal duodenum or jejunum
Watery diarrhea
Fasting serum gastrin greater than 750

49
Q

Gastrinoma triangle

A

common bile duct
Second/third portion of duodenum
Neck of the pancreas

50
Q

Extrapancreatic sites of gastrinoma

A 
Gastrinoma triangle
 bile duct
Heart
Liver
Lungs
Ovary
Kidney
Mesentery
Bones
51
Q

Most common false positive elevations in increased serum gastrin

A

atrophic gastritis the

achlorhydria

52
Q

Workup for gastrinoma

A

Fasting serum gastrin greater than 750
Secretary and stimulation test confirms diagnosis of positive doubling fasting level or absolute increase of 200
octreotide scan

53
Q

treatment of gastrinoma

A

Simple enucleation for many
May be multicentric
Bile duct, pancreatic duct, and vessels, and duodenum
Pregnancies blind pancreatic resection rarely indicated)
( total gastrectomy no longer performed given acid secretion inhibiting medication)

His poor risk patient or bulky mass then cannulated with PPI

54
Q

tropical pancreatitis

A 
Young
Trypsinogen inhibitor gene
Casava root
 Emilio
Treat with medications digestive enzymes
May require endoscopy decompression
Increased risk of cancer
55
Q

Treatment of large chronic pancreatic pseudocyst

A

INTERNAL drainage
Communicates with the pancreatic duct system 80%
Endoscopic approach we’ll fail with major duct disruption or stenosis seen on ERCP or cholangiopancreatography

56
Q

New onset diabetes with skin rash and pancreatic mass in tail

A

glucagon,
Medical lytic migratory erythema
Usually does not present with jaundiced because and tail

57
Q

Greasy floating stool, gallstones, pancreatic head mass

A 
somatostatinoma
exocrine insufficiency:
 steatorrhea and gallstones
 easily metastatic at presentation
Diagnoses somatostatin level
58
Q

Diagnosis with watery diarrhea and electrolyte abnormalities mass in the pancreas extension into the superior mesenteric vein and organs

A

VIPoma
Vasoactive intestinal peptide
WDHA (watery diarrhea, hypokalemia, achlorhydria)
“Verner-Morison syndrome”
Diagnosis CT scan
Tumors and tail
3 with tumor debulking even with metastases!
Adjunct hepatic artery embolization, radiofrequency ablation for liver metastases
Octreotide (somatostatin analog) for symptoms next she’ll

59
Q

Possible risk factors for pancreatic cancer

A 
Obesity
Atypical multiple small melanoma
Hereditary pancreatitis
Familial adenomatous polyposis
Her dietary non-polyposis colon cancer
Peutz-Jeghers  syndrome
Alcohol is debatable as a risk factor
60
Q

Most common pancreatic functional endocrine neoplasm

A 
insulinoma
Whipple triad:
Elevated C-peptide level diagnostic
Localizing CT and ultrasound
Even distribution pancreas
90% benign
Treatment the nucleation
61
Q

which pancreatic endocrine tumor is octreotide scan used for

A

gastrinoma -Confined tumors less than 1 cm

Also useful for carcinoid tumors

62
Q

Gallstone pancreatitis ERCP

A

Differential severe pancreatitis:
Early cholecystectomy associated increased mortality
ERCP performed with concomitant cholangitis or clear evidence of biliary obstruction (jaundice, persistent total bili greater than 4)

63
Q

Best predictor of retained common duct stone

A

persistently elevated total bili

64
Q

Pseudohyponatremia

A

seen with severe hypertriglyceridemia
water displaced by lipids causing air and measurement
Pancreatitis

65
Q

hereditary pancreatitis

A

defect in trypsin inactivation
Although nondominant
Results in uncontrolled proteolytic auto destruction of pancreas
Presents in childhood/adolescence
Calcifications of the pancreas
Risk of pancreatic carcinoma 40%!
Typically presents first 2 decades of life

66
Q

pancreatic divisum

A

ducts of Wirsung and Santorini failed to fuse

Majority of pancreas drained throughSantorini and LESSER papilla
inferior portion of pancreatic head and uncinate process is drained via Wirsung major papilla

considered normal anatomic variant and 10%
Increased for pancreatitis by overwhelming minor papilla no color change he is to

67
Q

Pancreatic lesion associated with persistent skin rash and glucose of 160

A

GLUCOGONoma

68
Q

findings with glucagonoma

A

necrolytic migratory erythema
Increased glucagon level
NO jaundice because lesions usually tail of pancreas

69
Q

clinical findings with exocrine insufficiency

A

steatorrhea
gallstones
(seen with somatostatin Oma)

70
Q

treatment with VIP Oma

A

even with distant metastases tumor debulk, embolized, radiofrequency ablation for liver, octreotide

71
Q

familial syndromes associated with pancreatic cancer

A 
FAP
 hereditary non-polyposis colon cancer
Peutz-Jegher's  syndrome
BRCA II
 melanoma-atypical
72
Q

Which pancreatic tumor it octreotide scan use for

A

GASTRINoma

73
Q

when preoperative ERCP be performed for gallstone pancreatitis

A 
and common cholangitis
Or
Clear evidence of biliary obstruction:
Jaundice
Total bilirubin greater than 4
74
Q

pseudohyponatremia

A

caused by hypertriglycerides

seen with pancreatitis

75
Q

and pancreatic divisum where do the head and uncinate drain

A

Duct of Wirsung major papilla

76
Q

treatment for recurrent acute pancreatitis due to pancreatic divisum

A

minor papilla sphincterotomy

77
Q

where do the majority of adenocarcinomas arise in the pancreas

A

main pancreatic DUCT

head or uncinate process

78
Q

workup for obstructive jaundice acholic stool weight loss and mass in the head of the pancreas on CT scan with no signs of distant metastases or vascular involvement

A

done

NO biopsy

79
Q

First study to perform a patient with obstructive jaundice

A

ultrasound

80
Q

we did a biopsy performed for pancreatic adenocarcinoma working diagnosis

A

paradoxically was appears unresectable:
helpful to guide chemotherapy with tissue

also rule out pancreatic lymphoma

81
Q

Effects of alcohol and the pancreas and producing pancreatitis

A 
#1 spasm of the sphincter over the
#2  toxin acinar cells
#3 increase his ductal permeability
#4 decrease his pancreatic blood flow
#5 and appropriately activates  pancreatic trypsin
82
Q

Drinking habits associated with alcoholic pancreatitis

A

18 ys mend

11 ys womne

83
Q

type 3 diabetes

A 
diabetes that develops in the setting of chronic pancreatitis or after pancreatic resection
Associated with decreased glucagon
Decreased PP level
Decrease insulin
Difficult to control
 INCREASED peripheral insulin SENSITIVITY
DECREASED hepatic and common sensitivity
Patient prone to develop HYPOglycemia
 marked hyperglycemia rare
84
Q

PP enzyme

A 
HEPATIC insulin receptor
 PP cells (F-cells) located proximal pancreas
85
Q

Characteristics of serous cystadenoma

A

CENTRAL SCAR
septations
Calcification (careful: also seen in mucinous)

86
Q

characteristic of mucinous cystadenoma

A

peripheral eggshell calcification

87
Q

workup for pancreatic ascites

A

paracentesis-
Elevated serum amylase
Protein greater than 25

88
Q

Management of pancreatic ascites

A

Bowel rest TPN n.p.o.
ERCP with stent
Surgery distal duct-distal pancreatectomy
Surgery pancreatic body Roux-en-Y pancreaticojejunostomy

89
Q

Diagnosis with compression of intrapancreatic common duct and biopsy with diffuse fibrosis plasma and lymphocytic infiltrate increased IgG

A 
autoimmune pancreatitis
Can be confused lymphoma
Hypoechoic pancreas
Often presents diabetes
Treatment steroids
90
Q

Diagnosis of factitious hypoglycemia

A

C-peptide low

In fundus C-peptide ratio greater than one

91
Q

treatment of pancreatic lymphoma

A

CHEMOTHERAPY

92
Q

Diagnosis of pancreatic lymphoma

A

one other rare case of the FNA should be done

93
Q

Most common cause of chronic pancreatitis worldwide

A

alcohol and

PANCREAS (1 decks)

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