PANCREAS Flashcards
relationship of the duodenum to the pancreas
head of the pancreas is surrounded by loop of the duodenum
Retroperitoneal
Relationship of pancreas to vasculature
Head of the pancreas extends to be right of the superior mesenteric VEIN
Anterior to this is gastroduodenal artery
Origin and course of gastroduodenal artery
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)
list right to left vascular structures related to the pancreas
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
pancreatic divisum
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
Normal pancreatic duct anatomy
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
Venous drainage of pancreas
Anterior venous arcade drains into superior mesenteric vein
Posterior venous arteriogram into portal vein
Enzymes is agreed to by the pancreas as inactive precursor
Trypsinogen
Chymotrypsinogen
activated by duodenum
alpha cells
Glucagon
Beta cells
Insulin
Delta cells
Somatostatin
Most common cause of pancreatitis
Cholelithiasis
List causes of pancreatitis
Cholelithiasis Alcohol Hyperlipoproteinemia/hypercalcemia Duodenal obstruction Cardiopulmonary bypass (ischemia)-this is most common abdominal problem post bypass Mumps Coxsackie B. Cytomegalovirus Cryptococcus
Drugs that cause pancreatitis
Steroids Dyazide Furosemide Estrogen Azathioprine Dideoxyinosine
Most common cause of mechanical etiology acute pancreatitis
gallstones
Gray Turner sign
Flank
TURN on side
Cullen sign
periumbilical ecchymosis
Fox sign
inguinal
Ranson criteria On admission
GA LAW glucose greater than 200 and AST greater than 250 LDH greater than 350 Age greater than 55 White count greater than 16
Ranson criteria at 48 hours after admission
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
Clinical management based on ransom criteria
3 or greater criteria ICU
3 or greater criteria 15% mortality
Ranson criteria not used for gallstone pancreatitis
Management of common duct stone
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
Antibiotics for pancreatitis
Imipenem
management of pancreatic pseudocyst
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
Pulmonary disease or causes pancreatitis
cystic fibrosis
The splenic vein thrombosis
-year-old bleed with erosion in the splenic artery
cannot band
Cannot decompress with tips (independent of portal vein flow)
SPLENECTOMY
chain of lakes
segmental ductal obstruction and alternating areas of obstruction and dilation
Best treated with lateral pancreaticojejunostomy or modified Puestow
utility of celiac block for chronic pancreatitis pain
not very helpful
risk factors for pancreatic adenocarcinoma
Age
Smoking double the risk
Possible diabetes/alcohol
most common site head
Most common cancer of the pancreas
Adenocarcinoma with ductal epithelium origin
Other cancer the pancreas beside adenocarcinoma
Islet cell tumor
Cystadenocarcinoma
Lymphoma- rare-treated with chemotherapy and radiation!
what is expected mortality from Whipple
2-4% based on hospital volume
advantage of pylorus preserving Whipple
no survival advantage
May decrease dumping
utility of neoadjuvant chemotherapy for adenocarcinoma of the pancreas
no survival advantage
May improve resectability
workup for adenocarcinoma pancreas
preoperative CTA
DO NOT BIOPSY preop
procedures performed during a Whipple
#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
Gastrinoma triangle
#1 common bile duct #2 portion the duodenum #3 pancreatic neck
What is considered incurable disease with adenocarcinoma pancreas
Liver metastases
Peritoneal seeding
Invasion of mesenteric root, celiac axis, mesenteric vessels
Treatment of unresectable pancreatic adenocarcinoma
Papillae with biliary drainage endoscopic stenting in most cases
Gastric outlet obstruction management gastrojejunostomy
Back pain is improved with the celiac axis block
Management of pancreaticojejunostomy leak after Whipple
Amylase rich drainage or abscess formation
Adequate drainage of secretions
Nutrition often TPN
Nonoperative therapy
Most common cystic tumor of the pancreas
Cystadenoma-
Serous
or
mucinous -more common
mucinous cystic neoplasm of the pancreas
Women Early age-50 Tall columnar cell Treatment WHIPPLE! Better prognosis than adenocarcinoma 50% 5 year survival rate
Cystic papillary neoplasm of the pancreas
Young women in their 20s
Resection!
islet cell tumor of the pancreas
Includes: insulinoma Gastrinoma Glucagon, Somatostatin, VIP, N
Most common eyelid cell tumor of the pancreas
NON-functional
Insulinoma
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
Treatment of insulinoma
ENUCLEATION
If patient not a candidate they alleviate with streptozotocin or diazoxide
Zollinger-Ellison syndrome
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
Gastrinoma triangle
common bile duct
Second/third portion of duodenum
Neck of the pancreas
Extrapancreatic sites of gastrinoma
Gastrinoma triangle bile duct Heart Liver Lungs Ovary Kidney Mesentery Bones
Most common false positive elevations in increased serum gastrin
atrophic gastritis the
achlorhydria
Workup for gastrinoma
Fasting serum gastrin greater than 750
Secretary and stimulation test confirms diagnosis of positive doubling fasting level or absolute increase of 200
octreotide scan
treatment of gastrinoma
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
tropical pancreatitis
Young Trypsinogen inhibitor gene Casava root Emilio Treat with medications digestive enzymes May require endoscopy decompression Increased risk of cancer
Treatment of large chronic pancreatic pseudocyst
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
New onset diabetes with skin rash and pancreatic mass in tail
glucagon,
Medical lytic migratory erythema
Usually does not present with jaundiced because and tail
Greasy floating stool, gallstones, pancreatic head mass
somatostatinoma exocrine insufficiency: steatorrhea and gallstones easily metastatic at presentation Diagnoses somatostatin level
Diagnosis with watery diarrhea and electrolyte abnormalities mass in the pancreas extension into the superior mesenteric vein and organs
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
Possible risk factors for pancreatic cancer
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
Most common pancreatic functional endocrine neoplasm
insulinoma Whipple triad: Elevated C-peptide level diagnostic Localizing CT and ultrasound Even distribution pancreas 90% benign Treatment the nucleation
which pancreatic endocrine tumor is octreotide scan used for
gastrinoma -Confined tumors less than 1 cm
Also useful for carcinoid tumors
Gallstone pancreatitis ERCP
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)
Best predictor of retained common duct stone
persistently elevated total bili
Pseudohyponatremia
seen with severe hypertriglyceridemia
water displaced by lipids causing air and measurement
Pancreatitis
hereditary pancreatitis
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
pancreatic divisum
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
Pancreatic lesion associated with persistent skin rash and glucose of 160
GLUCOGONoma
findings with glucagonoma
necrolytic migratory erythema
Increased glucagon level
NO jaundice because lesions usually tail of pancreas
clinical findings with exocrine insufficiency
steatorrhea
gallstones
(seen with somatostatin Oma)
treatment with VIP Oma
even with distant metastases tumor debulk, embolized, radiofrequency ablation for liver, octreotide
familial syndromes associated with pancreatic cancer
FAP hereditary non-polyposis colon cancer Peutz-Jegher's syndrome BRCA II melanoma-atypical
Which pancreatic tumor it octreotide scan use for
GASTRINoma
when preoperative ERCP be performed for gallstone pancreatitis
and common cholangitis Or Clear evidence of biliary obstruction: Jaundice Total bilirubin greater than 4
pseudohyponatremia
caused by hypertriglycerides
seen with pancreatitis
and pancreatic divisum where do the head and uncinate drain
Duct of Wirsung major papilla
treatment for recurrent acute pancreatitis due to pancreatic divisum
minor papilla sphincterotomy
where do the majority of adenocarcinomas arise in the pancreas
main pancreatic DUCT
head or uncinate process
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
done
NO biopsy
First study to perform a patient with obstructive jaundice
ultrasound
we did a biopsy performed for pancreatic adenocarcinoma working diagnosis
paradoxically was appears unresectable:
helpful to guide chemotherapy with tissue
also rule out pancreatic lymphoma
Effects of alcohol and the pancreas and producing pancreatitis
#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
Drinking habits associated with alcoholic pancreatitis
18 ys mend
11 ys womne
type 3 diabetes
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
PP enzyme
HEPATIC insulin receptor PP cells (F-cells) located proximal pancreas
Characteristics of serous cystadenoma
CENTRAL SCAR
septations
Calcification (careful: also seen in mucinous)
characteristic of mucinous cystadenoma
peripheral eggshell calcification
workup for pancreatic ascites
paracentesis-
Elevated serum amylase
Protein greater than 25
Management of pancreatic ascites
Bowel rest TPN n.p.o.
ERCP with stent
Surgery distal duct-distal pancreatectomy
Surgery pancreatic body Roux-en-Y pancreaticojejunostomy
Diagnosis with compression of intrapancreatic common duct and biopsy with diffuse fibrosis plasma and lymphocytic infiltrate increased IgG
autoimmune pancreatitis Can be confused lymphoma Hypoechoic pancreas Often presents diabetes Treatment steroids
Diagnosis of factitious hypoglycemia
C-peptide low
In fundus C-peptide ratio greater than one
treatment of pancreatic lymphoma
CHEMOTHERAPY
Diagnosis of pancreatic lymphoma
one other rare case of the FNA should be done
Most common cause of chronic pancreatitis worldwide
alcohol and
