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QUESTION NOTES > PANCREAS > Flashcards

PANCREAS Flashcards

1
Q

Absolute C/I endoscopic drainage of panc pseudocyst

A

pseudocyst c/b pseudoaneurysm

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2
Q

Ranson’s criteria components (on admission) - severity

A 
WBC >16
Age >55
glucose >200
AST >250
LDH >250
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3
Q

Ranson’s criteria components (48hrs into admission) - severity

A 
Hct drop >10%
BUN increase >5
Ca<8 within 48hrs
PaO2 <60mmHg
Base deficit (24-bicarb) >4
Fluid needs >6L within 48hrs
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4
Q

Size cut-off in which pseudocysts unlikely to resolve spontaneously

A

> 6cm

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5
Q

STEP-UP approach for mgmt necrotic pancreatitis

A

better prognosis if prolong surgical intervention

  1. ICU support, NPO, IVF, TPN/distal feeding tube
  2. if failing or sign of infection -> IV Abx, possible perQ drain
  3. Re-scan after perQ and still have fluid -> upsize drain, re-placement
  4. If worsening still -> video-assisted RP debridement (via flank)
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6
Q

Ranson criteria score that predicts 100% mortality

A

8

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7
Q

Atlanta classification system

A
  1. necrotizing vs. interstitial edematous

2. fluid vs. no fluid collection (and for how long?)

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8
Q

Puestow procedure; indications?

A

longitudinal pancreaticojejunostomy (decompressive operation); for large-duct chronic pancreatitis (>6mm) + normal panc head

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9
Q

Beger procedure

A

duodenal-preserving panc head resection

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10
Q

Frey procedure; indications?

A

lateral longitudinal pancreaticojejunostomy w/ excavation of panc head wo transection of pancreas (decompressive + resection of disease); for primary panc head involvement w/ or w/o duct dilation

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11
Q

Mgmt minimal change pancreatitis

A
  • total pancreatectomy

- if high surgical risk, then denervation via bilateral thoracoscopic splanctenectomy

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12
Q

Dx cystic pancreatic neoplasms

A
  • most found incidentally
  • further characterization w/ MRCP
  • EUS + FNA will differentiate type
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13
Q

FNA of cystic pancreatic neoplasms

A
  • high CEA (>190) -> mucinous

- high amylase -> ductal communication (ie. pseudocyst, IPMN)

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14
Q

Demographics of cystic pancreatic neoplasms

A

F>M

  • younger -> think solitary pseudopapillary lesions
  • middle-aged -> think mucinous
  • elderly -> think serous
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15
Q

Imaging characteristic: serous cystadenoma

A

well-circumscribed; multicystic, lobulated mass (“bunch of grapes”) +/- central stellate scar

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16
Q

Imaging characteristics: mucinous cystadenoma

A

thick-walled, single cyst with internal septations +/- peripheral calcifications

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17
Q

Pathognomonic endoscopic finding for main duct IPMN

A

fish-mouth papilla

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18
Q

Worrisome EUS findings for branch duct IPMN

A
  • cyst >3cm (for young pts, <2cm)
  • thickened cyst wall
  • non-enhancing mural nodules
  • lymphadenopathy
  • main duct >10mm
  • abrupt change in main duct size w/ distal atrophy
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19
Q

MC PNET

A

nonfunctional

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20
Q

MC functional PNET

A

insulinoma

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21
Q

MC PNET associated with MEN1

A

gastrinoma

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22
Q

Nonfunctional PNET (malignancy? location? sxs?)

A
  • majority malignant
  • MC head of panc
  • dx late bc incidentally found or mass effect
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23
Q

Insulinoma (malignancy? location? sxs?)

A
  • most benign
  • evenly distributed throughout panc
  • Whipple’s triad
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24
Q

Whipple’s triad

A
  • fasting hypoglycemia
  • neuroglycopenic sxs
  • relief sxs w/ glucose
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25
Q

Labs: Insulinoma

A
  • plasma glucose <55
  • insulin >18
  • C-peptide > 0.6
  • pro-insulin >5
  • beta-hydroxybuterate <2.7
  • increase plasma glucose >25 after glucose admin
  • neg urine test for oral hypoglycemic
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26
Q

Mgmt insulinoma

A

depends on location, suspicion for malignancy + presence of other tumors

  • solitary benign -> enucleation
  • distal -> distal spleen preserving pancreatectomy
  • malignant -> formal resection
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27
Q

Gastrinoma (malignancy? location? sxs?)

A
  • most malignant
  • located gastrinoma triangle
  • abd pain + diarrhea + weight loss + peptic ulcer disease
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28
Q

Gastrinoma triangle

A
  • jxn CBD + CD
  • jxn neck/body panc
  • jxn 2nd/3rd duodenum
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29
Q

If cannot localize gastrinoma, go to OR and do…

A
  1. intra-op US
  2. transduodenal palpation
  3. intra-op upper endoscopy w/ transduo illumination
  4. duodenotomy, then palpate head of panc
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30
Q

Mgmt gastrinoma

A
  • if small in duodenal mucosa -> enucleation + paraduo LN dissection
  • if noninvasive, <5cm at head -> (same as above)
  • if invasive or >5cm, at head -> Whipple
  • if in body/tail -> distal panc
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31
Q

Glucagonoma (malignancy? location? sxs?)

A
  • most malignant
  • MC tail of panc
  • sxs: dermatitis, DM, depression, DVT + necrolytic migratory erythema
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32
Q

Mgmt glucagnoma

A

NO enucleation, need resection w/ regional lymphadenectomy (bc high malignant potential) + cholecystectomy (bc need somatostatin adjuvant)

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33
Q

Somatostatinoma (malignancy? location? sxs?)

A
  • most malignant
  • MC head of panc, can be at 2nd duo
  • sxs: cholecystitis, DM, malabsorption, steatorrhea
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34
Q

Mgmt somatostatinoma

A

NO enucleation, need resection w/ regional lymphadenectomy + cholecystectomy

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35
Q

VIPoma (malignancy? location? sxs?)

A
  • most malignant
  • MC body/tail panc (extrapanc also possible @ adrenal, RP, mediastinum)
  • sxs: WDHA
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36
Q

Mgmt VIPoma

A

NO enucleation, need resection w/ regional lymphadenectomy + cholecystectomy (bc somatostatin adjuvant)

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37
Q

Characteristics of resectable panc adenocarcinoma

A
  • no arterial contact
  • <180 degree contact SMV or portal vein
  • wo vein contour irregularity (which would indicate invasion into vasculature structure)
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38
Q

Characteristics of unresectable panc adenocarcinoma

A
  • distant mets
  • > 180 degree contact w/ SMA or celiac
  • unresectable involvement with SMV or portal vein
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39
Q

What is / who gets adjuvant for panc adenocarcinoma?

A

everyone; folinic acid (leucovorin) + 5FU + irinotecan + oxaliplatin

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40
Q

hx pancreatitis + hematemesis, think…?

A

gastric varices 2/2 splenic vein thrombosis

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41
Q

2-cm branch IPMN incidental + microcytic anemia, also need w/u for…?

A

colonoscopy; bc IPMN pts have higher incidence extra-panc malignancy (MC colonic adenocarcinoma)

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42
Q

Mutations associated w/ panc adenocarcinoma

A
  • KRAS
  • p53
  • CDKN2A
  • SMAD4
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43
Q

Mgmt pancreatic fistula

A
  • most will close spontaneously 4-6 wks
  • ERCP w/ stent if still signif output (will close 85% pts)
  • somatostatin analog NOT helpful and is expensive
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44
Q

If choose to do dx lap for borderline panc adeno, must do what during procedure?

A

divide gastrocolic omentum to access lesser sac -> direct inspection of pancreas and peripanc LN burden + washing of lesser sac (for cytologic eval)

45
Q

MC serious Cx following Whipple

A

post-op pancreatic fistula

46
Q

Sxs post-op pancreatic fistula s/p Whipple

A

range from

  • asympt: leak from cut end panc -> self-limiting pseudocyst formation; to
  • complete disruption pancreatoJ, requiring emergency lap
47
Q

Mets from pancreatic ductal adenoCA MC where?

A

liver

48
Q

Imaging for preop determination of resectability for panc ductal adenoCA

A

3-phase pancreatic protocol CT

49
Q

Best blood biomarker for PNET

A

chromogranin A (CgA)

50
Q

ChemoRx used for metastatic PNET

A

everolimus (mTOR inhibitor), streptozocin, sunitinib

51
Q

Surveillance interval of BD-IPMN wo worrisome features <2cm

A

yearly CT/MRI

52
Q

Surveillance interval of BD-IPMN wo worrisome features >2cm

A

CT/MRI imaging alternating with endoscopic US q3-6mo

53
Q

If BD-IPMN with worrisome features, next step is…?

A

endoscopic US

54
Q

Worrisome features of BD-IPMN

A
  • cysts >3cm
  • thickened or enhancing cyst wall
  • main duct 5-9mm
  • nonenhancing mural nodule
55
Q

High-risk stigmata of BD-IPMN

A
  • obstructive jaundice
  • enhancing solid component within cyst
  • main duct >10mm
56
Q

Mgmt mature cyst abutting stomach on imaging, not resolved with conservative mgmt

A

endoscopic cystgastrostomy (drain into stomach via opening made through posterior stomach to collection)

57
Q

MCC death after Beger and Frey procedures

A

CV disease 2/2 endocrine insufficiency

58
Q

MC post-op Cx of distal pancreatectomy

A

leak from cut edge of pancreas

59
Q

Most reliable method to reduce pancreatic leak from distal pancreatectomy

A

direct suture ligation of the duct

60
Q

Direct retroperitoneal debridement AKA? Can be used for?

A

Direct perQ endoscopic debridement - can be used for walled-off pancreatic necrosis

61
Q

Which malignancies require dx lap for accurate dx of stage?

A
  • stomach
  • esophagus
  • pancreas (if >3cm, in body/tail, elevated CA19-9 >100, or uncertain CT findings)
62
Q

Cationic trypsinogen gene (PRSS1) mutation results in…?

A

hereditary pancreatitis - suspect in <35-yo with unexplained pancreatitis

63
Q

Smoking independently increases risk for ?? in chronic pancreatitis pts

A

pancreatic adenocarcinoma

64
Q

What type of pseudocysts are likely to resolve?

A
  • =/< 6cm

- present for <6 weeks

65
Q

Cause of pancreas divisum

A

from failure of fusion of ventral and dorsal pancreatic ducts

66
Q

Mgmt symptomatic pancreas divisum

A

ERCP + sphincteroplasty with stent placement

67
Q

What is Duct of Wirsung?

A

major pancreatic duct - drains uncinate process and part of head

68
Q

What is Duct of Santorini?

A

lessor papilla - drains head/body/tail of pancreas

69
Q

Cause of annular pancreas?

A

incomplete rotation of ventral pancreatic bud -> ring of panc tissue surrounding descending portion of duodenum

70
Q

Imaging finding for annular pancreas on XR?

A

double bubble sign

71
Q

Annular pancreas can result in ?? for duodenum

A

duodenal atresia

72
Q

Imaging dx for pancreas divisum

A

ERCP - see two papilla

73
Q

Most important predictor of overall survival for pancreatic adenoCA

A

tumor stage

74
Q

Indications for early ERCP for gallstone pancreatitis

A
  • CBD stone US
  • clinical ascending cholangitis
  • bilirubin >4
  • both dilated CBD >6mm + bili 1.4-4
75
Q

What pancreatic neoplasm associated with ovarian type of stroma?

A

Mucinous cystic neoplasms

76
Q

Three phases of exocrine pancreatic response + respective mediators

A
  1. Cephalic - sight/smell; vagus
  2. Gastric - food entering stomach; somatostatin primary inhibitor; vagus
  3. Intestinal - food entering duodenum; majority panc secretion here; vagus/CCK/secretin
77
Q

Most potent stimulator of pancreatic enzyme secretion

A

CCK

78
Q

Most potent stimulator of pancreatic bicarbonate

A

Secretin

79
Q

Tx for annular pancreas

A

Duodenojejunostomy (NO resection of obstructing pancreas)

80
Q

Tx pancreatic divisum

A

ERCP + sphincteroplasty with stent placement

81
Q

Medical (initial) Tx for chronic pancreatitis

A
  • anagelsic
  • stop EtOH and smoking
  • oral enzyme therapy
  • selective use of anti secretory therapy (somatostatin)
  • +/- PPI (assist in preventing inactivation of panc enzyme)
82
Q

Borders of where to open pancreatic duct - Puestow procedure

A

Anterior: open along its length
Medial: to level of GDA
Lateral: into tail beyond all pancreatic duct strictures

83
Q

Complications of pancreatic cyst

A
  • splenic vein thrombosis (bc compression of vein by cyst)
  • pseudoaneurysm (bc erosion into visceral arteries)
  • peritonitis
84
Q

Patho of chronic pancreatitis

A

Irreversible pancreatic fibrosis + loss of functional pancreatic exocrine/endocrine tissue

85
Q

Action of trypsin

A

Breakdown of proteins into AA

86
Q

Dx mass at ampulla of Vater

A
  • biopsy to determine if carcinoma

- EUS to identify duodenal invasion

87
Q

Which ampullary mass can be managed endoscopically?

A
  • no invasion
  • benign daemons
  • =/<2cm

*can be excised endoscopically or via transship approach with 2-3mm margins

88
Q

Which ampullary masses should be considered of pancreaticoduodenectomy?

A
  • pre-op dx of carcinoma

- >2cm

89
Q

Dx hereditary pancreatitis (PRSS1)

A
  • 2+ first degree relatives with unexplained pancreatitis
  • 3+ second degree relatives
  • over 2+ generations
90
Q

What enzyme actives trypsinogen to its active form (trypsin)?

A

Enterokinase

91
Q

Which of the pancreatic digestive enzymes are synthesized and secreted in their active forms?

A
  • amylase
  • lipase
  • ribonuclease
  • deoxyribonuclease
92
Q

Tx flare of chronic autoimmune pancreatitis

A

Steroids

93
Q

MC presentation of autoimmune pancreatitis

A

Jaundice

94
Q

Dx autoimmune pancreatitis

A
  • clinical (jaundice, pain)
  • elevated IgG4
  • imaging (enlarged peripanc LN; usually no intrapanc calcifications)
95
Q

Which pancreatic pseudocysts can be managed conservatively?

A
  • present <6 weeks

- 6cm and smaller

96
Q

Presentation and Dx of pancreatic lymphoma

A
  • B-symptoms (fever, night sweats, weight loss)
  • N/V + abdominal pain
  • CT: bulky pancreatic mass
97
Q

Tx pancreatic lymphoma

A

Cytotoxic chemotherapy

  • cyclophosphamide
  • doxorubicin (adriamycin)
  • vincristine
  • prednisone
98
Q

Action of pancreatic polypeptide

A

Suppress bile secretion, GB contraction, and exocrine pancreatic function

99
Q

Pancreatitis in pt with pancreas divisum likely due to…?

A

Alcohol or gallstones. Rare that pancreas divisum is primary cause of pancreatitis - but if it is, thought to be 2/2 minor papilla being insuff to drain pancreatic secretions (obstruction)

100
Q

Dx for pancreas divisum

A

ERCP

101
Q

Mgmt pancreatic divisum if refractory to endoscopic minor papillotomy and pancreatic duct stenting?

A

Surgical longitudinal duodenotomy + minor sphincteroplasty

102
Q

If presumed case of autoimmune pancreatitis does not completely respond to steroids, then consider possibility of…?

A

Pancreatic adenocarcinoma

103
Q

Which genetic change associated with pancreatic endocrine neoplasms (PEN) is associated with improved prognosis?

A

Microsatellite instability from hypermethylation of hMLH1

104
Q

Secretin stim test panc: end-stage pancreatitis

A
  • low total volume
  • low bicarb
  • low enzymes
105
Q

Secretin stim test panc: panc cancer

A
  • low total volume
  • nl bicarb
  • nl enzymes
106
Q

Secretin stim test panc: chronic pancreatitis

A
  • nl total volume
  • low bicarb
  • nl enzymes
107
Q

Secretin stim test panc: malnutrition

A
  • nl total volume
  • nl bicarb
  • low enzymes
108
Q

What basal acid output is necessary to confirm dx gastrinoma?

A

> 15 basal acid output

109
Q

VHL (von Hippel-Lindau) is associated with…?

A
  • hemangioblastomas of CNS and retina (bilateral, multiple)
  • pheo
  • clear cell renal cell CA (bilateral, multifocal)
  • cystadenomas and neuroendocrine tumors of pancreas

QUESTION NOTES (28 decks)

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