Pancreas Flashcards
If superior mesenteric a severed, how would pancreas be affected?
Inferior portion of pancreas (and duodenum) would receive decreased blood and oxygen
If celiac trunk severed, how would pancreas be affected?
Superior portion of pancreas (and duodenum) would receive decreased blood and oxygen
Lymph drainage of pancreas
to the peripancreatic nodes
Nerve supply of pancreas
vagus and splanchnic nerves
How does pancreas receive its blood?
From superior and inferior pancreaticoduodenal arteries
Major pancreatic duct aka
Wirsung duct
Minor pancreatic duct aka
Santorini duct
Most common causes of pancreatitis
Alcohol and gallstones. Alcohol most common cause of chronic, while gallstones most common cause of acute.
Process of trypsinogen being activated within pancreas and destroying cells in pancreas called?
Autodigestion of the pancreas caused by gallstones that obstruct common duct
Effect of alcohol in causing pancreatitis
alcohol has direct toxic effect in parenchymal cells, increases secretion and causes spasm at the sphincter of Oddi, increases duct permeability
Results of alcohol cessation in pancreatitis
decreases acute attacks. Ongoing parenchymal damage occurs due to obstruction and fibrosis of the duct
If suspicious of hyperlipidemia causing pancreatitis, check..
serum triglyceride levels - over 400 mg/dl
Drug induced pancreatitis causes
TEA- tetracyclines, thiazide diuretics, estrongen containing contraceptives, and azathrioprine. (and steroids)
Patient presents with severe upper abdominal pain radiating to the back, nausea, vomiting, retching, dehydration, tachycardia. Decreased or absent BS, tenderness across upper abdomen. Labs show elevated lipase, amylase, and mild leukocytosis. Xray shows non specific sign of sentinel loop. Dx?
Acute pancreatitis
Labs to order in acute pancreatitis to figure out cause
LFT, LDH, triglycerides, BUN/Cr, electrolytes, Ca, glucose
What are 2 signs that may predict severe acute pancreatitis?
Cullen sign and Grey turner sign
Describe cullen sign
hemorrhagic discoloration or bruising of umbilicus - around belly button
Describe grey turner sign
hemorrhagic discoloration/bruising of flanks
what criteria used for acute pancreatitis
Ranson’s criteria- assesses risk of death
Potential complications of acute pancreatitis
pseudocyst, necrosis, abscess- can be seen from CT
Medical Tx of acute pancreatitis
NPO allows pancreas to rest, IV fluids, NG decompression, parenteral nutrition or J tube, electrolyte replacement, oxygen, antibiotics in severe cases (Imipenem)
Surgical tx of acute pancreatits
If gallstones cause, treat pancreatitis then cholecystectomy. Do cholangiogram and if stones are present in duct- sphincterotomy.
Pancreatic pseudocyst complications
infection, rupture, hemorrhage
Patient with resolved acute pancreatitis, but there is still ongoing pain. There is fluid collection around the pancreas. What complication do you suspect
Pancreatic pseudocyst
What is tx for pancreatic pseudocyst
Wait for pseudocyst to mature 2-3 months then connect to GI tract for easier drainage via cystgastrostomy or cystjejunostomy. Interventional radiology used when fluid has become infected.
Patient with resolved acute pancreatitis, but there is still ongoing pain. There is fluid collection around the pancreas. Labs also show High wbC count, and fever in patient. What complication do you suspect
Abscess
Tx for abscess caused from acute pancreatitis
IR drainage, open surgical drainage, IV antibiotics
What diseases may you see steatorrhea in?
Cystic Fibrosis, chronic pancreatitis
Patient presents with abdominal pain radiating to back, malabsorption, fatty stools, diabetes. Acute pancreatitis episodes and addiction to narcotics. What do you suspect and what would xray show?
chronic pancreatitis- pancreatic calcification in half of patients shows in xray.
Pancreatic insufficiency occurs in 30% of chronic pancreatitis patients, resulting in..
malabsorption- steatorrhea (unabsorbed fat in stools) from exocrine malfunction, and diabetes from endocrine malfunction
ERCP mostly used for…
diagnosing and treating problems of biliary and pancreatic ductal systems
Complications of chronic pancreatitis
Pancreatic pseudocyst, biliary or duodenal obstruction, malnutrition, diabetes
Medical tx of chronic pancreatitis
think abt causes (alcohol)- alcohol cessation. think about what this disease results in and fix those problems- malabsorption and steatorrhea d/t exocrine dysfunction- give pancreatic enzymes. also diabets d/t endocrine dysfunction- give insulin. psychiatric tx because often addicted to narcotics. PAIN MANAGEMENT! - oral narcotics, patches, celiac plexus blackade
Surgical tx of chronic pancreatitis
Drainage via peustow (pancreaticojejunostomy), pancreatectomy (whipple procedure- pancreaticoduodenectomy), and celiac plexus block
To determine causes of chronic pancreatits or rule it out…
secretin and CCK test, pancreolauryl test, PABA excretion test, fecal fat balance
Malabsorption tx in chronic pancreatitis
Pancreatic enzyme- Pancrease, high calorie diet with fat restriction, and H2 blocker- can degrade the ingested enzymes
Pancreatic neoplasms
pancreatic adenocarcioma, cystic neoplasm, adenoma and adenocarcinoma of the ampulla of Vater, pancreatic islet cell tumors
Pancreatic islet cell tumors
non-functioning islet cell tumors, insulinoma, glucagonoma, somatostatinoma, pancreatic cholera
2/3rds of adenocarcinoma cases involve which part of pancreas?
head of pancreas, which is good because jaundice occurs faster- detection faster
Most common risk factor associated with pancreatic adenocarcinoma
Smoking. also obesity, tobacco, cirrhosis, chronic pancreatitis
Courvoisier sign
Palpable non-tender gallbladder in jaundiced patient- can indicate pancreatic adenocarcinoma of head
Labs in pancreatic adenocarcinoma
elevated alk phos, bilirubin, CA 19-9 which is a tumor marker
Imaging of pancreatic adenocarcinoma
CT, ERCP + biopsy, aspiration biopsy
Distal pancreatectomy removes…
tail
Whipple procedure…
pancreaticoduodenectomy- tx for pancreatic head tumors and chronic pancreatitis
Surgical resection done in pancreatic adenocarcinoma only if tumor does not involve…
hepatic artery, SMA, and liver, and regional lymph nodes
another tx option in adenocarcinoma is diversion of the biliary stream via…
connecting jejunum to gallbladder (cholecystojejunostomy) or connecting jejunum to bile duct (choledochojejunostomy)
Cystadenoma vs. cystadenocarcinoma
cystadenoma- benign, cystadenocarcinoma- malignant
serous vs. mucinous cystadenoma
serous- benign, resect. Mucinous- benign but can undergo malignant degeneration, resect
Cystic neoplasms
cystadenoma, cystadenocarcinoma, papillary-cystic neoplasm
Adenomoas/adenocarcinomas of ampulla of vater benign or malignant
1/3 adenoma, 2/3 adenocarcinoma
If adenoma/adenocarcinoma of ampulla of vater has become metastatic, do you still do resection?
No. Do sphincterotomy and stent placement
symptoms in non-functioning islet cell tumors vs. funcitoning islet cell tumors
non-functioning don’t have symptoms because no hormones released. pancreatic islet cell tumors release hormones so many symptoms
non-functioning islet cell tumor benign or malignant
malignant tumor of the head of the gland
Insulinoma symptoms
bizarre behavior- unconsciousness, memory lapse due to cerebral glucose deprivation. Weight gain because eating helps symptoms
To check for insulinoma
Fasting hypoglycemia- glucose and insulin levels checked every 6 hours until hypoglycemia results over 72 hours. Ratio of plasma insulin to glucose greater than 0.3 is diagnostic.
Pancreatic cholera symptoms
non-Beta islet cell tumor that secretes VIP and peptide histidine isoleucine. Profuse watery diarrhea, low serum K.
Which pancreatic tumor can present the same as chronic laxative use?
pancreatic cholera
pancreatic cholera often located in…
body or tail of pancreas
Glucoagonoma major sx
Prominent rash in a patient with diabetes (all over body)
Somatostatinoma characterized by..
diabetes, malabsorption, diarrhea, dialtion of gallbladder
somatostatinoma benign or malignant
half and half
Annular pancreas
rare congenital condition- ring of pancreas surrounding second portion of duodenum- duodenal obstruction in infancy
tx of annular pancreas
bypass obstruction with duodenojejunostomy
postprandial vomitting seen in which pancreatic condition?
annular pancreas (throwing up after eating)
pancreas divisum
failure of fusion of the dorsal and ventral duct structures
Why might pancreas divisum predispose to pancreatitis?
d/t obstruction of the outflow of the minor duct
