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ENTREGA > Pancreas > Flashcards

Pancreas Flashcards

1
Q

What structure is the tail of the pancreas said to “tickle”?

A

Spleen

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2
Q

What are the 2 pancreatic ducts?

A
  1. Wirsung duct

2. Santorini duct

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3
Q

Which duct is the main duct?

A

Wirsung duct (Mnemonic: Santorini = Small)

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4
Q

How is the blood supplied to the head of the pancreas?

A
  1. Celiac –> gastroduodenal –> anterior and posterior superior pancreaticoduodenal
  2. SMA –> anterior and posterior inferior pancreaticoduodenal
  3. Splenic –> dorsal pancreatic
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5
Q

Why must the duodenum be removed if the head of the pancreas is removed?

A

They share the same blood supply (gastroduodenal)

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6
Q

What is the endocrine portion of the pancreas?

A

Islets of Langerhans

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7
Q

What is the exocrine function of the pancreas?

A

Digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase

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8
Q

What maneuver is used to mobilize the duodenum and pancreas and evaluate the entire pancreas?

A

Kocher maneuver: Incise the lateral attachments of the duodenum and then lift the pancreas to examine the posterior surface

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9
Q

What is acute pancreatitis?

A

Inflammation of the pancreas

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10
Q

What are the most common etiologies of acute pancreatitis in the US?

A
  1. Alcohol abuse
  2. Gallstones
  3. Idiopathic
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11
Q

What is the acronym to remember all the causes of pancreatitis?

A

I GET SMASHED:
Idiopathic, Gallstones, Ethanol, Trauma, Scorpion bite, Mumps (viruses), Autoimmune, Steroids, Hyperlipidemia, ERCP, Drugs

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12
Q

What are the symptoms of acute pancreatitis?

A

Epigastric pain (frequently radiating to the back), N/V

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13
Q

What are the signs of pancreatitis?

A

Epigastric tenderness, diffuse abdominal tenderness, decreased bowel sounds (adynamic ileus), fever, dehydration, shock

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14
Q

What is the differential diagnosis of acute pancreatitis?

A

Gastritis, PUD, perforated viscus, acute cholecystitis, SBO, mesenteric ischemia, ruptured AAA, biliary colic, inferior MI, pneumonia

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15
Q

What lab tests should be ordered for acute pancreatitis?

A

CBC, LFT, amylase/lipase, T&C, ABG, Ca, coags, serum lipids

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16
Q

What are the associated diagnostic findings for acute pancreatitis?

A

Lab: high amylase, lipase, WBC
AXR: sentinel loop, colon cutoff, possibly gallstones
U/S: phlegmon, cholelithiasis
CT: phlegmon, pancreatic necrosis

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17
Q

What is the most common sign of pancreatitis on AXR?

A

Sentinel loops

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18
Q

What is the treatment for acute pancreatitis?

A

NPO, IVF, NGT if vomiting, +/- TPN vs. post-pyloric tube feeds, H2 blocker, PPI, analgesia (Demerol), correction of coags/electrolytes, +/- alcohol withdrawal prophylaxis

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19
Q

What are the possible complications of acute pancreatitis?

A

Pseudocyst, abscess/infection, pancreatic necrosis, splenic/mesenteric/portal vessel rupture or thrombosis, pancreatic ascites/pleural effusion, diabetes, ARDS, sepsis, MOF, coagulopathy, DIC, encephalopathy, severe hypocalcemia

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20
Q

What is the prognosis of acute pancreatitis?

A

Based on Ranson’s criteria

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21
Q

Are post-pyloric tube feeds safe in acute pancreatitis?

A

Yes

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22
Q

What are Ranson’s criteria at presentation for acute pancreatitis?

A
  1. Age > 55
  2. WBC > 16,000
  3. Glucose > 200
  4. AST > 250
  5. LDH > 350
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23
Q

What are Ranson’s criteria during the initial 48 hours of acute pancreatitis?

A
  1. Base deficit > 4
  2. BUN increase > 5 mg/dL
  3. Fluid sequestration > 6 L
  4. Serum Ca < 8
  5. Hct decrease > 10%
  6. PO2 < 60 mmHg
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24
Q

How can the admission Ranson criteria be remembered?

A 
GA LAW:
Glucose > 200
Age > 55
LDH > 350
AST > 250
WBC > 16,000
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25
Q

How can the Ranson’s criteria at less than 48 hours be remembered?

A 
C HOBBS:
Calcium < 8 mg/dL
Hct drop > 10%
O2 < 60
Base deficit > 4
BUN > 5 increase
Sequestration > 6L
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26
Q

How can the AST vs. LDH values in Ranson’s criteria be remembered?

A

A before L and 250 before 350

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27
Q

What is the etiology of hypocalcemia with pancreatitis?

A

Fat saponification: fat necrosis binds to calcium

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28
Q

What complication is associated with splenic vein thrombosis?

A

Gastric varices (treat with splenectomy)

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29
Q

Can TPN with lipids be given to a patient with pancreatitis?

A

Yes, if the patient does not suffer from hyperlipidemia

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30
Q

What is the least common cause of acute pancreatitis?

A

Scorpion bite (from Trinidad)

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31
Q

What is chronic pancreatitis?

A

Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine function

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32
Q

What are the subtypes of chronic pancreatitis?

A
  1. Chronic calcific pancreatitis

2. Chronic obstructive pancreatitis

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33
Q

What are the causes of chronic pancreatitis?

A

Alcohol abuse, idiopathic, hypercalcemia (hyperparathyroidism), hyperlipidemia, familial, trauma, iatrogenic, gallstones

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34
Q

What are the symptoms of chronic pancreatitis?

A

Epigastric and/or back pain, weight loss, steatorrhea

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35
Q

What are the associated signs of chronic pancreatitis?

A

Type 1 diabetes, steatorrhea, weight loss

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36
Q

What are the signs of pancreatic exocrine insufficiency?

A

Steatorrhea (fat malabsorption from lipase insufficiency), malnutrition

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37
Q

What are the signs of pancreatic endocrine insufficiency?

A

Diabetes (glucose intolerance)

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38
Q

What are the common pain patterns of chronic pancreatitis?

A

Unrelenting pain, recurrent pain

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39
Q

What is the differential diagnosis for chronic pancreatitis?

A

PUD, biliary tract disease, AAA, pancreatic cancer, angina

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40
Q

What percentage of patients with chronic pancreatitis have or will develop pancreatic cancer?

A

2%

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41
Q

What are the appropriate lab tests for chronic pancreatitis?

A

Amylase/lipase, 72-hr fecal fat analysis, glucose tolerance test

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42
Q

Why may amylase/lipase be normal in a patient with chronic pancreatitis?

A

Because of extensive pancreatic tissue loss

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43
Q

What radiographic tests should be performed for chronic pancreatitis?

A

CT: gland enlargement or atrophy, pseudocysts, calcifications, masses
KUB: calcifications
ERCP: ductal irregularities with dilation and stenosis, pseudocysts

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44
Q

What is the medical treatment for chronic pancreatitis?

A

D/c alcohol use, insulin, pancreatic enzyme replacement, narcotics

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45
Q

What is the surgical treatment for chronic pancreatitis?

A

Puestow (longitudinal pancreaticojejunostomy); Duval (distal pancreaticojejunostomy); near-total pancreatectomy

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46
Q

What is the Frey procedure?

A

Longitudinal pancreaticojejunostomy with core resection of the pancreatic head

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47
Q

What is the indication for surgical treatment of chronic pancreatitis?

A

Severe, prolonged or refractory pain

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48
Q

What are the possible complications of chronic pancreatitis?

A

Insulin-dependent diabetes, steatorrhea, malnutrition, biliary obstruction, splenic vein thrombosis, gastric varices, pancreatic pseudocyst, abscess, narcotic addiction, pancreatic ascites/pleural effusion, splenic artery aneurysm

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49
Q

What is gallstone pancreatitis?

A

Acute pancreatitis from a gallstone in or passing through the ampulla of Vater

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50
Q

How is the diagnosis of gallstone pancreatitis made?

A

Acute pancreatitis and cholelithiasis and/or choledocholithiasis and no other cause of pancreatitis

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51
Q

What radiologic tests should be performed for gallstone pancreatitis?

A

U/S: look for gallstones

CT: look at pancreas, if symptoms are severe

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52
Q

What is the treatment for gallstone pancreatitis?

A

Conservative measures and early interval cholecystectomy, IOC after pancreatic inflammation resolves

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53
Q

Why should early interval cholecystectomy be performed on patients with gallstone pancreatitis?

A

Pancreatitis will recur in 33% of patients within 8 weeks

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54
Q

What is the role of ERCP?

A
  1. Cholangitis

2. Refractory choledocholithiasis

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55
Q

What is hemorrhagic pancreatitis?

A

Bleeding into the parenchyma and retroperitoneal structures with extensive pancreatic necrosis

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56
Q

What are the signs of hemorrhagic pancreatitis?

A

Abdominal pain, shock, ARDS, Cullen’s sign, Grey-Turner’s sign, Fox’s sign

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57
Q

What is Cullen’s sign?

A

Bluish discoloration of the periumbilical are from retroperitoneal hemorrhage tracking around to the anterior abdominal wall through fascial planes

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58
Q

What is Grey-Turner’s sign?

A

Ecchymosis or discoloration of the flank in patients with retroperitoneal hemorrhage from dissecting blood from the retroperitoneum

(Grey TURNer = TURN side to side = flank)

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59
Q

What is Fox’s sign?

A

Ecchymosis of the inguinal ligament from blood tracking from the retroperitoneum and collecting at the inguinal ligament

60
Q

What are the significant lab values for hemorrhagic pancreatitis?

A

Increased amylase/lipase, decreased Hct, decreased Ca

61
Q

What radiologic test should be performed for hemorrhagic pancreatitis?

A

CT with IV contrast

62
Q

What is a pancreatic abscess?

A

Infected peripancreatic purulent fluid collection

63
Q

What are the signs and symptoms of pancreatic abscesses?

A

Fever, unresolving pancreatitis, epigastric mass

64
Q

What radiographic test should be performed for pancreatic abscesses?

A

Abdominal CT with needle aspiration (Gram stain and culture)

65
Q

What are the associated lab findings for pancreatic abscesses?

A

Positive Gram stain and culture of bacteria

66
Q

Which organisms are found in pancreatic abscesses?

A 
Gram negative (E. coli, Pseudomonas, Klebsiella)
Gram positive (Staph)
Candida
67
Q

What is the treatment for pancreatic abscesses?

A

Antibiotics and percutaneous drain placement; or operative debridement and placement of drains

68
Q

What is pancreatic necrosis?

A

Dead pancreatic tissue, usually following acute pancreatitis

69
Q

How is the diagnosis of pancreatic necrosis made?

A

Abdominal CT with IV contrast: dead pancreatic tissue does not take up contrast

70
Q

What is the treatment for sterile pancreatic necrosis?

A

Medical management

71
Q

What is the treatment for pancreatic necrosis suspicious of infection?

A

CT-guided FNA

72
Q

What is the treatment for toxic, hypotensive pancreatic necrosis?

A

Operative debridement

73
Q

What is a pancreatic pseudocyst?

A

Encapsulated collection of pancreatic fluid

74
Q

What makes a pancreatic pseudocyst “pseudo”?

A

Wall is formed by inflammatory fibrosis, not epithelial cell lining

75
Q

What is the incidence of pancreatic pseudocyst?

A

10% after alcoholic pancreatitis

76
Q

What are the associated risk factors for pancreatic pseudocysts?

A

Chronic > acute pancreatitis

77
Q

What is the most common cause of pancreatic pseudocyst in the US?

A

Chronic alcohol pancreatitis

78
Q

What are the symptoms of pancreatic pseudocysts?

A

Epigastric pain/mass, vomiting, mild fever, weight loss

79
Q

What are the signs of pancreatic pseudocyst?

A

Palpable epigastric mass, epigastric tenderness, ileus

80
Q

What lab tests should be performed for pancreatic pseudocyst?

A

Amylase/lipase, bilirubin, CBC

81
Q

What are the diagnostic findings for pancreatic pseudocyst?

A

Labs: high amylase, bilirubin (if obstruction), leukocytosis
U/S: fluid-filled mass
CT: fluid-filled mass
ERCP: radiopaque contrast material fills cyst if there is a communicating pseudocyst

82
Q

What is the differential diagnosis of a pancreatic pseudocyst?

A

Cystadenocarcinoma, cystadenoma

83
Q

What are the possible complications of a pancreatic pseudocyst?

A

Infection, bleeding into cyst, fistula, pancreatic ascites, gastric outlet obstruction, SBO, biliary obstruction

84
Q

What is the treatment for pancreatic pseudocyst?

A

Drainage of cyst or observation

85
Q

What is the waiting period before a pancreatic pseudocyst should be drained?

A

It takes 6 weeks for pseudocyst walls to become firm enough to hold sutures and most will resolve in this period of time if they are going to

86
Q

What percentage of pancreatic pseudocysts resolve spontaneously?

A

50%

87
Q

What is the treatment for pancreatic pseudocyst with bleeding into cyst?

A

Angiogram and embolization

88
Q

What is the treatment for pancreatic pseudocyst with infection?

A

Percutaneous external drainage and IV antibiotics

89
Q

What size pancreatic pseudocyst should be drained?

A

Over 5 cm (or if the cyst walls are thick or calcified)

90
Q

What are the three treatment options for pancreatic pseudocyst?

A
  1. Percutaneous aspiration/drainage
  2. Operative drainage
  3. Transpapillary stent via ERCP (must have communicating pancreatic duct)
91
Q

What are the surgical options for pancreatic pseudocyst adherent to the stomach?

A

Cystogastrostomy (drain into stomach)

92
Q

What are the surgical options for pancreatic pseudocyst adherent to the duodenum?

A

Cystoduodenostomy (drain into duodenum)

93
Q

What are the surgical options for pancreatic pseudocyst not adherent to the stomach or duodenum?

A

Roux-en-Y cystojejunostomy (drain into the Roux limb of the jejunum)

94
Q

What are the surgical options for pancreatic pseudocyst in the tail of the pancreas?

A

Resection of the pancreatic tail

95
Q

What is an endoscopic option for drainage of a pancreatic pseudocyst?

A

Endoscopic cystogastrostomy

96
Q

What must be done during a surgical drainage procedure for a pancreatic pseudocyst?

A

Biopsy of the cyst wall to rule out a cystadenocarcinoma.

97
Q

What is the most common cause of death due to pancreatic pseudocyst?

A

Massive hemorrhage into the pseudocyst

98
Q

What is the most common pancreatic cancer?

A

Adenocarcinoma arising from duct cells

99
Q

What are the associated risk factors for pancreatic cancer?

A

Smoking, diabetes, heavy alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy

100
Q

What is the average age of presentation with pancreatic cancer?

A

> 60 yo

101
Q

What are the different types of pancreatic cancer?

A

Duct cell adenocarcinoma, cystadenocarcinoma, acinar cell carcinoma

102
Q

What percentage of pancreatic cancers arise in the pancreatic head?

A

66%

103
Q

Why are most pancreatic cancers in the tail non-resectable?

A

There tumors grow without symptoms until it’s too late and they have metastasized

104
Q

What are signs and symptoms of pancreatic cancers in the head of the pancreas?

A

Jaundice (from obstruction of bile duct), weight loss, abdominal pain, back pain, weakness, pruritus, anorexia, Courvoisier’s sign, acholic stools, dark urine, diabetes

105
Q

What are the signs and symptoms of pancreatic cancers in the body or tail?

A

Weight loss, pain, migratory thrombophlebitis, jaundice, N/V, fatigue

106
Q

What are the most common symptoms of cancer of the pancreatic head?

A
  1. Weight loss
  2. Pain
  3. Jaundice
107
Q

What is Courvoisier’s sign?

A

Palpable, non-tender, distended gallbladder

108
Q

What percentage of patients with cancers of the pancreatic head have Courvoisier’s sign?

A

33%

109
Q

What is the classic presentation of pancreatic cancer in the head of the pancreas?

A

Painless jaundice

110
Q

What metastatic lymph nodes described classically for gastric cancer can be found with metastatic pancreatic cancer?

A

Virchow’s node; Sister Mary Joseph’s nodule

111
Q

What are the associated lab findings of pancreatic cancer?

A

Increased direct bilirubin, alkaline phosphatase (biliary obstruction), LFTs, pancreatic tumor markers

112
Q

Which tumor markers are associated with pancreatic cancer?

A

CA-19-9

113
Q

What does CA-19-9 stand for?

A

Carbohydrate Antigen 19-9

114
Q

What diagnostic studies are performed for pancreatic cancer?

A

Abdominal CT, U/S, cholangiography (ERCP to r/o choledocholithiasis and cell brushings), endoscopic U/S with biopsy

115
Q

What is stage I pancreatic cancer?

A

Tumor is limited to pancreas

116
Q

What is stage II pancreatic cancer?

A

Tumor extends into bile duct, peripancreatic tissues or duodenum

117
Q

What is stage III pancreatic cancer?

A

Stage II plus positive nodes or celiac/SMA involvement

118
Q

What is stage IVA pancreatic cancer?

A

Tumor extends to stomach, colon, spleen, or major vessels

119
Q

What is stage IVB pancreatic cancer?

A

Distant metastases

120
Q

What is the treatment for pancreatic cancer of the head?

A

Whipple procedure (pancreaticoduodenectomy)

121
Q

What is the treatment for pancreatic cancer of the body or tail?

A

Distal resection

122
Q

What factors signify inoperability of pancreatic cancer?

A

Vascular encasement (SMA, hepatic artery), liver mets, peritoneal implants, distant mets, malignant ascites

123
Q

Is portal vein or SMV involvement an absolute contraindication for resection of pancreatic cancer?

A

No, can be resected and reconstructed with vein interposition graft at some centers

124
Q

Should patients undergo preoperative biliary drainage (e.g. ERCP)?

A

No

125
Q

What is the Whipple procedure?

A

Cholecystectomy, truncal vagotomy, antrectomy, pancreaticoduodenectomy, choledochojejunostomy, pancreaticojejunostomy, gastrojejunostomy

126
Q

What is the complication rate after a Whipple procedure?

A

25%

127
Q

What mortality rate is associated with a Whipple procedure?

A

< 5%

128
Q

What is the pylorus-preserving Whipple?

A

No antrectomy; anastomose duodenum to jejunum

129
Q

What are the possible complications of a Whipple procedure?

A

Delayed gastric emptying, anastomotic leak, pancreatic/biliary fistula, wound infection, post-gastrectomy syndromes, sepsis, pancreatitis

130
Q

What is the postoperative adjuvant therapy for a Whipple procedure?

A

Chemotherapy +/- XRT

131
Q

What is the palliative treatment for pancreatic cancer if the tumor is inoperable and biliary obstruction is present?

A

PTC or ERCP and placement of stent across obstruction

132
Q

What is the prognosis at 1-year after diagnosis of pancreatic cancer?

A

Dismal: 10%

133
Q

What is the 5-year survival rate for operable pancreatic cancer?

A

20%

134
Q

What is an annular pancreas?

A

Pancreas encircling the duodenum

135
Q

What is pancreatic divisum?

A

Failure of the 2 pancreatic ducts to fuse; duct of Santorini usually acts as the main duct in such situations

136
Q

What is heterotopic pancreatic tissue?

A

Pancreatic tissue usually found in the stomach or small bowel

137
Q

What is a Puestow procedure?

A

Longitudinal filleting of the pancreas/pancreatic duct with a side-to-side anastomosis with the small bowel

138
Q

What medication decreases output from a pancreatic fistula?

A

Somatostatin

139
Q

Which has a longer half-life: amylase or lipase?

A

Lipase

140
Q

What is the WDHA syndrome?

A 
Pancreatic VIPoma (Vasoactive Intestinal Polypeptide tumor).  Causes:
Watery Diarrhea, Hypokalemia, Achlorhydria
141
Q

What is the Whipple triad of pancreatic insulinoma?

A
  1. Hypoglycemia (< 50)
  2. Symptoms of hypoglycemia: MSC, vasomotor instability
  3. Relief of symptoms with administration of glucose
142
Q

What is the most common islet cell tumor?

A

Insulinoma

143
Q

What pancreatic cancer is associated with gallstone formation?

A

Somatostatinoma (inhibits gallbladder contraction)

144
Q

What is the triad found with pancreatic somatostatinoma tumors?

A
  1. Gallstones
  2. Diabetes
  3. Steatorrhea
145
Q

What are the two classic findings with pancreatic glucagonoma tumors?

A
  1. Diabetes

2. Dermatitis/rash (necrotizing migratory erythema)

ENTREGA (40 decks)

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