Pancreas Flashcards by Denisse Tiangco

Pancreas develop from

Endoderm of primitive gut

Ventral and dorsal bud

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Small ventral bud from hepatic diverticulim gives rise to

proximal pancreatic structures 
proximal main pancreatic duct Wirsung 
Uncinate process 
CBD
Parts of head

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Dorsal bud from duodenum gives rise to

Accessory pancreatic duct (Santorini)
Pancreatic head
Pancreatic body, tail

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Most common congenital anomaly of pancreas

Pancreatic divisum

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Posterior to head of pancreas

IVC

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Posterior to body and tail of pancreas

Splenic artery and vein

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Posterior to neck of pancreas

Medial to uncinate

SMA
SMV
PV

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Failure to fuse

pancreatic divisum

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Pancreatic divisum tx

Sphincterotomy

Cholecystectomy

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Failure of ventral bud to rotate

Annular pancreas

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Annular pancreas tx

Duodenojejunostomy

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Blood supply head of pancreas

SMA

Superior and inferior pancreaticoduodenal branches of gastroduodenal artery

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Body of pancreas blood supply

Splenic artery

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Tail of pancreas blood supply

Branches from dorsal pancreatic splenic, gastroepiploic artery

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Branch of CHA comes off celiac trunk

Gastroduodenal artery

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Superior veins of pancreas drain to
Inferior veins drain to
Body and tail drain to

Portal vein
IMV
Splenic vein

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Pancreatic secretion is innvervated by

efferent fibers from parasympathetic

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Blood flow regulation to exocrine pancreas

Sympathetic innvervation

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Lymphatic drain of pancreas

Pancreaticoduodenal nodes (head)
Pancreaticosplenic nodes (neck body tail)
Superior mesenteric nodes

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Somatostatin analog for bleeding esophageal varices, inhibitory of pituitary adenoma and carcinoid

Ocreotide

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80% of acute pancreatitis is caused by

gallstone or alcohol

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Drugs associated with acute pancreatitis

Steroids
Diuretics (thiazide)
Immune modulating drug (azathioprine)
antiretroviral

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Flank ecchymosis

Grey turner sign

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Periumbilical ecchymosis

Cullen sign

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``` Inc WBC Inc glucose Inc LDH Inc AST Inc amylase and lipase ```

Pancreatitis

More sensitive and specific

Lipase

Confirms acute pancreatitis

CT scan: peripancreatic fat stranding, fluid collection, nonenhancing pancreatic parenchyma with gas (necrosis)

If pancreatic necrosis is seen, sx

CT guided aspiration to differentiate if sterile or infected Latter requires debridement

T/F: Pancreatic enzyme levels do not correlate with severity and outcome

True

Ranson’s criteria | On admission

``` Age >55 Glucose >200 mg/dl WBC >16 LDH >350 AST >250 ```

Ranson criteria | Within 48h of admission

``` BUN >5 Ca <8 Hct dec by >10 Base deficit >4 PaO2 <60 Fluid sequestration >6L ```

0-2 on Ranson criteria

2% Mortality

3-4 on Ranson criteria

15% Mortality

5-6 on Ranson

40% Mortality

7-8 on Ranson

100% mortality

Uncomplicated acute pancreatitis tx

``` conservative management fluid resuscitation NPO NGT Close monitoring of fluid balance Pain control Bowel rest with TPN (not for mild) ```

Necrotizing pancreatitis tx

Prophylactic antibiotic (imipenem with or without antifungal coverage)

Gallstone pancreatitis with obstructivr choledocholithiasis or cholangitis tx

ERCP with sphincterotomy followed by cholecystectomy

Infected necrotizing pancreatitis | Symptomatic organized necrosis tx

Necrosectomy

Prolonged pancreatic inflammation Fibrosis and ductal obstruction Inc ductal pressure and ductal dilation Irreversible change with loss of exocrine and endocrine function

Chronic pancreatitis

Most common cause of chronic pancreatitis

Alcohol ``` Others Gallstone Obstruction Pancreas divisum Autoimmune pancreatitis Familial predisposition (SPINK1, CFTR, fam hyperlipidemia) ```

Intermittent abdominal pain Weight loss DM Steatorrhea

Chronic pancreatitis

Normal or inc amylase and lipase Inc ALP Inc blood glucose

Chronic pancreatitis

Chronic pancreatitis dx

CT: dilated, calcified pancreatic duct with stenosis (chain of lakes)

Gold standard for dx in chronic pancreatitis

ERCP: irregular main duct, ductal dilation, duct stricture

Chronic panc tx

Avoid trigger (alcohol) Pain control (NSAID) Insulin if DM Replace pancreatic enzyme (pancrelipase) if exocrine insufficient

Pancreatic stone tx

Amenable to shockwave lithotripsy

Stricture tx

Sphincterotomy | Duct stenting

Surgery indications

Intractable pain Cancer Stenosis of pancreatic duct Obstruction of duodenum or biliary tree

Duct of normal diameter sx

Pancreaticoduodenectomy | Whipple

Dilated duct sx

Longitudinal pancreaticojejunostomy | Puestow

Distal disease sx

Distal pancreatectomy

Small duct with diffuse disease sx

Total pancreatectomy with autotransplantation of islet cell

Chronic pancreatitis complication

Pancreatic pseudocyst Pancreatic fistula Obstruction of duodenum or biliary tree

Most commonly associated with alcoholic pancreatitis

Pancreatic pseudocyst

Chronic peripancreatic fluid collections with nonepithelialized capsule Resolve in 4-6 weeks Persistent abdominal pain, early satiety Inc amylase and lipase Normal CEA and CA 19-9

Pancreatic pseudocyst

Management of pseudocyst depends on

Pain, size and duration of pseudocyst

Neoplasm, congenital cyst and retention cysts have

epithelialized lining

Pseudocyst differentiated by

MRI superior to CT

Pseudocyst tx

Endoscopic Percutaneous Surgical drain

If organized >6 weeks, pseudocyst may be subjected to

surgery

Complications of pseudocyst

``` Infection Rupture of pseudocyst Hemorrhage to nearby structure Biliary obstruction GOO ```

Single cyst No septation Absence of mass/nodularity Inside cyst + communication with main duct on ERCP/MRCP Inc amylase Normal CEA Normal CA 19-9

Pancreatic pseudocyst

``` Single or multiple lesion +/- septation +/- mass nodularity inside cyst + communication with main duct on ERCP/MRCP ``` Inc amylase Normal or inc CEA Normal or inc CA 19-9

IPMN | Intraductal papillary mucinous neoplasm

Single or multiple +/- septation +/- mass or nodularity inside cyst No communication with main duct on ERCP/MRCP Dec amylase Normal or inc CEA Normal or inc CA 19-9

mucinous neoplasm

``` Mucin production Dilation of pancreatic duct Communication main pancreatic duct Men Head of pancreas ```

Intraductal papillary mucinous neoplasm

IPMN tx

resection of main duct Whipple if head Distal pancreatectomy for tail Total pancreatectomy if multiple

``` Middle aged females Body or tail of pancreas Ovarial like stroma Lack of ductal communication Asymptomatic Incidental on imaging ```

Mucinous neoplasm

Mucinous neoplasm tx

Surgical resection (distal pancreatectomy) due to risk for malignant progression

Pathognomonic of MCN

Ovarian like stroma

Communicate with main pancreatic duct

IPMN

``` 55, F Persistent epigastric pain radiating to back CT scan: 3.5cm mass at head of pancreas Elevated CA 19-9 How is resectability determined? ```

Assess extrapancreatic disease Encasement or invasion of celiac axis hepatic artery SMA SMV PV

Pancreatic ductal adenocarcinoma rf

``` Age African american Tobacco Chronic pancreatitis DM Family history (familial multiple mole melanoma, hereditary breast-ovarian, hereditary pancreatitis-pancreatic cancer) ```

Pancreatic adenocarcinoma classic presentation

painless jaundice

Palpable gallbladder

Courvosier sign

Palpable periumbilical metastatic disease

Sister Mary Joseph nodule

Migratory thrombophlebitis

Trosseau sign

Palpable left supraclavicular fossa node

Virchow node

Palpable metastases on rectal exam

Blummer’s shelf

Missed by CT scan

Liver mets <1cm

``` Inc bilirubin Inc ALP Inc AST ALT normal amylase lipase Inc CA 19-9 and CEA ```

Pacreatic adenocarcinoma

More specific for pancreatic adenocarcinoma

CA 19-9

Dx for pancreatic adenocarcinoma

contrast enhanced triple phase CT for stage and resectability Hypoechoic associated with pancreatic atrophy and distal ductal dilation

Confirms dx of pancreatic adenocarcinoma

Endoscopic uts with fine needle aspiration

ERCP of pancreatic adenocarcinoma:

Double duct sign (CBD and pancreatic duct dilatation) with two stricture

ERCP: dilated pancreatic duct/CBD but only 1 stricture

Amupllary cancer

Unresectable at time of diagnosis

Tumor at body and tail

Resectability of PDAC

absence of extrapancreatic disease | no encasement or involvement of celiac axis, HA, SMA, SMV, PV

Complication following Whipples

Pancreatic fistuka Delayed gastric emptying Intraabdominal abscess Wound infection

Palliation:

GOO Biliary obstruction Pain

Chemoradiotherapeutics for PDAC

gemcitabine 5-FU radiation

35 M Collapsed while walking to work Diaphoretic, tachycardic Blood sugar 35mg/dl Most appropriate management?

Glucose CT scan with IV reveal hypervascular lesion in pancreas Resection Ocreotide scan for mets

B cell/insulin Evenly distributed in pancreas 10% malignant Whipple’s triad: Fasting hypoglycemia, blood sugat <50 mg/dl during episode, relief with glucose

Insulinoma

``` G cells/gastrin Gastrinoma triangle Pancreatic head 70% malignant Better prognosis if MEN-1 Epigastric pain and ulcers refractory to medical treatment diarrhea ```

Gastrinoma

``` Alpha cell/glucagon Tail 75% malignant with mets Migratory necrolytic erythema Anemia, DM, PM, Hypercoagulability, stomatitis ```

Glucagonoma

Dela cell/somatostatin Head 50% malignant with mets DM, diarrhea, biliary tract disease

Somatostatinoma

``` D2 cells/VIP Body, tail 50% malignant 75% metastatic Watery diarrhea, hypokalemia, achlorydia inc Ca ```

VIPoma | Verner Morrison Syndrome

Watery diarrhea Hypokalemia Achlorydia

Verner-Morrison Syndrome | WDHA syndrome

Most common functional endocrine tumor of pancreas Dec glucose Inc insulin Inc C peptide

Insulinoma

Preoperatively used to prevent hypoglycemia in insulinoma

diazoxide

Formal pancreatic resection for insulinomas

>2cm

Unresectable malignant tumors debulked and ff by

5-FU | streptozocin

Used to control symptoms of insulinoma

Ocreotide

Boundaries of gastrinoma triangle

Cystic duct Junction of second and third portion of duodenum Junction of neck and body of pancreas

second most common functional endocrine tumor

gastrinoma

Associated with ZES inc gastrin level >1000 inc gastrin >200 in secretin stimulation test Resect if >2cm

Gastrinoma

Fasting glucagon level >50 Preoperative reversal of catabolic state with ocreotide, enteral nutrition, AA supplementation Decarbazine or streptozocin if unresectable

Glucagonoma

Unresectable at diagnosis Chemotherapy: streptozocin, decarbazine, doxorubicin If resectable at head, perform Whipple

Somatostinoma

Inc serum VIP >200 Localized by CT or SRS Preoperative ocreotide to correct fluid and electrolyte imbalance

VIPoma

50, M Chronic pancreatitis with bleeding gastric varices Cause? Tx?

Splenic vein thrombosis Splenectomy

Most common location Insulinoma Gastrinoma Glucagonoma

Insulinoma: evenly distributed Gastrinoma: triangle Glucagonoma: pancreatic tail

65, M Painless jaundice suspected PDAC Most sensitive radiographic modality?

Endoscopic ultrasound

Chronic pancreatitis Intractable pain Pancreatic duct dilated at 1.2 cm Surgery? Length of anastomosis?

Puestow for pancreatic ducts dilated >1cm Anastomosis should extend to distance of at least 6cm