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Surgery > Pancreas > Flashcards

Pancreas Flashcards

1
Q

Pancreas develop from

A

Endoderm of primitive gut

Ventral and dorsal bud

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2
Q

Small ventral bud from hepatic diverticulim gives rise to

A 
proximal pancreatic structures 
proximal main pancreatic duct Wirsung 
Uncinate process 
CBD
Parts of head
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3
Q

Dorsal bud from duodenum gives rise to

A

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

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4
Q

Most common congenital anomaly of pancreas

A

Pancreatic divisum

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5
Q

Posterior to head of pancreas

A

IVC

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6
Q

Posterior to body and tail of pancreas

A

Splenic artery and vein

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7
Q

Posterior to neck of pancreas

Medial to uncinate

A

SMA
SMV
PV

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8
Q

Failure to fuse

A

pancreatic divisum

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9
Q

Pancreatic divisum tx

A

Sphincterotomy

Cholecystectomy

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10
Q

Failure of ventral bud to rotate

A

Annular pancreas

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11
Q

Annular pancreas tx

A

Duodenojejunostomy

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12
Q

Blood supply head of pancreas

A

SMA

Superior and inferior pancreaticoduodenal branches of gastroduodenal artery

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13
Q

Body of pancreas blood supply

A

Splenic artery

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14
Q

Tail of pancreas blood supply

A

Branches from dorsal pancreatic splenic, gastroepiploic artery

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15
Q

Branch of CHA comes off celiac trunk

A

Gastroduodenal artery

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16
Q

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

A

Portal vein
IMV
Splenic vein

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17
Q

Pancreatic secretion is innvervated by

A

efferent fibers from parasympathetic

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18
Q

Blood flow regulation to exocrine pancreas

A

Sympathetic innvervation

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19
Q

Lymphatic drain of pancreas

A 
Pancreaticoduodenal nodes (head)
Pancreaticosplenic nodes (neck body tail)
Superior mesenteric nodes
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20
Q

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

A

Ocreotide

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21
Q

80% of acute pancreatitis is caused by

A

gallstone or alcohol

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22
Q

Drugs associated with acute pancreatitis

A

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

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23
Q

Flank ecchymosis

A

Grey turner sign

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24
Q

Periumbilical ecchymosis

A

Cullen sign

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25
Q 
Inc WBC
Inc glucose
Inc LDH
Inc AST
Inc amylase and lipase
A

Pancreatitis

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26
Q

More sensitive and specific

A

Lipase

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27
Q

Confirms acute pancreatitis

A

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

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28
Q

If pancreatic necrosis is seen, sx

A

CT guided aspiration to differentiate if sterile or infected

Latter requires debridement

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29
Q

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

A

True

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30
Q

Ranson’s criteria

On admission

A 
Age >55
Glucose >200 mg/dl
WBC >16
LDH >350
AST >250
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31
Q

Ranson criteria

Within 48h of admission

A 
BUN >5 
Ca <8 
Hct dec by >10
Base deficit >4 
PaO2 <60 
Fluid sequestration >6L
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32
Q

0-2 on Ranson criteria

A

2% Mortality

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33
Q

3-4 on Ranson criteria

A

15% Mortality

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34
Q

5-6 on Ranson

A

40% Mortality

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35
Q

7-8 on Ranson

A

100% mortality

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36
Q

Uncomplicated acute pancreatitis tx

A 
conservative management 
fluid resuscitation
NPO
NGT
Close monitoring of fluid balance
Pain control 
Bowel rest with TPN (not for mild)
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37
Q

Necrotizing pancreatitis tx

A

Prophylactic antibiotic (imipenem with or without antifungal coverage)

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38
Q

Gallstone pancreatitis with obstructivr choledocholithiasis or cholangitis tx

A

ERCP with sphincterotomy followed by cholecystectomy

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39
Q

Infected necrotizing pancreatitis

Symptomatic organized necrosis tx

A

Necrosectomy

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40
Q

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

A

Chronic pancreatitis

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41
Q

Most common cause of chronic pancreatitis

A

Alcohol

Others
Gallstone
Obstruction
Pancreas divisum
Autoimmune pancreatitis
Familial predisposition (SPINK1, CFTR, fam hyperlipidemia)
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42
Q

Intermittent abdominal pain
Weight loss
DM
Steatorrhea

A

Chronic pancreatitis

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43
Q

Normal or inc amylase and lipase
Inc ALP
Inc blood glucose

A

Chronic pancreatitis

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44
Q

Chronic pancreatitis dx

A

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

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45
Q

Gold standard for dx in chronic pancreatitis

A

ERCP: irregular main duct, ductal dilation, duct stricture

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46
Q

Chronic panc tx

A

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

47
Q

Pancreatic stone tx

A

Amenable to shockwave lithotripsy

48
Q

Stricture tx

A

Sphincterotomy

Duct stenting

49
Q

Surgery indications

A

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

50
Q

Duct of normal diameter sx

A

Pancreaticoduodenectomy

Whipple

51
Q

Dilated duct sx

A

Longitudinal pancreaticojejunostomy

Puestow

52
Q

Distal disease sx

A

Distal pancreatectomy

53
Q

Small duct with diffuse disease sx

A

Total pancreatectomy with autotransplantation of islet cell

54
Q

Chronic pancreatitis complication

A

Pancreatic pseudocyst
Pancreatic fistula
Obstruction of duodenum or biliary tree

55
Q

Most commonly associated with alcoholic pancreatitis

A

Pancreatic pseudocyst

56
Q

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

A

Pancreatic pseudocyst

57
Q

Management of pseudocyst depends on

A

Pain, size and duration of pseudocyst

58
Q

Neoplasm, congenital cyst and retention cysts have

A

epithelialized lining

59
Q

Pseudocyst differentiated by

A

MRI superior to CT

60
Q

Pseudocyst tx

A

Endoscopic
Percutaneous
Surgical drain

61
Q

If organized >6 weeks, pseudocyst may be subjected to

A

surgery

62
Q

Complications of pseudocyst

A 
Infection
Rupture of pseudocyst
Hemorrhage to nearby structure
Biliary obstruction
GOO
63
Q

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

A

Pancreatic pseudocyst

64
Q 
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

A

IPMN

Intraductal papillary mucinous neoplasm

65
Q

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

A

mucinous neoplasm

66
Q 
Mucin production 
Dilation of pancreatic duct
Communication main pancreatic duct
Men
Head of pancreas
A

Intraductal papillary mucinous neoplasm

67
Q

IPMN tx

A

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

68
Q 
Middle aged females
Body or tail of pancreas
Ovarial like stroma 
Lack of ductal communication 
Asymptomatic 
Incidental on imaging
A

Mucinous neoplasm

69
Q

Mucinous neoplasm tx

A

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

70
Q

Pathognomonic of MCN

A

Ovarian like stroma

71
Q

Communicate with main pancreatic duct

A

IPMN

72
Q 
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?
A

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

73
Q

Pancreatic ductal adenocarcinoma rf

A 
Age
African american
Tobacco
Chronic pancreatitis
DM
Family history (familial multiple mole melanoma, hereditary breast-ovarian, hereditary pancreatitis-pancreatic cancer)
74
Q

Pancreatic adenocarcinoma classic presentation

A

painless jaundice

75
Q

Palpable gallbladder

A

Courvosier sign

76
Q

Palpable periumbilical metastatic disease

A

Sister Mary Joseph nodule

77
Q

Migratory thrombophlebitis

A

Trosseau sign

78
Q

Palpable left supraclavicular fossa node

A

Virchow node

79
Q

Palpable metastases on rectal exam

A

Blummer’s shelf

80
Q

Missed by CT scan

A

Liver mets <1cm

81
Q 
Inc bilirubin
Inc ALP
Inc AST ALT
normal amylase lipase
Inc CA 19-9 and CEA
A

Pacreatic adenocarcinoma

82
Q

More specific for pancreatic adenocarcinoma

A

CA 19-9

83
Q

Dx for pancreatic adenocarcinoma

A

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

84
Q

Confirms dx of pancreatic adenocarcinoma

A

Endoscopic uts with fine needle aspiration

85
Q

ERCP of pancreatic adenocarcinoma:

A

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

86
Q

ERCP: dilated pancreatic duct/CBD but only 1 stricture

A

Amupllary cancer

87
Q

Unresectable at time of diagnosis

A

Tumor at body and tail

88
Q

Resectability of PDAC

A

absence of extrapancreatic disease

no encasement or involvement of celiac axis, HA, SMA, SMV, PV

89
Q

Complication following Whipples

A

Pancreatic fistuka
Delayed gastric emptying
Intraabdominal abscess
Wound infection

90
Q

Palliation:

A

GOO
Biliary obstruction
Pain

91
Q

Chemoradiotherapeutics for PDAC

A

gemcitabine
5-FU
radiation

92
Q

35 M
Collapsed while walking to work
Diaphoretic, tachycardic
Blood sugar 35mg/dl

Most appropriate management?

A

Glucose

CT scan with IV reveal hypervascular lesion in pancreas

Resection

Ocreotide scan for mets

93
Q

B cell/insulin
Evenly distributed in pancreas
10% malignant

Whipple’s triad: Fasting hypoglycemia, blood sugat <50 mg/dl during episode, relief with glucose

A

Insulinoma

94
Q 
G cells/gastrin
Gastrinoma triangle
Pancreatic head
70% malignant 
Better prognosis if MEN-1
Epigastric pain and ulcers refractory to medical treatment 
diarrhea
A

Gastrinoma

95
Q 
Alpha cell/glucagon
Tail 
75% malignant with mets
Migratory necrolytic erythema
Anemia, DM, PM, Hypercoagulability, stomatitis
A

Glucagonoma

96
Q

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

A

Somatostatinoma

97
Q 
D2 cells/VIP
Body, tail
50% malignant
75% metastatic
Watery diarrhea, hypokalemia, achlorydia inc Ca
A

VIPoma

Verner Morrison Syndrome

98
Q

Watery diarrhea
Hypokalemia
Achlorydia

A

Verner-Morrison Syndrome

WDHA syndrome

99
Q

Most common functional endocrine tumor of pancreas

Dec glucose
Inc insulin
Inc C peptide

A

Insulinoma

100
Q

Preoperatively used to prevent hypoglycemia in insulinoma

A

diazoxide

101
Q

Formal pancreatic resection for insulinomas

A

> 2cm

102
Q

Unresectable malignant tumors debulked and ff by

A

5-FU

streptozocin

103
Q

Used to control symptoms of insulinoma

A

Ocreotide

104
Q

Boundaries of gastrinoma triangle

A

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

105
Q

second most common functional endocrine tumor

A

gastrinoma

106
Q

Associated with ZES
inc gastrin level >1000
inc gastrin >200 in secretin stimulation test

Resect if >2cm

A

Gastrinoma

107
Q

Fasting glucagon level >50
Preoperative reversal of catabolic state with ocreotide, enteral nutrition, AA supplementation

Decarbazine or streptozocin if unresectable

A

Glucagonoma

108
Q

Unresectable at diagnosis
Chemotherapy: streptozocin, decarbazine, doxorubicin

If resectable at head, perform Whipple

A

Somatostinoma

109
Q

Inc serum VIP >200
Localized by CT or SRS

Preoperative ocreotide to correct fluid and electrolyte imbalance

A

VIPoma

110
Q

50, M
Chronic pancreatitis with bleeding gastric varices

Cause?

Tx?

A

Splenic vein thrombosis

Splenectomy

111
Q

Most common location

Insulinoma

Gastrinoma

Glucagonoma

A

Insulinoma: evenly distributed

Gastrinoma: triangle

Glucagonoma: pancreatic tail

112
Q

65, M
Painless jaundice suspected PDAC

Most sensitive radiographic modality?

A

Endoscopic ultrasound

113
Q

Chronic pancreatitis
Intractable pain
Pancreatic duct dilated at 1.2 cm

Surgery?

Length of anastomosis?

A

Puestow for pancreatic ducts dilated >1cm

Anastomosis should extend to distance of at least 6cm

Surgery (17 decks)

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