PANCREAS Flashcards
2 pancreatic ducts
Wirsung duct
Santorini duct
Major duct
Wirsung duct
Blood supply (head of the pancreas)
- Celiac trunk –> gastroduodenal –> Anterior superior pancreaticoduodenal artery
Posterior superior pancreaticoduodenal artery
- Superior mesenteric artery –> Anterior inferior pancreaticoduodenal artery
Posterior inferior pancreaticoduodenal artery
- Splenic artery –> Dorsal pancreatic artery
Endocrine function of the pancreas
Islets of Langerhans:
alpha-cells: glucagon
beta-cells: insulin
delta cells: somatostatin
PP cells: pancreatic polypeptide
Exocrine function of the pancreas
Digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase
Kocher maneuver
Used to mobilize the duodenum and pancreas and evaluate the
entire pancreas
Incise the lateral attachments of the duodenum and then lift the pancreas to examine the posterior surface
Admission Ranson Criteria
“GA LAW (Georgia law)”:
Glucose >200 Age >55 LDH >350 AST >250 WBC >16,000
Ranson’s criteria at less than 48 hours be remembered
“C HOBBS (Calvin and Hobbes)”:
Calcium <8 mg/dL Hct drop of >10% O2 <60 (PaO2) Base deficit >4 Bun >5 increase Sequestration >6 L
Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and
exocrine tissue
Chronic Pancreatitis
Chronic inflammatory changes that are caused by the compression or occlusion of the proximal ductal system by tumor, gallstone, posttraumatic scar, or inadequate duct caliber (as in pancreas divisum)
Chronic Pancreatitis
TIGAR-O Classification
Toxic and metabolic Idiopathic Genetic Predisposition Autoimmune Recurrent and Severe acute pancreatitis Obstructive
Represents a special case of obstructive pancreatitis and the MC congenital anomaly involving the pancreas
Pancreas divisum
Characterized by diffuse fibrosis and a loss of acinar elements with a predominant mononuclear cell infiltration throughout the gland
Chronic Inflammatory Pancreatitis
Common feature of all forms of chronic pancreatitis
perilobular fibrosis
The MC symptom of chronic pancreatitis
pain
For patients with focal inflammatory changes localized to the body and tail, or in whom no significant ductal dilatation exists
Distal Pancreatectomy
Proximal pancreatectomy or pancreaticoduodenectomy, with or without pylorus preservation
Proximal Pancreatectomy
Origin of cells of the endocrine pancreas, or islet cells
neural crest cells
Multiple Endocrine Neoplasm (MEN) I – 3 Ps
pituitary tumors
parathyroid hyperplasia
pancreatic neoplasms
The MC functional pancreatic endocrine neoplasms
Insulinomas
Associated with beta-cell hypertrophy, islet hyperplasia and ↑ beta-cell mass
Noninsulinoma Hyperinsulinemia Hypoglycemia Syndrome
Endocrine tumor that secretes gastrin –> acid hypersecretion and peptic ulceration
causes Zollinger-Ellison syndrome (ZES)
Gastrinoma
Whipple’s triad
- symptomatic fasting hypoglycemia
- documented serum glucose level <50 mg/dL
- relief of symptoms with the administration of glucose
Location of primary gastrinoma i in 70% to 90% of patients
Passaro’s triangle
Also called WDHA syndrome due to the presence of WATERY DIARRHEA, HYPOKALEMIA, and ACHLORHYDIA
Vasoactive Intestinal Peptide-Secreting Tumor
DIABETES in association with DERMATITIS
Glucagonoma
Serum glucagon level in glucagonoma
> 500 pg/mL
Presents with:
GALLSTONES due to bile stasis
DIABETES due to inhibition of insulin secretion
STEATORRHEA due to inhibition of pancreatic exocrine secretion and bile secretion
Somatostinoma
MC site of somatostinoma
ampulla and periampullary area
Serum somatostatin level in somatostinoma
> 10 ng/mL
The most commonly mutated gene in pancreatic cancer, with ~ 90% of tumors having a mutation
K-ras oncogene
The MC cystic lesion of the pancreas
No epithelial lining and is a nonneoplastic complication of pancreatitis or pancreatic duct injury
Pseudocysts
Essentially considered benign tumors without malignant potential
Cystadenoma
encompass a spectrum ranging
from benign but potentially malignant to carcinoma with a very aggressive behavior
commonly seen in perimenopausal women
about 2/3 are located in the body or tail of the pancreas
Mucinous Cystadenoma and Cystadenocarcinoma
Surgical Treatment for Chronic Pancreatitis
Puestow—LONGITUDINAL pancreaticojejunostomy (pancreatic duct must be dilated)
Duval—DISTAL pancreaticojejunostomy
Near-total pancreatectomy
Frey Procedure
Longitudinal pancreaticojejunostomy with core resection of the pancreatic head
Acute pancreatitis from a gallstone in or
passing through the ampulla of Vater (the exact mechanism is unknown)
Gallstone Pancreatitis
Encapsulated collection of pancreatic
fluid
Pancreatic Pseudocyst
Surgical option for pseudocyst ADHERENT to the STOMACH
Cystogastrostomy (drain into the stomach)
Surgical option for pseudocyst ADHERENT to the DUODENUM
Cystoduodenostomy (drain into the duodenum)
Surgical option for pseudocyst NOT ADHERENT to the stomach or duodenum
Roux-en-Y cystojejunostomy (drain into
the Roux limb of the jejunum)
Surgical option for pseudocyst in the TAIL of the pancreas
Resection of the pancreatic tail with the pseudocyst
MC cause of death due to pancreatic pseudocyst
massive hemorrhage into the pseudocyst
Adenocarcinoma of the pancreas arising
from duct cells
Pancreatic carcinoma
Pancreatic carcinoma
66% - pancreatic HEAD
33% - BODY and TAIL
Why are most pancreatic cancers in the tail nonresectable?
These tumors grow without symptoms until it is too late and they have already spread— head of the pancreas tumors draw attention earlier because of biliary obstruction
Signs/ symptoms of tumors based on location
HEAD (pancreas)
PAINLESS JAUNDICE from obstruction of CBD; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes
BODY OR TAIL
weight loss and pain (90%); migratory thrombophlebitis (10%); jaundice (<10%); nausea and vomiting; fatigue
The MC symptoms of cancer of the pancreatic HEAD
Weight loss (90%)
Pain (75%)
Jaundice (70%)
“Courvoisier’s sign”
palpable
nontender
distended gallbladder
Metastatic lymph nodes described classically for
gastric cancer which can be found with metastatic pancreatic cancer
Virchow’s node
Sister Mary Joseph’s nodule
Tumor markers associated with pancreatic cancer
CA - 19
carbohydrate antigen
Treatment based on location
head of the pancreas - Whipple procedure
(pancreaticoduodenectomy)
tail - Distal resection
Whipple procedure
pancreaticoduodenectomy
Cholecystectomy Truncal vagotomy Antrectomy Pancreaticoduodenectomy—removal of head of pancreas and duodenum Choledochojejunostomy—anastomosis of CBD to jejunum Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum Gastrojejunostomy—anastomosis of stomach to jejunum
“pylorus preserving Whipple”
No antrectomy; anastomose duodenum
to jejunum
possible post-Whipple complications
delayed gastric emptying (if antrectomy is performed)
anastomotic leak (from the bile duct or pancreatic anastomosis)
causing pancreatic/biliary fistula
wound infection
postgastrectomy syndromes
sepsis
pancreatitis
Pancreas encircling the duodenum; if obstruction is present, bypass, do NOT resect
annular pancreas
Failure of the two pancreatic ducts to fuse; the normally small duct (Small Santorini) of Santorini acts as the main duct
Pancreatic Duct
Longitudinal filleting of the pancreas/ pancreatic duct with a side-to-side anastomosis with the small bowel
Puestow procedure
Pancreatic tumor is associated with gallstone
formation
Somatostatinoma
Triad found with pancreatic somatostatinoma
tumor
Gallstones
Diabetes
Steatorrhea
2 classic findings with pancreatic glucagonoma tumors
Diabetes
Dermatitis/rash (necrotizing migratory erythema)
The only therapy shown to prevent the progression of
chronic pancreatitis
Pancreatic duct decompression
