Pancreas SCORE Flashcards
Pseudocysts have what cytology?
low CEA
high amylase
serous fluid
Serous cystic neoplasms have what cytology?
low CEA
low amylase
serous fluid
IPMN and MCN have what fluid cytology?
IPMN: high CEA, high amylase, mucinous fluid
MCN; high CEA, low amylase, mucinous fluid
What do we do with asymptomatic pseudocysts?
don’t require treatment
50% of pts will develop psueodocysts after an episode of severe acute pancreatitis
70% will resolve spontaneously
**you operate when pts have intractable abdominal pain, oral intolerance, and can’t exclude cystic neoplasm
What % of cases of chronic pancreatitis in US are due to etoh?
50%
Management of main-duct IPMN vs branched type IPMN:
main duct–> surgical resection; 60% malignant potential
branched type–> plan based on tumor size
Mortality of surgical intervention in acute pancreatitis within 2 weeks is?
75%
decreases to 8% after 28 days
What are two duodenum-preserving pancreatic head resection procedures?
Begger
Frey
(these procedures are not appropriate when pancreatic cancer is considered)
Do we resect mucinous cystic neoplasms of pancreas?
YES
considered pre-malignant
What are pancreatic MCNs?
mucinous cystic neoplasms
made of mucin producing epithelial cells
walls of cyst contain a distinctive ovarian-type stroma
For a Puestow procedure, what is the minimal length of your anastomosis?
6cm
Gold standard to diagnose pancreas divisum?
MRCP
What’s the risk of post-ERCP pancreatitis?
5%
What enzymes produced by pancreas in active form, that helps digest starch (sugars)?
amylase secreted in active form from pancreas and saliva
When do we performa a longitudinal pancreaticojejunostomy?
dilated pancreatic duct >6 mm w/out pancreatic head enlargement
When do we perform a Frey procedure?
enlarged pancreatic head
dilated pancreatic duct
(involves pancreatic duct drainage and a focal pancreatic head resection)
Pts w/ Lynch syndrome have an increased risk of pancreatic cancer; Lynch syndrome is caused by what??
germline mutation in mismatch repair
Most common symptom assc/ w pancreas divisum?
no symptoms
95% of pts remain asymptomatic
Serous cystadenomas of pancreas tend be located anywhere in pancreas, and their fluid cytology shows:
clear fluid
low CEA
neg mucin
low amylase
Most frequent complication of pancreaticoduodenectomy?
pancreatic fistula
For all patients undergoing surgical debridement of pancreatic necrosis; what’s the incidence of developing DM?
25%
risk is assc/ w % of gland lost, with more gland lost, more chance of developing DM
30 days following a necrosectomy, a pt’s JP drain has been putting out 60 /cc a day, what do you do next?
most pancreatic fistulas will close in 4-6 weeks
if they fail to close, ERCP and stent placement help close > 85% of fistulas
When is the Beger procedure used?
used for pancreatitis w/ large pancreatic head and small pancreatic ducts
it’s a duodenal preserving pancreatic head resection
transect the pancreatic neck, core out pancreatic head
Puestow procedure?
longitudinal pancreaticojejunostomy
used for pancreatic ducts 6 mm >, without enlarged pancreatic head
Frey procedure?
lateral pancreaticojejunostomy with local pancreatic head resection
When do we use Frey procedure?
dilated pancreatic duct from obstruction due to enlarged pancreatic head
Duodenal sparing pancreatic head resection?
Beger procedure
When is Beger used?
enlarged pancreatic head with normal caliber pancreatic duct
Most common cause for pancreatic insufficiency is chronic pancreatitis, 2nd most common cause is?
cystic fibrosis
When we have food in the duodenum, pancreatic ductal cells secrete HCO3 to neutralize acidity of food, HCO3 release is mediated by?
secretin
HCO3 is pumped outside the ductal cell into the lumen, and Cl is exchanged inside the cell
Pancreas divisom is failure of the ventral and dorsal pancreatic ducts to fuse, rarely does it present with symptoms, how is it treated?
ERCP and sphincteroplasty
Wirsung and Santorini ducts drain via what papilla?
duct of Wirsong drains via major papilla; drains head and uncinate process
duct of Santorini drains via minor papilla; drains body and tail
Mucinous cystic neoplasms are commonly found where?
body and tail of pancreas
due to malignancy risk; laparoscopic spleen preserving pancreatectomy can be performed
there is no risk to rest of pancreas once removed, so no need for surveillance
In terms of cystic neoplastic lesion of pancreas, which one has a starburst calcification pattern?
serous cystic neoplasms
In terms of cystic neoplastic lesion of pancreas, which one has a eggshell calcification pattern?
MCNs
Why are mucinous cystic neoplasms usually amenable to spleen preserving distal pancreatectomy?
b/c they are usually found in tail of pancreas
Normal pancreatic duct drainage vs what happens in pancreas divisum:
normally; 70% of pancreas drained by ventral duct via major papilla
PD; major pancreatic drainage is via dorsal duct which drains into minor papilla
What % of pts with acute pancreatitis that develop peri-pancreatic fluid collections will develop pseudocysts?
5-15%
What enzyme secreted by pancreas in active form?
lipase
How long does it take for pancreatic pseudocysts to develop?
4-8 weeks
Tell me things about insulinomas;
benign
usually less than 2 cm
can be found anywhere in pancreas
What is the most common neuroendocrine tumor?
insulinomas
Ranson criteria and morality;
each category gets 1 point
0-2–> 2 % mortality
3-4–> 15%
5-6–>40%
+7 –> 100%
Which enzyme cleared first in pancreatitis?
amylase
usually cleared in less than 48 hrs
Whipple’s triad in insulinomas?
hypoglycemia
neuro-glycopenic symptoms ; weak, confused, palpatations
relief of sxs with glucose
What are the most common functional pancreatic neuroendocrine tumors?
insulinomas
Diagnostic study for insulinomas?
72 hr fast period in a hospital monitored setting
pts have a high ratio of insulin;glucose
Whipple’s triad of insulinma?
hypoglycemia when fasting
blood glucose less than 50
relief after glucose given
Insulinomas, benign or malignant?
BENIGN
Diabetes associated with necrolytic migratory erythema?
glucagonoma
What rash is seen with glucagonoma>
necrolytic migratory erythema
Where are glucagonomas normally located?
head + tail
tend to be large with mets when diagnosed
Tx for glucagonomas?
surgical removal with debulking if necessary
How do we diagnose glucagonomas?
serum glucagon >500
With this PNET; pts are at an increased risk of DVT?
glucagonoma
Watery diarrhea, achlorhydria, hypokalemia?
VIPOMA
What is WDAH syndrome seen with VIPOMAS?
watery diarrhea
achlorhydria
hypokalemia
Most VIPOMAs found where?
Tail
Pts with VIPOMAs, why do they have hypokalemia?
massive amts of watery diarrhea (>5L/day)
This causes ZE syndrome;
gastrinomas
Gastrinomas cause what syndrome?
ZE syndrome
How do we diagnose gastrinoams?
gastrin level > 1000
Borders of gastrinoma triangle;
cystic duct/CBD
2nd/3rd part of duodenum
neck/body pancreas
How do we find gastrinomas?
ocreotide scanning with EUS
With gastrinomas, what do we have to make sure?
MEN1
How do pts with somatistainomas present?
gallstones
DM
steatorrhea
How do we confirm diagnosis of somatistainomas?
> 10
most have mets at time of presentation
resection and GB removal appropriate in many times
Serous cystic neoplasms of pancreas, stain positive for what?
periodic acid schiff stain
Periodic acid schiff staining seen in what Ca>
serous cystic neoplasms
Fish mouth ampulla seen in?
main duct IPMN
Single best predictor of 30 day mortality in cirrhotic pts?
MELD (Bilirubin, INR, Cr)
MOst common PNET in a MEN syndrome?
gastrinoma
