Surgical Recall - Ch. 55 Pancreas

Question 1

Acute Pancreatitis

1. What is it?
2. Causes?
3. Symptoms?
4. What is the etiology of hypocalcemia with pancreatitis?

Answer 1

Acute Pancreatitis

1. What is it? Inflammation of the pancreas
2. Causes?
   
   1. Idiopathic
   2. Gallstones
   3. Ethanol
   4. Trauma
   5. Scorpion bite
   6. Mumps (viruses)
   7. Autoimmune
   8. Steroids
   9. Hyperlipidemia
   10. ERCP
   11. Drugs
3. ​Symptoms? Epigastric pain (frequently radiates to back); N/V
4. Etiology of hypocalcemia with pancreatitis? Fat saponification: fat necrosis binds to calcium

Question 2

Acute Pancreatitis

1. What are Ranson’s criteria for the following stages:
   
   1. At presentation?
   2. During the initial 48 hrs?

Answer 2

Acute Pancreatitis

1. What are Ranson’s criteria for the following stages:
   
   1. At presentation?
      
      1. “GA LAW”:
         
         1. ​Glucose > 200
         2. Age > 55
         3. LDH > 350
         4. AST > 250
         5. WBC > 16,000
   2. During the initial 48 hrs?
      
      1. “C HOBBS”
         
         1. ​Calcium < 8 mg/dL
         2. Hct drop of > 10%
         3. O2 < 60 (PaO2)
         4. Base deficit > 4
         5. BUN > 5 inc.
         6. Sequestration > 6 L

Question 3

Chronic Pancreatitis

1. What is it?
2. What are the causes?
3. What are the associated signs?
4. What are the appropriate lab tests?
5. Why may amylase/lipase be normal in a patient with chronic pancreatitis?
6. What radiographic tests should be performed?
7. Medical treatment?
8. Surgical treatment?

Answer 3

Chronic Pancreatitis

1. What is it? Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification resulting in loss of endocrine and exocrine tissue
2. What are the causes?
   
   1. Alcohol abuse (most common; 70% of cases)
   2. Idiopathic (15%)
   3. Hypercalcemia (HPTH)
3. What are the associated signs?
   
   1. Type 1 DM
   2. Steatorrhea
   3. Weight loss
4. ​Appropriate lab tests:
   
   1. Amylase/lipase
   2. 72-hr fecal fat analysis
   3. Glc tolerance test (IDDM)
5. Why may amylase/lipase be normal in a patient with chronic pancreatitis? Extensive pancreatic tissue loss (“burned-out pancreas”)
6. What radiographic tests should be performed?
   
   1. CT– greatest sensitivity for gland enlargement/atrophy, calcifications, masses, pseudocysts
   2. KUB– calcification in pancreas
   3. ERCP– ductal ireegularities with dilation and stenosis (Chain of Lakes), pseudocysts
7. Medical treatment?​
   
   1. Discontinuation of alcohol
   2. Insulin for Type 1 DM
   3. Pancreatic enzyme replacement
   4. Narcotics for pain
8. ​Surgical treatment? Near-total pancreatectomy

Question 4

Pancreatic Abscess

1. What radiographic tests should be performed?
2. Which organisms are found in pancreatic abscesses?
3. Treatment?

Answer 4

Pancreatic Abscess

1. What radiographic tests should be performed? Abdominal CT with needle aspiration –> send for Gram stain/culture
2. Which organisms are found in pancreatic abscesses?
   
   1. Gram negative (most common): E. coli, Pseudomonas, Klebsiella
   2. Gram positive: Staph, Candida
3. Treatment? Abx and percutaneous drain placement

Question 5

Pancreatic Pseudocyst

1. What makes it a “pseudo” cyst?
2. What is the incidence?
3. Treatment?
4. Treatment for pseudocyst with bleeding into cyst?
5. Treatment for pseudocyst with infection?
6. What are the surgical options for the following conditions:
   
   1. Pseudocyst adherent to the stomach?
   2. Pseudocyst adherent to the duodenum?
   3. Pseudocyst not adherent to the stomach or duodenum?
   4. Pseudocyst in the tail of the pancreas?
7. What must be done during a surgical drainage procedure for a pancreatic pseudocyst?

Answer 5

Pancreatic Pseudocyst

1. What makes it a “pseudo” cyst? Wall is formed by inflammatory fibrosis, NOT epithelial cell lining
2. What is the incidence? ~1 in 10 after alcoholic pancreatitis
3. Treatment? Drainage of the cyst or observation
4. Treatment for pseudocyst with bleeding into cyst? Angiogram and embolization
5. Treatment for pseudocyst with infection? Percutaneous external drainage/IV abx
6. What are the surgical options for the following conditions:
   
   1. Pseudocyst adherent to the stomach? Cystogastrostomy (drain into stomach)
   2. Pseudocyst adherent to the duodenum? Cystoduodenostomy (drain into duodenum)
   3. Pseudocyst not adherent to the stomach or duodenum? Roux-en-Y cystojejunostomy (drain into Roux limb of jejunum)
   4. Pseudocyst in the tail of the pancreas? Resection of the pancreatic tail with pseudocyst
7. ​What must be done during a surgical drainage procedure for a pancreatic pseudocyst? Biopsy of cystic wall to r/o cystic carcinoma (e.g., cystadenocarcinoma)

Question 6

Pancreatic Carcinoma

1. What is it?
2. What are the associated risk factors?
3. What is the average age?
4. What percentage arise in the head?
5. What are the signs/symptoms of tumors based on location:
   
   1. Head of pancreas?
   2. Body or tail?
6. What diagnostic tests are performed?
7. What metastatic lymph nodes described classicaly for gastric cancer can be found with metastatic pancreatic cancer?
8. Associated lab findings?
9. What is the treatment based on location:
   
   1. Head?
   2. Body or tail?

Answer 6

Pancreatic Carcinoma

1. What is it? Adenocarcinoma of pancreas arising from duct cells
2. What are the associated risk factors? Smoking 3x risk, DM, heavy alcohol use, chronic pancreatitis
3. What is the average age? >60 yrs
4. What percentage arise in the head? 66%
5. What are the signs/symptoms of tumors based on location:
   
   1. Head of pancreas?
      
      1. Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritis from bile salts in skin; anorexia; Courvoisier’s sign (palpable, nontender, distended gallbladder)
   2. Body or tail?
      
      1. Weight loss and pain (90%); migratory thrombophlebitis (10%)
6. What diagnostic tests are performed? CT / ERCP to r/o choledolithiasis​​
7. What metastatic lymph nodes described classicaly for gastric cancer can be found with metastatic pancreatic cancer?
   
   1. Virchow’s node
   2. Sister Mary Joseph’s nodule
8. ​Associated lab findings?
   
   1. Increased direct bilirubin and AP (result of biliary obstruction)
   2. Increased LFTs
   3. Elevated pancreatic tumor markers (CA-19-9)​
9. What is the treatment based on location:
   
   1. Head? Whipple
   2. Body or tail? Distal pancreatectomy

Question 7

56 y/o previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical exam, the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous U/S of abdomen demonstrates biliary ductal dilation without gallstones. What is the most appropriate next step in the workup of this patient?

Answer 7

CT scan

Painless jaundice + weight loss = pancreatic cancer involving head or uncinate process…. CT scan is sensitive for tumors > 2cm diameter