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Surgery > Chapter 14 > Flashcards

Chapter 14 Flashcards

1
Q

From which two endodermal tissues does the pancreas develop?

When in development does this begin?

A

Dorsal and ventral pancreatic buds

4th wk of gestation

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2
Q

Position of the pancreas

A

Lies retroperitoneal, posterior to the stomach at the level of the first and second lumbar vertebrae

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3
Q

Composition of the pancreas

A 
Head
Uncinate process
Neck
Body
Tail
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4
Q

Position of head of the pancreas

A

Rests within the C-loop of the duodenum to the right of the midline

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5
Q

Uncinate process

A

An inferior projection of the head, which curves posterior to the superior mesenteric vessels and anterior to the IVC

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6
Q

Neck of the pancreas

A

The portion of the pancreas that lies anterior to the portal vein and superior to mesenteric vessels

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7
Q

Body of the pancreas

A

To the left of the mesenteric vessels

Lies superior to the fourth portion of the duodenum and forms the floor of the lesser sac

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8
Q

Tail of the pancreas

A

The smallest portion of the pancreas

Lies in proximity to the splenic hilum

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9
Q

Blood supply of head and uncinate process

A

Vast majority is supplied by anterior and posterior superior and inferior pancreaticoduodenal arteries

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10
Q

Superior pancreaticoduodenal artery branches

A

Branches off the gastroduodenal artery, which emanates from the celiac axis

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11
Q

Inferior pancreaticoduodenal artery pathway

A

Arises from the SMA

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12
Q

Blood supply to body and tail of the pancreas

A

Branches of the splenic and left gastroepiploic arteries supply the distal body and tail of the pancreas
Within the posterosuperior and posteroinferior aspect of the body of the pancreas lie the superior and inferior pancreatic arteries, respectively

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13
Q

Venous drainage of the pancreas

A

Parallels its arterial supply
All drainage ultimately enters the portal vein, which is formed posterior to the neck of the pancreas by the confluence of the splenic and SMVs

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14
Q

Sympathetic pathway of the pancreas

A

Preganglionic sympathetic axons arise from cell bodies withint he thoracic sympathetic ganglia and travel as splanchnic nerves terminating within the celiac ganglia
Postganglionic sympathetic fibers traverse retroperitoneal tissue to innervate the pancreas and serve as the principal pathways for pain of pancreatic origin

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15
Q

Parasympathetic innervation

A

Preganglionic fiber cell bodies that reside within the vagal nuclei and travel through the posterior vagal trunk.
These axons traverse the celiac plexus and terminate in parasympathetic ganglia within the pancreatic parenchyma
Short postganglionic parasympathetic fibers then innervate the pancreatic islets, acini, and ducts, serving an exclusively efferent function

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16
Q

What are the two general categories of cellular components of the pancreas?

A

Exocrine

Endocrine

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17
Q

What are the primary exocrine units of the pancreas?

A

Acinar cells

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18
Q

How are acinar cells connected?

A

Connected to each other by a network of tubules and ducts, which eventually drain into the duodenum

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19
Q

Types of islet cells

A

Alpha
Beta
Delta

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20
Q

What does each islet consist of?

A

A core composed of beta cells

A peripheral mantle composed of alpha, delta, and pancreatic polypeptide cells

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21
Q

How much does the exocrine pancreas produce?

A

Up to 20 g of digestive enzymes and 2.5 L of bicarb-rich fluid each day.

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22
Q

Purpose of the acinar cells

A

Responsible for the production of enzymes

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23
Q

Purpose of the ductal cells

A

Secrete fluid and electrolytes under both vagal and humoral control

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24
Q

Sodium and potassium concentrations and exocrine physiology

A

Remain constant and are approximately equivalent to plasma concentrations

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25
Q

Anion concentration of pancreatic exocrine secretion

A

Dependent on secretory rate

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26
Q

What is the most potent endogenous stimulant of pancreatic bicarb secretion?

A

Secretin

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27
Q

Where is secretin synthesized?

A

In the mucosal S cells of the crypts of Lieberkuhn of the proximal small bowel and is released int he presence of luminal acid and bile

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28
Q

Physiology of secretin

A

Circulates in the blood and binds to secretin receptors on pancreatic ductal cells, effecting signal transduction through the intracellular adenylate cyclase system
The resultant bicarb secretion serves to neutralize stomach acid that enters the duodenum

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29
Q

What are the other components of exocrine pancreatic juice?

A

Digestive enzymes, which aid in amino acid, lipid, and complex carbohydrate breakdown

30
Q

What are the three phases of the contribution of the pancreas to digestion?

A

Cephalic phase
Gastric phase
Intestinal phase

31
Q

Cephalic phase

A

Stimuli (smell and taste) activate vagal efferent signals, which stimulate pancreatic enzyme release
The net effect of cephalic phase stimulation is the secretion of an enzyme-rich, bicarb-poor fluid

32
Q

Gastric phase

A

Antral distention and protein delivery stimulate the release of gastrin
Gastrin promotes gastric acid secretion from parietal cells and also serves as a weak stimulant for pancreatic enzyme secretion
Acidification of the duodenum in turn leads to secretin release, which stimulates pancreatic bicarb secretion.

33
Q

Intestinal phase

A

Secretin and CCK serve a major function in mediating pancreatic exocrine secretion
Duodenal acid and bile stimulate secretin release, in turn stimulating pancreatic bicarb secretion from ductal cells
Duodenal fat and protein stimulate CCK release, stimulating the secretion of pancreatic enzymes from acinar cells

34
Q

General purpose of endocrine cells

A

Whole body metabolism and energy utilization

35
Q

Endocrine hormone associated with alpha cells

A

Glucagon

36
Q

Primary functions of alpha cells

A

Glycogenolysis
Gluconeogenesis
Lipolysis
Increase blood sugar

37
Q

Endocrine hormone associated with beta cells

A

Insulin

38
Q

Primary functions of beta cells

A

Glucose uptake at cellular level

Protein synthesis

39
Q

Endocrine hormone associated with delta cells

A

Somatostatin

40
Q

Primary functions of delta cells

A

General inhibitor of acid production, pancreatic and biliary secretion
Helps regulate pancreatic endocrine function in a paracrine manner

41
Q

Characteristics of acute pancreatitis

A

Diffuse inflammation of the pancreas and encompasses a wide spectrum of clinical dz

42
Q

_____ of cases of acute pancreatitis resolve without complications

A

80%

43
Q

Complications of acute pancreatitis

A 
Hemorrhage
Pancreatic necrosis
Infection
Shock
Multisystem organ failure
44
Q

Goals of management of acute pancreatitis

A

Early dx
Supportive therapy
Tx of the underlying cause

45
Q

Presentation of acute pancreatitis

A

Sudden onset of epigastric pain that radiates to the back, usually accompanied by nausea and vomiting

46
Q

PE of acute pancreatitis

A

Epigastric tenderness
Retroperitoneal hemorrhage may manifest as Turner’s sign (flank ecchymosis), Cullen’s sign (periumbilical ecchymosis), or Fox’s sign (ecchymosis below the inguinal ligament and/or involving the scrotum)
Left pleural effusion may be present

47
Q

A systemic inflammatory response in acute pancreatitis may lead to…

A

Tachycardia
Edema
Hypovolemic shock

48
Q

Causes of early complications of acute pancreatitis

A

Usually related to massive fluid sequestration

49
Q

Early complications of acute pancreatitis

A

Pulmonary edema
Circulatory collapse
Renal failure

50
Q

Causes of late complications of acute pancreatitis

A

Infection or hemorrhage

51
Q

What are the vast majority of causes of acute pancreatitis?

A

Gallstones or alcohol

52
Q

What types of gallstones are likely to lead to acute pancreatitis?

A

Small stones <5 mm

53
Q

Pathophysiology of acute pancreatitis

A

Autodigestion and inflammation caused by unregulated release of pancreatic enzymes within the organ

54
Q

What are the end points of acute pancreatitis?

A

Organ edema
Peripancreatic inflammation with severe fluid loss
Multiorgan dysfunction secondary to circulating toxins

55
Q

What are the primary diagnostic markers of pancreatitis?

A

Amylase and lipase

56
Q

Difference between amylase and lipase in pancreatitis

A

Amylase levels peak early in the dz process and do not stay elevated beyond 5 days of ongoing inflammation
Lipase peaks later, but remains elevated for a longer period of time

57
Q

Imaging in pancreatitis-plain films

A

May show a dilated, air-filled duodenal loop in the RUQ, focal jejunal ileus (sentinal loop sign), or transverse colonic ileus (colon cutoff sign)

58
Q

Imaging in pancreatitis-abdominal u/s

A

Sensitivity is as low as 70%

59
Q

What is the imaging modality of choice for pancreatitis?

A

CT scan- computerized with contrast

60
Q

What are some contemporary systems for grading pancreatitis?

A 
APACHE II
Sequential Organ Failure Assessment (SOFA)
Marshall 
Balthazar score
Atlanta classification
61
Q

Tx of mild acute pancreatitis

A

Aggressive fluid resuscitation with crystalloid solution

Correction of metabolic and electrolyte derangements

62
Q

Tx of mild-moderate acute pancreatitis

A

In initial phase, restriction of oral intake
Consider nasogastric tube placement for ileus
Supplementary nutrition if prolonged inflammation or complications
H2 receptor antagonists or antacids for prophylaxis against upper GI tract hemorrhage in critically ill pts

63
Q

When is early cholecystectomy recommended for pancreatitis?

A

In all cases of gallstone pancreatitis and most cases of idiopathic pancreatitis

64
Q

What may be definitive therapy for pts considered too infirm to tolerate cholecystectomy for pancreatitis?

A

ERCP

65
Q

Tx of severe acute pancreatitis

A

Fluid resuscitation
Apply a low threshold for invasive monitoring
Antibiotic therapy if infected pancreatic necrosis is strongly suspected or documented

66
Q

Antimicrobials effective for acute pancreatitis

A 
Imipenem
3rd gen cephalosporins
Piperacillin
Mezlocillin
FQs
Metronidazole
67
Q

Three life-threatening infectious complications of acute pancreatitis

A

Pancreatic abscess
Infected pancreatic pseudocyst
Infected pancreatic necrosis

68
Q

Cause of pancreatic infection

A

Most are polymicrobial and may arise from transmural migration of bacteria from adjacent inflamed bowel or from hematogenous seeding

69
Q

Who is susceptible to fungal superinfection?

A

Pts subjected to long courses of powerful antibiotics

70
Q

When should one suspect septic complications in pancreatic infection?

A

In pts with severe pancreatitis
Documented bacteremia
Clinical deterioration
Failure of resolution of pancreatitis within 7-10 days

71
Q

Clinical manifestations of pancreatic infection

A

Fever
Tachycardia
Abdominal pain
Abdominal distention

Surgery (30 decks)

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