Ch 33 Pancreas Flashcards
(153 cards)
1
Q
Vascular anatomy of superior abdominal aorta
A
Celiac trunk - L gastric, splenic, common hepatic
Splenic - short gastrics, L gastroepiploic, splenic, pancreatic (great, dorsal, caudal)
Common hepatic - proper hepatic, gastroduodenal (GDA)
Proper hepatic - R gastric, L/R hepatic
GDA - R gastroepiploic, antero/posterosuperior pancreaticoduodenal
SMA - postero/anteroinferior pancreaticoduodenal artery, jejunal arteries
2
Q
Pancreas components
A
head (incl. uncinate), body, tail
3
Q
Location of uncinate relative to vessels
A
rests on aorta, behind SMV
4
Q
Relation of SMV/SMA/pancreas
A
SMV anterior and to the right –> both lie behind neck of pancreas
5
Q
Relation of IVC/Aorta
A
IVC anterior and to the right/ L renal vein crosses over aorta
6
Q
Relation of portal vein/pancreas
A
Formation of SMV/splenic vein occurs behind neck of pancreas
7
Q
Pancreas Blood Supply: head
A
superior (GDA) and inferior pancreaticoduodenal (SMA) arteries (both have anterior/posterior branches)
8
Q
Pancreas Blood Supply: body
A
great, dorsal, and caudal pancreatic arteries (Splenic) come together to form inferior pancreatic artery which anastomoses with superior pancreaticoduodenal artery
9
Q
Pancreas Blood Supply: tail
A
splenic, gastroepiploic, dorsal pancreatic artery
10
Q
Venous drainage of the pancreas enters the _____
A
portal system
11
Q
Lymphatic drainage of the pancreas include _____ nodes (2)
A
celiac and SMA
12
Q
_____cells secrete HCO3-
A
ductal
13
Q
_____cells secrete digestive enzymes
A
acinar
14
Q
6 exocrine products of the pancreas
A
hco3-, amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase
15
Q
____ is the only pancreatic enzyme secreted in active form and its function is to ______
A
amylase; hydrolyze alpha 1-4 linkages of glucose chains
16
Q
6 endocrine functions of the pancreas and cells of origin
A
alpha- glucagon beta - insulin (at center of islets) delta - somatostatin pp/f - pancreatic polypeptide islet cells - VIP, serotonin
17
Q
_____ cells receive the majority of pancreatic blood supply on a size basis
A
islet cells (followed by acinar cells)
18
Q
____ from ____ structure activates trypsinogen to ____ which does _____ function
A
enterokinase; duodenum; trypsin; activates enzymes including trypsinogen (but not amylase)
19
Q
Secretin inc/dec ____ primarily
A
increase HCO3
20
Q
CCK inc/dec ____ primarily
A
increase pancreatic enzymes
21
Q
ACh inc/dec ____ primarily
A
increases HCO3 and enzymes
22
Q
Somatostatin and glucagons inc/dec ____ primarily
A
decrease exocrine function
23
Q
CCK and secretin are primarily released by the _____
A
duodenum
24
Q
Embryology of pancreas
A
ventral pancreatic bud migrates posteriorly to the right and clockwise to fuse with the dorsal bud; forms the uncinate and inferior portion of the head
dorsal pancreatc bud composes body, tail, and superior aspect of pancreatic head
25
the duct of _____ is in the ventral pancreatic bud and the duct of _____ is in the dorsal pancreatic bud. Which is the major duct?
wirsung, santorini; wirsung
26
The duct of wirsung drains into the _____ and the duct of santorini drains into the ____
merges with CBD and then enters duodenum; directly into duodenum
27
Failure of clockwise rotation of the pancreas leads to _____ which is associated with ____ disease which can lead to ____ on xray and can lead to ____ clinical syndrome
annular pancreas; down's syndrome; double bubble; dudodenal obstruction from pancreas "strangling duodenum"/preventing passage of bolus through duodenum
28
Tx of annular pancreas
duodenojejunostomy or duodenoduodenostomy with possible sphincteroplasty
*pancreas not resected
29
Failed fusion of the pancreatic ducts known as ______ can lead to ____ clinical syndrome from ____ stenosis
pancreas divisum; pancreatitis; duct of santorini
30
Dx of pancreas divisum
ERCP - minor papilla will show long and large duct of santorini; major papilla will show short duct of wirsung
31
Tx of pancreas divisum
ERCP with sphincteroplasty; open sphincteroplasty if that fails
32
Heterotopic pancreas are most commonly found in the ______ and are a/symptomatic and are treated with ____
duodenum; asymptomatic; surgical resection if symptomatic
33
Most common etiologies of acute pancreatitis (and others)
gallstone and etoh
others = ercp, trauma (children most common), hyperlipidemia, hypercalcemia, viral infection, medications (aza, furosemide, steroids, cimetidine)
34
Pathophysiology of gallstone pancreatitis
gallstone blocks ampulla of vater leading to impaired extrusion of zymogen granules and activation of degradation enzymes --> pancreatic autodigestion
35
Pathophysiology of etoh pancreatitis
leads to autoactivation of pancreatic enzymes
36
General and specific findings in acute pancreatitis
General: abd pain, n/v, anorexia
Specific: jaundice, L pleural effusion, ascites, sentinal loop --> dilated small bowel near the pancreas as a result of inflammation
37
Mortality rate of acute pancreatitis
10% (50% with hemorrhagic)
38
What do we think if a patient has pancreatitis without obvious cause
malignancy!
39
Ranson's criteria - how many are there, what are they, what is the mortality rate if they are all hit
8,
on admission: age>55, wbc>16, gluc>200, AST>250, LDH >350
after 48 hours: hct down 10%, bun up 5, ca4, fluid sequestration >6L
100% if 8 are hit
```
GALAW and CHOBBS
glucose
ast
ldh
age
wbc
```
```
calcium
hct
o2
base
bun
sequestration
```
40
Labs in pancreatitis
increased amylase, lipase, wbc
41
DX pancreatitis
ultrasound - gallstones and CBD dilation
| CT - complications(e.g abscess); necrotic pancreas does not uptake contrast
42
_____ pancreas does not uptake contrast
necrotic
43
Tx acute pancreatitis
NPO, aggressive fluid resuscitation
ERCP for gallstones/CBD stones = sphincterotomy and extraction
ABx for stones, failure to improve, suspected infection
TPN for recovery
Chole after recovered (same admission)
avoid morphine
44
Role of morphine in acute pancreatitis
avoid --> can contract sphincter of oddi and worsen attack
45
3x bleeding signs in pancreatitis
grey turner - flank ecchymosis
cullen - periumbilical ecchymosis
fox - inguinal ecchymosis
46
What % of acute pancreatitis gets necrosis? What to do about it?
15%
- leave sterile necrosis alone
- if infected (wbc, fever, sepsis, blood cultures, ct aspiration of fluid) --> surgical debridement
47
Tx of pancreatic abscess
surgical debridement
48
Role of CT guided drainage for pancreatic necrosis/abscess
Not effective
49
What to do about gas in pancreatic necrosis
need open debridement
50
Leading cause of death in pancreatitis
infection with GNRs
51
Indications for surgery in acute pancreatitis
infected, abscess or post-pancreatitis for chole
52
What is the link between acute pancreatitis and ARDS?
release of phospholipases leads to ARDS
53
What is the link between acute pancreatitis and coagulopathy?
related to release of proteases
54
What causes pancreatic fat necrosis in pancreatitis?
release of phospholipases
55
In what conditions do amylase and lipase increase?
pancreatitis, sbo, intestinal infarct, cholecystitis, perforated ulcer, sialoadenitis
56
Pancreatic pseudocysts are most common in patients with _____
chronic pancreatitis
57
Concern for pseudocysts not related to pancreatitis
rule out cancer (mucinous cystadenocarcinoma)
58
symptoms of pancreatic pseudocyst
pain, fever, weight loss, bowel obstruction from compression
59
Where do pseudocysts happen?
head of pancreas (non epithelialized sac)
60
Tx of pancreatic pseudocyst
- most resolve spontaneously (esp if
61
Pseudocyst grows for 3 months--> tx?
resection to r/o ca
62
Pseudocyst persists after 3 months > tx?
perc or open cystogastrostomy
63
Complications of pseudocyst
infection, portal or splenic vein thrombosis
64
What cancers are of concern in pseudocysts not related to pancreatitis?
mucinous cystadenocarcinoma
intraductal papillary-mucinous neoplasms (IPMN)
UNLESS serous and non-complex
65
Malignancy risk of non-complex serous cystadenomas and mgmt
follow
66
Mgmt of pancreatic fistulae
most close spontaneously (esp if low output ERCP/sphincterotomy/stent --> remove stent after closure
67
Pathophysiology of pleural effusion in pancreatitis
retroperitoneal leakage of pancreatic fluid from duct or cyst/not a fistula!
68
Tx pleural effusion in pancreatitis
- majority close on own
- thoracentesis followed by conservative Tx (NPO,TPN,octreotide) and then follow fistula pathway
- amylase will be elevated in fluid
69
chronic pancreatitis correlates with irreversible _____
parenchymal fibrosis
70
MCC chronic pancreatitis
etoh, idiopathic 2nd most common
71
MC presentation of chronic pancreatitis
mc pain
| -anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis
72
Exocrine/endocrine function in chronic pancreatitis
endocrine function preserved; exocrine decreased
| -malabsorption of fat soluble vitamins
73
Tx malabsorption in chronic pancreatitis
pancrelipase
74
Dx chronic pancreatitis
abdominal CT - shrunken pancreas with calcifications
US -shows pancreatic ducts >4mm, cysts, atrophy
ERCP - sensitive at dx
75
Term for alternating dilation and stenosis in pancreatic duct --> what is this?
chain of lakes, sign of advanced disease in chronic pancreatitis
76
Tx chronic pancreatitis
pancrelipase, pain control, nutritional support, surgery for specific indications
77
indications for surgery in chronic pancreatitis
- pain that interferes with qol
- nutrition abnormalities
- addiction to narcotics
- failure to rule out ca
- biliary obstruction
78
6 surgical options for chronic pancreatitis and their indications
1. puestow procedure (pancreaticojejunostomy for enlarged ducts>8mm)
2. distal pancreatic resection (for normal/small ducts and only distal involvement)
3. Whipple (for normal/small ducts with isolated head disease)
4. Beger-Frey- duodenal preserving head coreout for normal/small ducts with isolated pancreatic head enlargement
5. Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy- pain control
6. hepaticojejunostomy or choledochojejunostomy for CBD dilation for pain, jaundice, cirrhosis, cholangitis after r/o not CA
79
Puestow procedure
chronic pancreatitis - pancreaticojejunostomy for enlarged ducts>8mm --> most improve
open along main duct and drain into jejunum
80
MCC splenic vein thrombosis
chronic pancreatitis
81
Tx splenic vein thrombosis
splenectomy for isolated bleeding gastric varices
82
Problem with splenic vein thrombosis
bleeding from isolated gastric varices that form collaterals
83
MCC pancreatic insufficiency
long-standing pancreatitis or after total pancreatectomy (over 90% function must be lost)
84
Symptoms of pancreatic insufficiency
generally refers to exocrine function --> malabsoprtion, steatorrhea
85
Dx pancreatic insufficiency
fecal fat testing
86
Tx pancreatic insufficiency
high carb, high protein, low fat diet, pancrease (pancreatic enzymes)
87
Jaundice workup
1. US
- positive CBD stones, no mass --> ERCP
- no cbd stones, no mass --> MRCP
- positive mass --> MRCP
88
Epidemiology of pancreatic adenocarcinoma
males 6th and 7th decades
89
symptoms pancreatic adenocarcinoma
weight loss (MC), jaundice, pain
90
survival rate pancreatic adenocarcinoma
20% 5 year survival with resection
91
MC risk factor pancreatic adenocarcinoma
tobacco
92
marker pancreatic adenocarcinoma
CA 19-9
93
MC mutation pancreatic adenocarcinoma
95% p16 mutation (tumor suppressor, binds cyclin complexes)
94
initial spread of pancreatic adenocarcinoma
lymphatic
95
location and invasion pancreatic adenocarcinoma
70% head
- 50% invade portal vein, smv, or retroperitoneum at time of diagnosis --> unresectable
- mets to peritoneum, omentum, liver --> unresectable
- mets to celiac/sma nodes --> unresectable
- head masses are most curable
96
Which location of pancreatic cancer is most curable?
head masses
97
What's the story on resectability for pancreatic adenocarcinoma?
If there is any invasion to other structures or plexus nodes, it is unresectable
98
MC subtype pancreatic adenocarcinoma
ductal adenocarcinoma
99
favorable subtypes pancreatic adenocarcinoma
papillary or mucinous cystadenocarcinoma
100
labs in pancreatic adenocarcinoma
increased bilirubin and alkphos
101
when to biopsy pancreatic adenocarcinoma
if resectable --> no biopsy, resect
| if mets --> biopsy to direct therapy
102
imaging to differentiate chronic pancreatitis from CA
mrcp
103
mrcp findings in ca (3)
```
duct with irregular narrowing
displacement
destruction
-also can detect vessel involvement
3Ds
```
104
ct signs for pancreatic head tumors (2)
- double duct sign (dilation of pancreatic and CBD)
| - lesion
105
Tx of unresectable pancreatic adenocarcinoma
palliation - biliary stents, hepaticojejunostomy (for biliary obstruction), gastrojejunostomy (for duodenal obstruction), and celiac plexus ablation (for pain)
106
Whipple complications
1. delayed gastric emptying (MC)
2. fistula
3. leak
4. marginal ulceration
5. bleeding
107
tx of delayed gastric emptying
metoclopramide
108
tx of post-whipple fistula
conservative
109
tx of post-whipple leak
place drains and tx like fistula
110
tx of marginal ulceration post-whipple
ppi
111
tx of bleeding post whipple or pancreatic surgery
angio for embolization (tissue planes are friable after surgery so operative control of bleeding is difficult)
112
chemo for pancreatic adenocarcinoma
gemcitabine post op
113
What are the predictors of prognosis for non-metastatic pancreatic adenocarcinoma?
nodal invasion, ability to get a clear margin
114
what proportion of pancreatic endocrine neoplasms are non-functional?
1/3
115
what percent of pancreatic nonfunctional endocrine neoplasms malignant?
90
116
how does the course of nonfunctional endocine neoplasms compare to that of pancreatic adenocarcinoma
indolent and protracted course
117
Tx of nonfunctional endocrine neoplasms
- resect; metastatic disease precludes resection
| - 5fu, streptozocin
118
most common metastasis in nonfunctional endocrine neoplasms
liver
119
what proportion of pancreatic endocrine neoplasms are functional tumors?
2/3
120
Most common endocrine pancreatic tumors in head
gastrinoma, somatostatinoma
121
Tx of functional endocrine neoplasm of pancreas
octreotide or debulking - insulinoma, glucagonoma, gastrinoma, VIPoma
122
first metastatic location for functional endocrine neoplasm of pancreas
liver
123
MC functional endocrine neoplasm of pancreas
insulinoma - most common islet cell tumor
124
malignant potential of insulinomas
10%
| 90% are benign and evenly distributed throughout pancreas
125
Dx insulinoma
insulin to glucose ratio > 0.4 after fasting, elevated C peptide and proinsulin --> if not elevated, suspect munchausen
126
Tx insulinoma
- enucleate if 2cm
| - tx metastatic with 5fu, streptozocin and octreotide
127
Most common pancreatic islet cell tumor in MEN1 patients
gastrinoma/zes
128
malignancy of gastrinoma/zes
50%
129
single/multiple gastrinoma/zes frequency
50% multiple
130
spontaneity frequency gastrinoma/zes
75% spontaneous
| 25% MEN1
131
location of gastrinoma/zes
gastrinoma triangle - cbd, neck of pancreas, third portion of duodenum
132
symptoms of gastrinoma/zes
refractory or complicated ulcer disease and diarrhea (improved with ppi)
133
dx gastrinoma/zes
- serum gastrin usually >200, 1000s is diagnostic
| - secretin stimulation test - ZES patients: elevate gastrin >200; normal patients reduce gastrin
134
Tx gastrinoma/zes
enucleate 2cm
- malignant disease --> excise suspicious nodes
- cannot find tumor --> perform duodenostomy and look inside duodenum
- duodenonal tumor --> resection with primary closure/whipple if extensive (check pancreas)
- debulking --> can improve symptoms
135
what % of microgastrinomas are present inside the duodenum
15
136
Best study for localizing gastrinoma
octreotide scan
137
Symptoms of glucagonoma
diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema)
138
rash in glucagonoma
necrolytic migratory erythema
139
dx glucagonoma
fasting glucagon level
140
location of glucagonoma
distal pancreas
141
what proportion of glucagonomas are malignant
most of them
142
Tx of necrolytic migratory erythema
zinc, amino acids, fatty acids
143
VIPoma AKA _____ has ___ symptoms
verner-morrison
| watery diarrhea, hypokalemia, achlorhydria (WDHA)
144
Dx VIPoma
rule out other causes of diarrhea, elevated VIP levels
145
what proportion of vipomas are malignant
most of them
146
location of vipoma
distal pancreas MC, 10% extrapancreatic (RP, thoracic)
147
Frequency of somatostatinoma
very rare
148
Symptoms of somatostatinoma
diabetes, gallstones, steatorrhea, hypochlorhydria
149
Dx somatostatinoma
fasting somatostatin level
150
location of somatostatinoma
head of pancreas
151
malignancy of somatostatinoma
most malignant
152
tx somatostatinoma
chole with resection
153
Symptoms of insulinoma AKA _____
hypoglycemia (
