55 yo woman w/ no PMH is brought to the ED by her husband b/c of a 24hr hx of abd pain, N/V. She has hx of HTN, non-insulin dependent DM and PUD and underwent tx for H. pylori 2 yrs ago. She underwent cholecystectomy empirically following a bout of pancreatitis 4 years ago. There were no gallstones. Her meds are glyburide and simvastatin. On exam she is tachycardic and has tenderness in the mid-abd and back. Lab values on admin reveal WBC and amylase ?250 consistent w/ acute pancretitis. A CT shows evidence of edematous pancreatitis and pancreas divisum. Which of the following is the most likely cause of her recurrent pancreatitis?
A 45 yo woman is undergoing an upper endoscopy b/c of severe abd pain that is not relieved by an OTC PPI and antacids. She recently has been having frequent diarrhea. She has otherwise been healthy and there is no FHx of chronic or inheritable disease. Endoscopy shows hypertrophic gastric rugal folds and a large antral ulcer and multiple duodenal ulcers. Serum gastrin level is 1200 pg/mL. Where is the most likely place to find her gastrinoma?
A 75 yo man comes to the office b/c of painless jaundice for 6days and a 20pound wt loss over the past two months. He has HTN treated with lisinopril and hydrochlorothiaxide. He has never had surgery. He quit smoking 10 yrs ago, but had a 40 pack year history prior to that time. He is quite thin and is profoundly jaundiced. There is a palpable globular mass in the RUQ of the abd that is minimally tender to deep palpation. A CT scan shows dilated intra and extra hepatic bile ducts, a distended GB, and a 2cm hypodense mass in the pancreatic head consistent with the dx of pancreatic cancer. The tumor mass does not appear to involve any vascular structures and there is no evidence of metastatic disease. Which of the following is the next best step in management for this patient?
A 62 yo woman comes to office w/ abd pain and fullness for the past 6 weeks. She was d/c from the hospital 10w ago when she was treated for severe bout of pancreatitis. CT scan now shows a 12 cm cystic structure of the central pancreas, which was not present on prior scans. ERCP shows that the cyst communicates with the main pancreatic duct. What is the next best step in management?
Pancreatic cyst gastrostomy
A 37 yo man comes to the office b/c of palpitations and tremulousness for the past 2mo. His sxs are relieved by eating. He has a hx of PUD and was treated for H pylori 2yrs ago. He has had IBS since he was a teen, manifested by alt constipation and diarrhea. He takes no meds. His PE is normal. Fasting blood sugar is 40 mg/dL and C peptide level elevated. CT showed 1.5cm mass in head of pancreas that enhances brightly on the arteriogram phase. The mass is easily visible on somatostatin scan and there are no other lesions identified. What is the most likely diagnosis?
A 65yo man has been dx w/ pancreatic cancer. He is physically fit to undergo a major pancreatic resection. A CTA shows 2.5cm tumor in uncinate process that is not impinging on any major vascular structures, and the tumor is deemed to be resectable. A pancreaticoduodectomy is planned. In addition to the gastroduodenal artery, which of the following arteries must be ligated divided to complete the procedure?
Inferior anterior pancreaticoduodenal
65 yo man is admitted to hospital b/c of severe abd pain. He has a hx of recurrent bouts of pancreatitis related to alcohol abuse and has been admitted to the hospital multiple times for pain control. CT scan of abd reveals atrophic pancreas w/ some calcifications consistent w/ chronic pancreatitis. In addition to chronic pain, he is at risk for developing which of the following complications of chrrnic pancretitis.
A 46 yo man was admitted to the surgical ICU 3w ago w/ severe pancreatitis. He required intensive IVF resuscitation and was intubated upon admission. He remains on parenteral pain meds and insulin. He is afebrile. Vital signs are BP 130/80, P100, R18. He is making urine. He was transfused yesterday w/ two units of PRBC b/c of a severe anemia. He remains NPO and cannot tolerate anything by mouth. Attempts at passing a feeding tube beyond the pylorus have failed and he is receiving TPN. His abd is distended and tender in the epigastrium. CT scan yesterday showed large pancreatic phlegmon w/ assoc narrowing of the duodenum and 3 small acute fluid collections. Most recent blood work shows: glucose 140, amylase 200, hct 29. What is the best indication for surgical intervention in this pt?
Gastric outlet obstruction
A 65 yo man is scheduled to undergo an 80% subtotal pancreatectomy b/c of a mucinous cystic tumor involving the body of the pancreas. The surgeon explains to him that the body and tail of the pancreas wil be removed w/ only the head and uncinate remaining. The pt is concerd about his risk for developing DM after the surgery. Which of the following is most accurate info to share w the pt?
The Islets of Langerhans are more abundant in the tial of the pancreas than in the head and uncinated
A 67 yo man who has been otherwise healthy is undergoing an operation for bx-proven adeno Ca of the pancreas in living the head and uncinate process. A bile duct stent was placed preoperatively b/c severe jaundice and pruritus. Pre-op CT imaging and endoscopic US showed a 2.6cm mass in the head and uncinate process and vascular involvement. During exploration the pancreatic mass is easily palpable and the pancreas is not fixed to the surrounding tissue. A 5mm lesion on surface of right lobe of liver was excised and frozen section confirmed a bile duct hamartoma. There are no other findings. What is the best procedure to do at this time?
Pancreaticoduodenectomy (Whipple procedure)