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Surgery Rotation > EOR GI part 11-chronic pancreatitis, pancreatic pseudocyst, pancreatic carcinoma > Flashcards

EOR GI part 11-chronic pancreatitis, pancreatic pseudocyst, pancreatic carcinoma Flashcards

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1
Q

What is chronic pancreatitis?

A

Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine tissue

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2
Q

What are the subtypes of chronic pancreatitis?

A

Chronic calcific pancreatitis

Chronic obstructive pancreatitis

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3
Q

Causes of chronic pancreatitis

A 
EtOH abuse (MC)
Idiopathic
Hypercalcemia (hyperparathyroidism)
HLD
Familial
Trauma
Iatrogenic
Gallstones
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4
Q

Sx of chronic pancreatitis

A

Epigastric and/or back pain
Wt loss
Steatorrhea

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5
Q

Associated signs of chronic pancreatitis

A

Type 1 DM
Steatorrhea
Wt loss

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6
Q

What are the signs of pancreatic exocrine insufficiency?

A

Steatorrhea

Malnutrition

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7
Q

What are the signs of pancreatic endocrine insufficiency?

A

DM

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8
Q

What are the common pain patterns in chronic pancreatitis?

A

Unrelenting pain

Recurrent pain

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9
Q

DDx of chronic pancreatitis

A 
PUD
Biliary dz
AAA
Pancreatic CA
Angina
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10
Q

Appropriate lab tests for chronic pancreatitis

A

Amylase/lipase
72-hr fecal fat analysis
Glucose tolerance test

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11
Q

Why may amylase/lipase be normal in a pt with chronic pancreatitis?

A

Because of extensive pancreatic tissue loss

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12
Q

What radiographic tests should be performed for chronic pancreatitis?

A

CT scan- has greatest sensitivity for gland enlargement/atrophy, calcification, masses, pseudocysts
KUB- Calcification in the pancreas
ERCP- Ductal irregularities with dilation and stenosis, pseudocysts

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13
Q

Medical tx for chronic pancreatitis

A

Discontinuation of EtOH use- can reduce attacks, though parenchymal damage continues secondary to ductal obstruction and fibrosis
Insulin for type 1 DM
Pancreatic enzyme replacement
Narcotics for pain

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14
Q

Surgical tx for chronic pancreatitis

A

Pestow- longitudinal pancreaticojejunostomy (pancreatic duct must be dilated)
Duval- distal pancreaticojejunostomy
Near-total pancreatectomy

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15
Q

What is the Frey procedure?

A

Longitudinal pancreaticojejunostomy with core resection of the pancreatic head

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16
Q

What is the indication for surgical tx of chronic pancreatitis?

A

Severe, prolonged/refractory

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17
Q

What are the possible complications of chronic pancreatitis?

A 
Insulin dependent DM
Steatorrhea
Malnutrition
Biliary obstruction
Splenic vein thrombosis
Gastric varices
Pancreatic pseudocyst/abscess
Narcotic addiction
Pancreatic ascites/pleural effusion
Splenic artery aneurysm
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18
Q

What is a pancreatic pseudocyst?

A

Encapsulated collection of pancreatic fluid

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19
Q

What makes a pancreatic pseudocyst a pseudocyst?

A

Wall is formed by inflammatory fibrosis, NOT epithelial cell lining

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20
Q

Associated RFs of pancreatic pseudocyst

A

Acute pancreatitis < chronic pancreatitis from EtOH

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21
Q

What is the MCC of pancreatic pseudocyst in the US?

A

Chronic alcoholic pancreatitis

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22
Q

Sx of pancreatic pseudocyst

A 
Epigastric pain/mass
Emesis
Mild fever
Wt loss
Should be suspected when a pt with acute pancreatitis fails to resolve pain
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23
Q

Signs of pancreatic pseudocyst

A

Palpable epigastric mass
Tender epigastrium
Ileus

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24
Q

What is the DDx of pancreatic pseudocyst

A

Cystadenocarcinoma

Cystadenoma

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25
What are the possible complications of a pancreatic pseudocyst?
``` Infection Bleeding into the cyst Fistula Pancreatic ascites Gastric outlet obstruction SBO Biliary obstruction ```
26
Tx of pancreatic pseudocyst
Drainage of the cyst or observation
27
What is the waiting period before a pancreatic pseudocyst should be drained?
It takes 6 wks for pseudocyst walls to mature or become firm enough to hold sutures, and most will resolve during this period if they are going to
28
What percentage of pancreatic pseudocysts resolve spontaneously?
~50%
29
What is the tx for pseudocyst with bleeding into cyst?
Angiogram and embolization
30
What is the tx for pancreatic pseudocyst with infection?
Percutaneous external drainage/ IV abx
31
What size pancreatic pseudocyst should be drained?
Pseudocysts >5 cm have a small chance of resolving and have a higher chance of complications Calcified cyst wall Thick cyst wall
32
What are three tx options for pancreatic pseudocyst?
Percutaneous aspiration/drain Operative drainage Transpapillary stent via ERCP (pseudocyst must communicate with pancreatic duct)
33
What is an endoscopic option for drainage of a pancreatic pseudocyst?
Endoscopic cystogastrostomy
34
What must be done during a surgical drainage procedure for a pancreatic pseudocyst?
Bx of the cyst wall to r/o a cystic carcinoma
35
What is the MCC of death d/t pancreatic pseudocyst?
Massive hemorrhage into the pseudocyst
36
Associated RFs of pancreatic carcinoma
``` Smoking 3x risk DM Heavy EtOH use Chronic pancreatitis Diet high in fried meats Previous gastrectomy ```
37
Average age of pancreatic carcinoma
>60 yrs
38
What are the different types of pancreatic carcinoma?
>80% are duct cell adenocarcinomas | Other types include cystadenocarcinoma and acinar cell carcinoma
39
What percentage of pancreatic carcinomas arise in the pancreatic head?
66% | 33% arise in the body and tail
40
Why are most pancreatic cancers in the tail nonresectable?
These tumors grow without sx until it is too late and they have already spread- head of the pancreas tumors draw attention earlier because of biliary obstruction
41
What are the s/sx of pancreatic carcinoma in the head of the pancreas?
``` Painless jaundice from obstruction of common bile duct Wt loss Abd pain Back pain Weakness Pruritis from bile salts in skin Anorexia Courvoisier's sign Acholic stools Dark urine DM ```
42
S/sx of pancreatic carcinoma in the body or tail
``` Wt loss and pain (90%) Migratory thrombophlebitis (10%) Jaundice (<10%) Nausea and vomiting Fatigue ```
43
What are the MC sx of pancreatic carcinoma of the pancreatic head?
Wt loss Pain Jaundice
44
What is Courvoisier's sign?
Palpable, nontender, distended gallbladder
45
What is the classic presentation of pancreatic CA in the head of the pancreas?
Painless jaundice
46
Associated lab findings of pancreatic carcinoma
Increased direct bilirubin and alk phos (as a result of biliary obstruction) Increased LFTs Elevated pancreatic tumor markers
47
Which tumor markers are associated with pancreatic CA?
CA 19-9
48
What diagnostic studies are performed for pancreatic carcinoma?
Abdominal CT U/s Cholangiography (ERCP to r/o choledocholithiasis and cell brushings) Endoscopic u/s with bx
49
Treatment for pancreatic CA in head of pancreas
Whipple (pancreaticoduodenectomy)
50
Tx of pancreatic CA in body or tail
Distal resection
51
What factors signify inoperability in pancreatic carcinoma?
``` Vascular encasement Liver metastasis Peritoneal implants Distant LN metastasis (periaortic/celiac nodes) Distant metastasis Malignant ascites ```
52
Is portal vein or SMV involvement an absolute CI for resection in pancreatic carcinoma?
No- can be resected and reconstructed with vein interposition graft at some centers
53
What mortality rate is associated with a Whipple?
<5% at busy high volume centers
54
What is the pylorus-preserving Whipple?
No antrectomy | Anastomose duodenum to jejunum
55
What are the possible post-Whipple complications?
Delayed gastric emptying (if antrectomy is performed) Anastomotic leak (from the bile duct or pancreatic anastomosis), causing pancreatic/biliary fistula Wound infection Postgastrectomy syndromes Sepsis Pancreatitis
56
Why must the duodenum be removed if the head of the pancreas is resected?
They share the same blood supply
57
What is the postop adjuvant therapy in pancreatic CA?
Chemo +/- radiation therapy
58
What is the palliative tx if the pancreatic tumor is inoperable and biliary obstruction is present?
Percutaneous transhepatic cholangiography or ERCP and placement of stent across obstruction
59
What is the prognosis at 1 yr after dx of pancreatic CA?
Dismal | 90% of pts die within 1 yr of dx
60
What is the survival rate of pancreatic CA at 5 yrs after resection?
20%

Surgery Rotation (19 decks)

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