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Flashcards in NMS Pancreas 1 (includes gallbladder) Deck (237):
0

Pancreas divisum

due to failure of ventral and dorsal ducts to fuse, majority of pancreatic drainage is accomplished via accessory papilla and duct of Santorini.

--> most common congenital anomaly of pancreas (5% of population) but usually asymptomatic.

rarely chronic pain and recurrent pancreatitis result from inadequate drainage

1

annular pancreas

usually presents in infancy w duodenal obstruction (postprandial vomiting). caused by malrotation of ventral pancreas --> ring of pancreatic tissue around second portion of duodenum

pancreatitis and peptic ulcers also may result

2

heterotopic pancreas

pancreatic tissue in an abnormal location (stomach, duodenum, Meckel's diverticulum)

3

why does resection of head of pancreas require resection of duodenum

bc they have shared blood supply (gastroduodenal --> pancreaticoduodenal artery)

4

pancreatic ducts

- duct of wirsung is main duct; runs entire length of pancreas. it joins common bile duct and empties into 2nd part of duodenum at ampulla of vater
- duct of santorini (small duct) is an accessory duct often joining the duodenum more proximally than ampulla of vater

5

blood supply of pancreas

1. head: anterior and posterior superior pancreaticoduodenal arteries = branches of gastroduodenal artery;
anterior and posterior inferior pancreaticoduodenal arteries=branches of SMA

2. NECK, BODY, TAIL: splenic artery and branches (dorsal pancreatic artery)

6

exocrine physiology of pancreas

secretion of 1-2L/d of clear, isosmotic alkaline fluid containing digestive enzymes.

exocrine pancreas makes up 85% of pancreatic volume;
endocrine pancreas accounts for only 2%, with the rest composed of extracellular matrix and vessels or ducts

7

what kind of block can be done for pain control in pancreatic dz

celiac plexus block

8

secretin

most potent endogenous stimulant for bicarbonate secretion

9

endocrine function of pancreas

Islets of Langerhans make up 2% of pancreas by weigh:
1) insulin: from beta cells in islets of Langerhans (glucose absorption and storage);
2) glucagon: from islet alpha cells (glycogenolysis and release of glucose);
3) somatostatin: from islet delta cells (generally --> inhibitory function of GI tract)

10

uses of somatostatin

1. treat symptoms of neuroendocrine tumors (islet cell, carcinoid, gastrinoma, VIPoma, and acromegaly)
2. convert high output fistulae to low output fistula (bc of its antimotility and antisecretory effects)

11

acute pancreatitis

inflammation of pancreas due to parenchymal autodigestion by proteolytic enzymes

CAUSES: 1) alcohol abuse (40-50%); 2) gallstones (40%)

12

Less common causes of acute pancreatitis

1. hyperlipidemia
2. hypercalcemia: 2/2 hyper PTH
3. trauma
4. post op and post ERCP
5. pancreatic duct obstruction (tumor, pancreatic divisum)
6. vasculitis
7. scorpion venom
8. viral infections
9. drugs (azathioprine, INH, cimetidine)

13

signs and symptoms of acute pancreatitis

1. severe, constant epigastric pain radiating to the back. pain may be improved by sitting forward or standing
2. nausea/vomiting
3. low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but no rebound. bowel sounds may be absent due to adynamic ileus.

signs of hypovolemic shock may also be present due to massive retroperitoneal fluid sequestration and dehydration

14

cullens sign

bluish discoloration of periumbilicus

hemorrhagic pancreatitis

15

grey-turners sign

bluish discoloration of flank

hemorrhagic pancreatitis

16

fox's sign

bluish discoloration of inguinal ligament

hemorrhagic pancreatitis

17

cullens, grey turners, fox's sign

indicative of severe, hemorrhagic pancreatitis

18

MEDVIPS: drug-induced pancreatitis

1. methyldopa/metronidazole
2. estrogen
3. didanosine (inhibits HIV DNA polymerase reverse transcriptase)
4. valproate
5. INH
6. pentamidine
7. sulfonamides

19

elevate lipase

only found in gastric and intestinal mucosa and liver, in addition to pancreas, so is more specific for pancreatitis than amylase

20

elevated amylase

also found in salivary glands, small bowel, ovaries, skeletal muscle (+pancreas) so not specific marker for pancreatitis

21

Ranson's criteria : on admission

1. age>55
2. blood glucose>200
3. AST>250
4. LDH> 350
5. WBC >16k

22

Ranson's criteria: after 48 h

1. base deficit >4
2. increase in BUN >5
3. fluid deficit > 6L
4. Calcium 10%
6. PO2 < 60 mm Hg

23

diagnostic choice for acute pancreatitis

CT scan: 90% sensitive, 100% specific.

demonstrates pseudocysts, phlegmon, abscess, or pancreatic necrosis

24

causes of elevated amylase levels

high amylase levels are seen in intestinal disease, perforated ulcer, ruptured ectopic pregnancy, salpingitis, salivary gland disorders, renal failure, and diabetic ketoacidosis

25

treatment of acute pancreatitis

1. aggressive hydration with electrolyte monitoring to maintain adequate intravascular volume
2. NG tube if vomiting
3. antibiotics if infection identified
4. NPO with nutritional support via post-pyloric feeding or TPN
5. avoid morphine-possible spasm of sphincter of Oddi (use IV fentanyl or hydromorphone; meperidine favored over morphine)
6. surgery indicated for either infected necrosis of pancreas or correction of associated biliary tract dz

26

chronic pancreatitis

chronic inflammation or recurrent acute pancreatitis causes irreversible parenchymal fibrosis, destruction, and calcification --> loss of endocrine and exocrine function

27

causes of chronic pancreatitis

1. EtOH abuse (70%)
2. idiopathic (20%)
3. other (10%): hyper PTH, HLD, congenital pancreatic abnormalities, hereditary, obstruction

28

signs and symptoms of chronic pancreatitis

1. recurrent or constant epigastric/back pain
2. malabsorption/malnutrition (exocrine dysfunction)
3. steatorrhea (exocrine dysfunction-fat soluble vitamin deficiency (ADEK)
4. Type 1 diabetes mellitus
5. polyuria

29

diagnosis of chronic pancreatitis

1. pancreatic calcifications
2. chain of lakes pattern on ERCP with ductal irregularities/dilatation/stenosis
3. pseudocysts with gland enlargement/atrophy, masses

30

Pseudocysts

nonepithelialized, encapsulated pancreatic fluid collections. up to 30% of pseudocysts resolve on their own with bowel rest (TPN and NPO). if after 6 wks they have not resolved and are > 6 cm in size, internal drainage of the mature cysts indicated via cyst gastrostomy or Roux-en-Y cyst jejunostomy.

31

pancreatic adenocarcinoma

1. originate in exocrine pancreas (ductal cells)
2. 2/3 occur in head of pancreas

risk factors:
1. male
2. african-american
3. tobacco user

32

Courvoisier's sign

jaundice with palpable gallbladder that is nontender

33

signs and symptoms of pancreatic adenocarcinoma

1. weight loss
2. (painless) jaundice
3. posterior epigastric pain radiating to the back
4. migratory thrombophlebitis (Trousseau's syndrome esp seen in tumors of body or tail)

34

diagnosis of pancreatic adenocarcinoma

1. elevated CEA or CA19-9
2. CT scan is study of choice
3. PTC and ERCP useful in periampullary lesions

35

treatment of pancreatic adenocarcinoma

1. tumors of head: Whipple procedure (pancreaticoduodenectomy)
2. tumors of body/tail: distal near-total pancreatectomy
3. if unresectable 2/2 liver or peritoneal mets, nodal mets beyond zone of resection, or tumor invasion of SMA, palliative procedures considered

36

Whipple procedure

removal of gallbladder, common bile duct, antrum of stomach, duodenum, proximal jejunum and head of pancreas (en bloc);

reconstruction with pancreaticojejunostomy , choledochojejunostomy, and gastrojejunostomy

37

prognosis for adenocarcinoma

median survival for patients who undergo successful resection is approximately 12-19 months, with 5y survival rate of 15-20%

38

pancreatic cystadenocarcinoma

1. commonly seen in females 40-60y
2. occurs in body/tail
3. accounts for <2% of all pancreatic exocrine tumors
4. prognosis better than adenocarcinoma
5. TREATMENT: distal/total pancreatectomy

39

pancreatic cystadenoma

1. seen in older/middle aged women
two types:
a. serious: benign
b. mucinous: generally benign, but potential to be malignant

2. treatment: surgical resection

40

insulinoma

beta cell neoplasm with overproduction of insulin

1. MC islet cell tumor
2. 90% are benign
3. most are solitary lesions with even distribution in head/body/tail of pancreas
4. if associated with MEN I (<10% of all cases), then multiple insulinomas may be present

41

diagnosis of insulinoma

1. fasting serum insulin level >10 uU/mL [nL is 0.3
3. prosinulin or C-peptide levels should be measured to rule out surreptitious exogenous insulin administration

42

treatment for insulinoma

1. surgical enucleation/resection usually curative
2. diazoxide can improve hypoglycemic symptoms by inhibiting pancreatic insulin release

43

what is Whipple's triad

characterizes insulinoma
1. symptoms of hypoglycemia with fasting
2. fasting glucose <50 mg/dL
3. relief of symptoms after eating (glucose)

44

gastrinoma

neoplasm associated with overproduction of gastrin; aka Zollinger-Ellison syndrome

45

epidemiology of gastrinomas

1. second most common islet cell tumor
2. 90% are located in gastrinoma triangle bordered by junction of second and third part of duodenum, cystic duct, and SMA under the neck of the pancreas
3. 25% of gastrinomas are associated with MEN-1

46

signs and symptoms of gastrinomas

1. signs mimicking peptic ulcer dz
2. epigastric pain most prominent after eating
3. profuse, watery diarrhea

47

diagnosis of gastrinoma

1. fasting serum gastrin level > 500 pg/mL [nl: <100 pg/mL]
2. secretin stimulation test will cause paradoxical increase in gastrin in patients with Zollinger-Ellison syndrome
3. ulcers in unusual locations (ie, 3rd part of duodenum or jejunum) is highly suggestive
4. octreotide scan to localize tumor

48

treatment of gastrinoma

1. PPI
2. surgical resection
3. chemotherapy

49

VIPoma

overproduction of VIP; aka Verner Morrison syndrome or WDHA syndrome (Watery Diarrhea, Hypokalemia, Achlorhydria);

most are malignant and majority have metastasized to lymph nodes and the liver at time of dx

10% extrapancreatic

50

signs and symptoms of VIPoma

1. severe, watery diarrhea
2. signs of hypokalemia-palpitations/arrhythmias, muscle fasciculations/tetany, paresthesias

51

treatment of VIPoma

fasting serum VIP>800 pg/mL (normal<200 pg/mL) with exclusion of other causes of diarrhea

52

glucagonoma

rare alpha cell neoplasm resulting in overproduction of glucagon

53

signs and symptoms of glucagonoma

1. mild diabetes (hyperglycemia)
2. anemia
3. mucositis
4. weight loss due to low amino acid levels
5. severe dermatitis: often a red psoriatic like rash with serpiginous borders over trunk and lower limbs

54

skin condition associated with glucagonoma

necrolytic migratory erythema

55

diagnosis of glucagonoma

1. fasting serum level glucagon > 1000 pg/mL
2. skin bx to confirm presence of necrolytic migratory erythema

56

common bile duct forms in which pancreatic bud

ventral

57

which pancreatic bud migrates to fuse with other

ventral

58

what does ventral pancreatic bud form in adult

uncinate process and inferior aspect of pancreatic head

59

what does dorsal bud form

superior aspect of head, body, tail

60

from which pancreatic bud does small accessory pancreatic duct of santorini form

from dorsal bud

61

main duct of wirsung forms from entire ventral pancreatic duct which fuses with ...

distal pancreatic duct of dorsal bud

62

what abnormality arises if ventral pancreatic bud migrates posteriorly AND anteriorly to fuse with dorsal pancreatic bud

annular pancreas

63

name parts of pancreas

head, neck, body, tail

64

on what structure does pancreatic head rest

IVC, renal vessels

65

on what structure does uncinate process rest

aorta

66

what lies behind pancreatic neck

SMA

67

how is blood supplied to head of pancreas from celiac axis

gastroduodenal artery branches into SUPERIOR posterior and anterior pancreaticoduodenal artery

68

how is blood supplied to pancreatic head from celiac axis (2)

SMA branches into INFERIOR posterior and anterior branches of pancreaticoduodenal

69

which arteries supply body and tail of pancreas

splenic --> dorsal pancreatic --> joining branch from SMA --> forming inferior pancreatic

also multiple branches from splenic + inferior pancreatic arteries supply tail

70

into which veins do pancreatic veins drain

splenic vein into portal vein

71

which nodal groups drain pancreas

head: subpyloric, portal, mesocholic, aortocaval
body and tail: retroperitoneal in splenic hilum
to mesocolic, mesenteric, aortocaval

72

what do islet cells make

insulin (beta)
glucagon (alpha)
somatostatin (delta)

73

type of cells in exocrine pancreas

acinar, centroacinar, intercalated ductal, ductal

74

pH of pancreatic secretions

8

75

enzymes from pancreas

peptidases, trypsin, chymotrypsin, elastase, kallikrein, carboxypeptidase A and B

76

what stimulates exocrine secretion

bicarb: vagal efferents and secretin

enzymes: cholecystokinin and acetylcholine

77

what GI hormone is structurally similar to CCK

gastrin

78

what activates peptidases

enterokinase

79

what % acute pancreatitis is idiopathic

10%

80

metabolic causes of pancreatitis

hyperlipidemia, hypercalcemia

81

other surgical dzs causing pancreatitis

perforating peptic ulcer, Crohn dz of duodenum

82

diagnostic GI test that can cause pancreatitis

ERCP

83

arachnid bite that can cause pancreatitis

scorpion

84

worms that can cause obstructive pancreatitis

Ascaris, clonorchis sinensis

85

tests for diagnosing acute pancreatitis

amylase in serum, peritoneal fluid and urinary amylase

serum lipase, WBC, total bilirubin, LFT

AXR, US, CT

86

what is a sentinel loop

adynamic, dilated loop of small bowel associated with a focal area of inflammation initially described in relation to pancreatitis-associated ileus

87

when can patients with pancreatitis be fed

NOT early; this causes reactivation

(but i saw that early enteral feeds is good...what??)

88

should abx be used in treatment of acute pancreatitis

yes, necrotizing pancreatitis

(this is controversial i think?)

89

which abx to use for necrotizing pancreatitis

imipenem/cilastatin

90

how many patients with acute pancreatitis need surgery

10%

91

does early use of minidose heparin prevent intravascular thrombosis during acute pancreatitis or alter the course of pancreatitis

prob not

92

does peritoneal lavage alter clinical course of severe or necrotizing pancreatitis

controversial

recent study showed that patients with 5 or more of Ranson's criteria had reduced sepsis/death (with peritoneal lavage)

93

how should patients with severe pancreatitis be nourished

TPN;

but when peristalsis returns, nasoenteric or enteric feeding tubes (early enteral feeds?) may offer better nutrition without worsening pancreatitis (beyond ligament of Treitz)

94

what causes gallstone pancreatitis

- bile reflux into pancreas
- reflux of duodenal succus from a loose sphincter of Oddi
- stone blockage of pancreatic duct

95

if surgically untreated, what % of patients with gallstone pancreatitis will have recurrence within 8 weeks

33%

96

what other causes of pancreatitis must be ruled out in a patient with gallstones?

alcohol abuse, medications, hyperlipidemia, hypercalcemia

97

appropriate treatment of mild gallstone pancreatitis

laparoscopoic cholecystectomy; intraoperative cholangiogram on HD 3-5 if pancreatitis resolves

98

definition of chronic pancreatitis

recurrent bounts of acute, chronic pain, exocrine and endocrine dysfunction, irreversible parenchymal fibrosis

99

signs and symptoms of chronic pancreatitis

abdominal pain, diabetes, steatorrhea, pancreatic calcification

100

anatomic pancreatic changes in chronic pancreatitis

sclerosis with duct stenosis and dilatation

loss of acinar tissue

101

most common cause of chronic pancreatitis

alcohol abuse

102

CT findings with chronic pancreatitis

dilated pancreatic duct, calcifications, parenchymal atrophy (pseudocyst)

103

findings associated with chronic pancreatitis on CT

(she may have meant ERCP)

chain of lakes

(did she mean ERCP?)

104

most sensitive test for chronic pancreatitis

ERCP

105

factors indicating surgery for chronic pancreatitis

refractory, disabling pain; frequent recurrent acute exacerbations; possible malignancy; GI or biliary obstruction; splenic vein thrombosis with portal HTN

106

how are patients with chronic pancreatitis managed non-operatively

tx of pain; pancreatic exocrine replacement; insulin therapy

107

what are pseudocysts

pancreatic juice enclosed by a false capsule of fibrous or granulation tissue that arises as a consequence of pancreatitis or trauma

108

percentage of patients with acute pancreatitis forming pseudocysts

20%

109

what % of patients with chronic pancreatitis develop pseudocysts

20-40%

110

What % of ppl with acute pancreatitis develop persistent pseudocysts

4%

111

most common cause of pancreatic pseudocysts in kids

trauma

112

signs/symptoms of pancreatic pseudocysts

persistent pain, persistent n/v, weight loss, abdominal mass, persistent amylase elevation, jaundice, distension

113

% of patients with pseudocysts that have persistent abdominal pain

>90%

114

% of patients with pseudocysts that have abdominal mass

up to 50%

115

appropriate treatment of an infected pseudocyst

external drainage

no abx??

116

avg time for 4 cm pseudocyst to resolve

2-3 months

117

complications a/w pseudocyst

hemorrhage
infection,
leak
gastric outlet obstruction
bile duct obstruction

118

treatment of an unstable patient with hemorrhage into pseudocyst

arteriogram and possible embolization

119

what portion of pancreas gets carcinoma

exocrine

120

% of pop with pancreas divisum

6-10%

121

risk factors for pancreatic carcinoma

advanced age, smoking
diabetes (esp in women)
heavy alcohol use
exposure to benzidine and naphthylamine
partial gastrectomy

122

most common type of pancreatic carcinoma

90% adenocarcinoma
others are cystadenoma and acinar

123

most common location of pancreatic carcinoma

2/3 in head
1/3 in body/tail

124

signs/symptoms of pancreatic carcinoma

pain, weight loss, nausea, anorexia, painless jaundice

125

tumor markers for pancreatic cancer

CA19-9, Ca50

126

diagnostic test for pancreatic carcinoma

CT

127

diagnostic test for patients with jaundice

ERCP

128

why is tissue dx important for pancreatic carcinoma

ddx includes lymphoma, sarcoidosis, TB, choledocolithiasis, pancreatitis

129

what is disadvantage of FNA

seeding

130

when should tissue dx of potentially resectable tumors be performed

in OR (FNA)

but is this still done

131

which patients are the best candidates for percutaneous needle bx of a periampullary tumor

nonoperative candidates

132

which primary tumor location is associated with the most major vessel tumor involvement

head of pancreas

133

what are main sites of metastasis for pancreatic cancer

liver, peritoneum

134

what contraindicates resection in pancreatic cancer

mets, even just to local nodes; tumor involvement of SMA, SMV

135

goal of pancreas surgery for carcinoma

cure

136

Kocher maneuver

to determine if SMA is involved in pancreatic carcinoma

--> hand needs to be able to identify a normal tissue plane between pancreas and SMA

137

what intraoperative maneuvers simplify visualization of portal vein

cholecystectomy, transection of common hepatic duct

138

what is appropriate treatment of distal pancreatic cancer

distal pancreatectomy with splenectomy

139

what is appropriate treatment of cancer of head

Whipple, if resectable

140

what is treatment option of unresectable pancreatic cancer

radiation and 5-fluoro

141

what is an option for post-op adjuvant treatment (pancreatic cancer)

5-fluoro and radiation

142

is pylorus preserving Whipple a/w any survival disadvantage

NO

143

what is current operative mortality rate with whipple

<3%

144

what is most common postop complication of whipple

delayed gastric emptying

145

appropriate treatment of delayed gastric emptying

metoclopramide

146

percent of patients who develop a postop pancreatic fistula

up to 20%

147

appropriate treatment of pancreatic fistula

controlled drainage, with or without somatostatin

148

potential complications a/w standard whipple

delayed gastric emptying (1/3)
pancreatic fistula (1/5)
abscess (1/10)
wound infection (1/12)
bile leak (1/20)
pancreatitis (1/20)

149

what is prognosis for pancreatic cancer patients after resection

up to 20% are alive after 5 years

150

what are most important post resection prognostic factors

positive lymph nodes, need for blood transfusions, clear margins, vascular invasion by histology

151

various endocrine tumors of pancreas

insulinoma, glucagonoma, VIPoma, somatostatinoma, gastrinoma, calcitoninoma and neurotensin secreting tumors

152

what is most common pancreatic endocrine tumor

insulinoma

153

Whipple triad for insulinoma

fasting blood sugar <50
symptoms of hypoglycemia when fasting
symptomatic relief following glucose replacement

154

diagnosing insulinoma

72h fast with blood glucose and insulin levels; insulin/glucose ratio > 0.4; elevated C protein and proinsulin

155

do you image for pancreatic endocrine tumors

yes, CT with contrast

156

location for insulomas

1/3 in each part of pancreas

157

how to treat insulinomas

resection

(enucleation for small tumors)

158

role of diazoxide for patients with unresectable dz (insulinoma)

can attenuate hypoglycemia (less insulin released)

159

Zollinger-Ellison syndrome

pancreatic endocrine tumor that secretes gastrin

160

how to dx gastrinoma

secretin stimulation test

161

where are gastrinomas usually located

gastrinoma triangle:

1. confluence of cystic and CBD
2. junction of 2nd and 3rd portions of duodenum
3. junction of neck and body of pancreas

162

what % of gastrinomas are malignant

60% at time of dx

163

treatment for gastrinoma

resection with medical anti-acid production therapy

164

how to localize gastrinomas

CT with contrast, intraoperative ultrasound, duodenotomy, somatostatin, indium scan

165

Verner-morrison syndrome (WDHA)

watery diarrhea, hypokalemia, achlorydiria

a/w VIPomas

166

where are VIPomas usually

body and tail

167

should VIPomas be resected

yes, though half have metastasized by dx

168

what action should be taken if no tumor is identified in a patient with watery diarrhea, hypokalemia, achlorydria syndrome

subtotal pancreatectomy, bc there can be diffuse islet-cell hyperplasia

169

what condition would a patient with diabetes and a migratory rash be likely to develop?

glucagonoma

170

which enzyme, when activated, is thought to initiate many of the deleterious events a/w pancreatitis

trypsin!

171

which lipolytic enzyme causes pancreatic necrosis in the presence of bile?

phospholipase A

172

which enzyme is responsible for creating intrapancreatic hemorrhage

elastase

173

what causes fat necrosis in pancreatitis

lipase, esp in presence of bile

174

most important risk factor for severe necrotizing pancreatitis

obesity = more lipase

175

% patients with cholelithiasis that develop gallstone pancreatitis

4-8%

176

peritoneal tap findings a/w severe necrotizing pancreatitis

dark brown, sterile, non-foul smelling fluid

177

do NG tubes reduce the length of hospital stay or decrease pain in cases of acute pancreatitis

NO
just use for vomiting/ileus

178

is somatostatin helpful in acute pancreatitis

NO

but does decrease pancreatic fistula output

179

cause of coagulopathy in pancreatitis

release of proteases

180

appropriate treatment for coagulopathies

fresh frozen plasma as required

181

mxn for pulmonary dysfunction during pancreatitis

digestion of surfactant by phospholipase A

182

appropriate treatment for pulmonary problems in acute pancreatitis

mechanical ventilation

183

most common bacteria that infect necrotic pancreatic tissue

gram negative rods

184

appropriate treatment of infected pancreatic tissue

surgical debridement, antibiotics

185

presentation of acute pancreatitis

epigastric pain and tenderness, abdominal distension, fever, tachycardia, jaundice (when a/w gallstone pancreatitis)

186

most common causes of acute pancreatitis

alcoholism, gallstone

187

Ranson's criteria utility

mortality in pancreatitis

188

what 3 groups need asymptomatic gallstones removed

1. immunocompromised
2. porcelain gallbladder (chronic cholecystitis, at risk for adenocarcinoma of the gallbladder)
3. larger than 3 cm

189

6 factors that predispose to gallstones

1. age >40
2. fam hx of gallstones
3. female
4. obesity
5. recent pregnancy
6. prev dx gallstones

190

RUQ due to cholelithiasis can radiate to where

right subscapular

191

most efficient way to dx cholelithiasis

ultrasound

192

lab values to expect with cholelithiasis

mild leukocytosis, mild jaundice, elevated bilis, alk phos and transaminases can also be elevated

193

in uncomplicated cholelithiasis, what is abx regimen

1 dose preop 1G cephalosporin : cefalexin, cefazedone, cefazolin

194

who needs abx in cholelithiasis

high riskers for sepsis: over 70, acute cholecystitis, hx obstructive jaundice, common duct stones, those with preop ERCP done

195

whats major complication of lap chole

common bile duct injury: chronic biliary strictures, infection, cirrhosis;
injury to hepatic artery: hepatic ischemic injury, bile duct ischemia, strictures

196

most common species for acute cholecystitis

1. E. coli
2. enterobacter, klebsiella, enterococcus

197

abx regimen for acute cholecystitis after blood cultures

2G cephalosporin for GNRs and anaerobes: Cefotetan, Cefoxitin

--> give preop and 24h postop

198

when bili and/or liver enzymes are elevated, what to suspect? what to do?

common duct stone! preop or post op ERCP

199

how should gallstone pancreatitis and symptomatic cholelithiasis be managed in pregnant pts

IV hydration and pain mgmt. avoid surg until after delivery if possible but safest to do in 2nd trimester. ERCP and sphincterotomy generally save

--> i also read that chole is safer than peritonitis so sometimes better to do elective? or am i thinking of appy...

200

when biliary pancreatitis suspected, what procedure is necessary operatively?

operative cholangiogram. but delay surgery until complications from pancreatitis relieved: high fluid requirements, hypocalcemia, oliguria, hypotension, pulmonary complications.

201

causes of pancreatitis mnemonic

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps (paramyxovirus and other viruses like epstein barr and cmv)
Autoimmune (PAN/SLE)
Scorpion
Hypercalcemia (or hyperlipidemia, hypertriglyceridemia, hypothermia)
ERCP
Drugs (steroids, sulfonamides, azathioprine, NSAIDs, diuretics, duodenal ulcers)

202

clinical signs of pancreatitis

- grey-turners sign: hemorrhagic discoloration of flanks
- cullen's sign: hemorrhagic discoloration of umbilicus
- grunwald sign: appearance of ecchymosis around umbilicus due to local toxic lesion of vessels
- korte sign (pain or resistance in zone where head of pancreas is located in epigastrium, 6-7 cm above umbilicus)
- kamenchik's sign (pain with pressure under xiphoid process)
- mayo-robson sign (pain while pressing at top of angle lateral to erector spinae muscles and below left 12th rib =left costovertebral angle, CVA)

203

RUQ pain and high fever would be suspicious for

acute cholecystitis and complication like cholangitis, empyema of gallbladder, pericholecystic abscess

204

what ultrasound signs would you see with empyema of gallbladder

distended gallbladder with fluid that has internal echoes and gallstones

205

Tx for empyema of gallbladder

emergent exploration, cholecystectomy, IV abx.

if general health is poor: percutaneous cholecystostomy to drain

206

what does air in the biliary system mean? tx?

pneumobilia: suppurative cholangitis! gas forming organisms.
emergent ERCP w sphincterotomy, decompression of biliary tree, stone removal if feasible.
if unsuccessful: transhepatic cholangiogram and stone extraction, or cholecystectomy and CBD drainage

207

Definition of SIRS/sepsis

1. temp >38 (100.4) or 90
3. RR>20, or PaCO212 or 10% bands

sepsis = SIRS + suspected infection
severe sepsis = sepsis + organ dysfunction
septic shock = sepsis induced hypotension NOT RESPONSIVE TO FLUIDS
(elderly get hypothermic and leukopenic in sepsis!)

208

what does it mean when you have palpable gallbladder? what to do

inflamed gallbladder walled off by omentum. need emergent cholecystectomy when resuscitation occurs. high risk of rupture and mortality! watch out for change in mental status = sign of sepsis

209

Charcot's triad? meaning

1. RUQ pain
2. fever
3. jaundice

means cholangitis

210

tx of cholangitis

1. IVF
2. abx
3. ultrasound
4. ERCP if obstruction or dilatation of CBD seen

211

what is a retained stone

common duct stone within 2 yrs of cholecystectomy. after 2 yrs = primary CBD stone

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post lap chole fever and pain might be?

infection/biliary leak/hepatic (CT scan) abscess/hepatic duct obstruction

213

HIDA scan is good for detecting what

biliary leaks, cholecystitis, obstructions

214

post lap chole cystic duct stump leak on HIDA or ERCP requires what

drainage and temporary stent

215

if HIDA or ERCP shows complete CBD obstruction post cholecystectomy, what to do?

1. biliary drainage using percutaneous drain
2. choledochojejunostomy (CBD to jejunum)

216

differential for painless jaundice, pruritus, elevated liver enzymes?

biliary tree obstruction, cancer at head of pancreas, periampullary carcinoma, Klatskin tumor, CBD stricture, CBD stone (unusual for this presentation)

217

if you see CBD dilation but no stones in ultrasound, what are next steps

1. CT
2. endoscopic ultrasound through duodenal wall to visualize head of pancreas
3. ultrasound guided bx

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what would stop you from resecting a pancreatic adenocarcinoma at the head of pancreas

distant mets esp to liver, LN mets esp to periarotic or celiac region, bone pain, neuro symptoms, involvement of vena cava, aorta, SMA, SMV or portal veins

219

procedure for resection of tumor at head of pancreas

pancreaticoduodenectomy

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what would you do if you found unresectable pancreatic adenocarcinoma with local spread

palliative biliary and gastric bypass to prevent gastric outlet or duodenal obstruction or bile duct obstruction. alcohol injection at celiac axis to decrease back and abdominal pain.

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painless jaundice + dilated intrahepatic ducts + no dilation of CBD

cholangiocarcinoma or Klatskin tumor!

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how to visualize cholangiocarcinoma or Klatskin

ERCP or percutaneous transhepatic cholangiography, which is better for proximal hepatic ducts

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are Klatskin tumors resectable

generally no, but may be able to do resection of gallbladder and bile ducts, hepatic lobectomy or trisegmentectomy

5yr survival with klatskins is 15% after curative resection

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what should you do with unresectable Klatskins or cholangiocarcinoma

palliative stenting of hepatic duct strictures

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type of biliary cancer with best prognosis

ampullary adenocarcinoma. requires a whipple (pancreaticoduodenectomy)

226

what does a mass in the gallbladder fossa mean?

gallbladder adenocarcinoma. do open chole and wide resection of surrounding liver with hilar LN resection.

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porcelain gallbladder associated with what?

50% a/w adenocarcinoma

228

when you suspect pancreatitis what imaging should you get to rule out other stuff

obstructive abdominal series to r/o perforated ulcer. will usually see generalized ileus

229

tx for pancreatitis

NPO, IVF, pain control, observation, TPN if necessary

230

tx for gallstone pancreatitis

IVF, NPO, pain control, observation, lap chole when stable

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tx of severe necrotizing pancreatitis

major fluid resuscitation, CT abd for additional causes of decompensation such as bowel necrosis, performations, abscess, biliary obstruction with infection

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Ransons criteria

admission: age>55, wbc>16, glucose>200, LDH>350, AST>250

48h: hct drop 10%, BUN increase 5, Ca6L

2 or less <5% mortality
3-4 15-20%
5-6 40%
7+ 99% mortality

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what do you do for a person with labored breathing and low pulse ox

1. chest auscultation
2. ABG
3. CXR
4. supply O2

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potential causes of resp distress in pancreatitis

pulm edema from overhydration, ARDS from response to pancreatitis, atelectasis, pneumonia

235

do amylase levels correlate with severity or prognosis

NO!

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if a person with pancreatitis goes into sepsis, what should you suspect? what to do?

pancreatic abscess or other source of sepsis like pneumonia, IV access infection, UTI.

sample percutaneously under CT or ultrasound guidance, drain abscess surgically or percutaneously.

culture. give abx for GNR and anaerobes: imipenem alone or fluoroquinolone plus metronidazole.