Pancreas Flashcards Preview

*OldSurgery > Pancreas > Flashcards

Flashcards in Pancreas Deck (133):
1

where is the pancreas?

retroperitoneal
behind posterior peritoneal membrane at level of L2

2

where does the head of the pancreas sit?

the duodenal C loop

3

where does the neck of the pancreas sit

over the superior mesenteric vein

4

where is the body of the pancreas?

left of the SMV

5

where is the tail of the pancreas

the distal-most portion and abuts the splenic hilum

6

_____ descends in the posterior surface of the pancreatic head to join the main pancreatic duct at the ampulla of Vater which is surrounded by the sphincter of Oddi

CBD

7

main pancreatic duct

Duct of Wirsung

8

lesser duct that drains the superior portion of the head through the lesser papilla

Duct of Santorini

9

what supplies the arterial supply of the head of the pancreas

Celiac trunk to the hepatic artery to the GDA to the superior pancreaticoduodenal artery
SMA to the inferior pancreaticoduodenal artery

10

what blood supply goes to the body and tail of the pancreas

Celiac trunk to the splenic artery

11

where do the veins of the pancreas drain?

portal vein

12

likely responsible for high incidence of metastases with pancreatic cancer

abundant and diffuse lymphatic drainage of the pancreas

13

what is 80-90% of the pancreatic mass?

exocrine
Amylases
Lipases
proteases
Secrete fluid and electrolytes and bicarbonate

14

what are the endocrine portions of the pancreas

Islets of Langerhans - secretes hormones that control glucose homeostasis

15

2 main causes of acute pancreatitis?

alcohol
gallstones

16

what cells are injuired in acute pancreatitis

acinar cell injury

17

____________ tends to have a higher mortality rate than alcoholic pancreatitis

biliary pancreatitis

18

the beta cells of the pancreas secrete what?

insulin and amylin

19

the delta cells of the pancreas secrete what?

somatostatin

20

what is the Ddx for acute pancreatitis?

Acute cholecystitis
Ascending cholangitis
Perforated peptic ulcer
Mesenteric ischemia
Esophageal perforation
MI

21

what bite can cause acute pancreatitis?

scorpion bites

22

what happens w/ amylase and lipase levels w/ pancreatitis?

will go up then back down

23

location of acute pancreatitis pain

Epigastric. May radiate to back, LUQ or RUQ

24

character of acute pancreatitis pain

Dull, boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until reaching a constant ache. Severity varies

25

associated symptoms w/ acute pancreatitis

N/V. Hematemesis or melena if severe

26

precipitating factors w/ acute pancreatitis

Large fatty meal if GS pancreatitis. Alcohol ingestion if EtOH pancreatitis

27

alleviating factors w/ acute pancreatitis?

sitting or standing

28

if acute pancreatitis is severe what 2 signs can you see?

grey turner's sign
cullen's sign

29

blood around flank (pancreatitis)

grey turner's signs

30

what will the abdominal exam look like w/ acute pancreatitis

Upper abdominal tenderness with distention +/- guarding and rebound

31

blood around umbilicus (pancreatitis)

cullen's sign

32

if there a correlation w/ amylase and lipase levels w/ severity of acute pancreatitis

no

33

what will you often see on ABG w/ acute pancreatitis

metabolic acidiosis

34

What are the criteria for Ranson's for acute pancreatitis (on admission)

Age >55 years
WBC >16,000/µL
Blood glucose level >200 mg/dL
Serum LDH level >350 IU/L
AST level >250 IU/L

35

If the Ranson score is greater than what pancreatitis is likely?

equal to or greater than 3

36

what is the CT grade for a normal pancreas

Grade A

37

what grade on a CT scan is "Inflammation of pancreas or peipancreatic fat"

Grade C

38

grade of pancreas on CT with "Focal or diffuse gland enlargement"

Grade B

39

Grade on CT scan with "Single ill-defined collection or phlegmon"

Grade D

40

Grade of pancreatitis with "Two or more ill-defined collections or the presence of gas in or nearby the pancreas"

Grade E

41

what causes gas near or by the pancreas

gas forming bacteria

42

what are some signs w/ pancratitis on x-ray

sentienel loop
cut off sign

43

what is the tx for mild pancreatitis

most will resolve on own
make NPO
IVF
Analgesics
NO ABX

44

if a patient has gallstone pancreatitis what should you do?

cholecystectomy same admission
after pancreatitis resolves but before they go home

45

how do you determine if pancreatitis is resolved?

based on patient
pain better, no nausea
then you can start feeding them

46

complications that can occur w/ severe pancreatitis

shock
pulmonary failure
renal failure
GI bleed
MOS failure

47

for severe pancreatitis what do you need to monitor?

Folye catheter
Central venous catheter
PA catheter (fluid levels)

48

how do you tx severe pancreatitis?

agressive fluid resuscitation
may need pharmacologic assistance

49

how do you monitor respiratory for severe pancreatitis

pulse ox
ABG

50

what is one of the main causes of ARDS?

acute pancreatitis

51

when should you only give antibiotics for pancreatitis?

if you suspect infection
(don't prophylaxis)

52

how can you determine infection w/ pancreatitis?

gas on CT scan
CT guided fine needle aspiration to get a culture

53

tx for severe pancreatitis?

NGT and antiemetics for N/V prn
prophylaxis for gastritis and PUD
prophylaxis for DVT
Nasojejunal feeding past LOT (TPN is second choice)

54

when does infected pancreatitis occur?

2-3 weeks into pancreatitis

55

if pancreatic infection is confirmed what do you do?

necrosectomy- agressive surgical debridement to remove dead tissue (usually multiple OR trips)
drainage
ABX

56

A collection of pus adjacent to the pancreas without necrosis

pancreatic abscess

57

how do you tx a pancreatic abscess?

external drainage (CT guided) or operative drainage
ABX

58

a cyst has what?

epithelial cell wall

59

what is the most common complication of acute pancreatitis?

Peripancreatic fluid collections

60

do you treat most Peripancreatic fluid collections?

no they resolve spontaneously- if not they are a pseudocyst

61

what can a pancreatic pseudocyst cause?

May cause abdominal pain, N/V, early satiety, jaundice

62

how do you drain a non-communicated Pancreatic pseudocyst?

externally

63

how do you drain a communicated Pancreatic pseudocyst?

drained internally (can have it drain into stomach)

64

what is caused by chronic, irreversible inflammation that leads to fibrosis with calcification?

chronic pancreatitis

65

what will someone w/ chronic pancreatitits have?

Chronic abdominal pain and normal or mildly elevated pancreatic enzyme levels

66

when do endocrine and exocrine insufficiencies occur w/ chornic pancreatitis?

When 90% of gland is replaced with scar

67

what occur when endocrine and exocrine insufficiencies occur ?

DM and steatorrhea

68

most common cause of chronic pancreatitis?

excessive alcohol consumption

69

location of pain w/ chronic pancreatitis and character of pain

epigastric can radiate to back
dull character

70

associated symptoms w/ chronic pancreatitis?

steatorrhea and weight loss
DM

71

duration of pain w/ chronic pancreatitis?

Initially intermittent lasting hours to days
Becomes constant and unrelenting

72

precipitating factors for chronic pancreatitis?

supine position
food and ETOH

73

alleviating factors w/ chronic pancreatitis

leaning forward

74

in advanced chronic pancreatitis how will patients look?

decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition

75

what will the abdominal exam be like w/ chronic pancreatitis?

Upper abdominal tenderness
Fullness or mass in epigastrium

76

what is seen on radiography w/ chronic pancreatitis?

Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases

77

if pain relieved w/ chronic pancreatitis?

rarely

78

what replacements do those w/ chronic pancreatitis need?

enzyme replacement
insulin

79

how can you allieve pain w/ chronic pancreatitis?

Analgesics
Celiac plexus blockade

80

what is endoscopic tx for chronic pancreatitis (rarely helps w/ pain)

Decompressing an obstructed pancreatic duct

81

procedure to drain the pancreatic duct
can only do w/ a dilated pancreatic duct
pain relief in 42%

pancreaticojejunostomy (Puestow procedure)

82

for unresectable pancreatic cancer what is the median survival?

6 months

83

risks for pancreatitic cancer

smoking and smokeless tobacco
long standing DM
chronic pancreatitis

84

what type are more pancreatitic cancer?

adenocaricoma
3/4 are in head or neck

85

most people with pancreatic cancer present how?

painless jaundice due to obstruction of common bile duct

86

what are associated symptoms w/ pancreatic cancer?

Significant weight loss
Anorexia
Malaise
Fatigue
Nausea

87

if someone presents w/ painless jaundice and signs of malnourishment?

pancreatic cancer

88

courvoisier's sign- will see on someone w/ pancreatic cancer

palpable gallbladder (non tender)
feels like a balloon

89

how will someone w/ advanced pancreatic cancer present?

Ascites, palpable abdominal mass, hepatomegaly, splenomegaly
Sister Mary Joseph nodule
Blumer’s shelf ()
Virchow’s node

90

Sister Mary Joseph nodule

nodule at belly button)

91

what is a Blumer’s shelf?

palpable ridge on rectal exam

92

what is virchow's node

(suprclavicular) node

93

what labs will be elevated with pancreatic cancer?

Elevation of total and direct bilirubin, alk phos and g-GGT
Mild elevation of transaminases (low hundreds)
Preoperative CA19-9 levels may be of prognostic value with high levels indicating poorer outcome and less chance of being resectable
CEA elevated in 40 – 45%

94

what does an US allow you to see w/ pancreatic cancer?

dilated ductal system
needs to be followed up

95

mainstay for initial diagnostic modality for pancreatic cancer

CT
may miss small tumors

96

Patient requires conscious sedation
Better than CT at detecting small tumors (in the right hands)
FNA
Can’t detect distant metastases

EUS

97

diagnostic for pancreatic cancer
More invasive
Can do brush cytology and forcep biopsy
Therapeutic palliation
Can’t detect distant metastases

ERCP

98

what can be used to stage pancreatic cancer that is a sx procdure?

Preoperative staging laparoscopy

99

surgical procedure of tumors at head of pancreas

Pancreaticoduodenectomy (Whipple procedure)

100

what is the dread complication of a whipple?

pancreatic leak

101

surgery for for tumor at the body or tail of the pancreas

distal pancreatectomy

102

after surgical resection for pancreatic cancer what is done?

chemo/ radiation

103

palliative treatment for pancreatic cancer?

narcotic analgesics
tricyclic antidepressants
antiemetics
celiac axis neurolysis
RT or chemo

104

palliative tx for jaundice w/ pancreatic cancer

endoscopic or percutaneous stent placement
operative biliary decompression at time of operation for resectability assessment

105

for a duodenal obstruction w/ pancreatic cancer what can be done?

gastrojejunostomy
endoscopic stenting of duodenal obstruction

106

Usually large (avg 10cm) and well-circumscribed
Frequently at body or tail
Women > men, > 50yo
Abdominal mass or pain or incidental
Benign
Most removed for symptoms or to differentiate from other tumors

Serous cystadenoma

107

is the serous cystadenoma multiloculated or not?

Multiloculated w/ clear and serous fluid

108

potentially lethal pancreatic neoplasm
contain at least a focal area of atypia
unilocaular w/ thick mucous

Mucinous cystadenoma or cystadenocarcinoma

109

how will mucinous cystadenoma or cystadenocarcinoma present?

abdominal pain or mass

110

what are the 2 other names for pancreatic endocrine tumors

Pancreatic islet cell tumors
Pancreatic neuroendocrine neoplasms

111

how to dx a pancreatic endocrine tumor

CT or MRI
visceral angiography
endoscopic US
octreotide scan (nuclear medicine)
Transhepatic portal venous hormone sampling
Surgical exploration with intraoperative US

112

most common pancreatic endocrine tumor

insulinoma

113

what is the whipple triad w/ insulinoma

Symptoms of hypoglycemia during fasting
Documentation of hypoglycemia with serum glucose < 50 mg/dL
Relief of hypoglycemic symptoms with exogenous glucose

114

what must there be an absence of in the urine to diagnose insulinoma?

sulfonylurea in plasma and/or urine
(from exogenous insulin of DM meds)

115

what labs are needed for a biochemica diagnosis of insulinoma

Blood glucose < 40 mg/dl
Concominent serum insulin ≥ 10 uU/L
C-peptide levels > 2.5 mg/dL
Serum proinsulin levels > 25% normal (nl < 2 ng/mL)

116

diagnosis for insulinoma

monitored fast checking serum insulin:glucose ratio q 4 – 6 hr

117

treament fo rinsulinoma

surgery
debulk if there is metastatiic dz

118

what drugs can be used for non-surgical canidates w/ an insulinoma

Octreotide and diazoxide

119

what syndrome is caused by gastrinoma?

zollinger and ellison

120

where are gastrinomas found

found within the gastrinoma triangle

121

what diagnoses gastrinoma

Fasting gastrin level > 1000 pg/mL while gastric pH < 2

122

tx for non-surgical canidats for gastinoma

PPI
CT (mets and non-surgical canidates)
excision

123

how will people w/ gastrinoma present?

bad peptic ulcers
Severe esophagitis
Severe diarrhea

124

tx for gastinoma

surgical excision

125

how will someone w/ a glucagonoma present

Weight loss, diarrhea, stomatitis, necrolytic migratory erythema, DVT, psychiatric disorders, cachexia, anemia

126

diagnosis for glucagonoma

Elevated fasting serum glucagon levels (500 – 1000 pg/dL)

127

where are most glucagonomas?

body or tail

128

tx for glucagonoma

resection/debulking and octreotide (unresectable).

129

presents with WDHA (watery diarrhea, hypokalemia and achlorhydria)
will ahve meatbolic acidosis

VIPoma (Verner-Morrison syndrome)

130

Seen in Pancreas, ampulla, duodenum, jejunum, cystic duct or rectum
Present w/ Steatorrhea, diabetes, hypochlorhydria and cholelethiasis

somatostatinoma

131

diagnosis for stomatostatinoma

Diagnosis with fasting serum somatostatin levels (>160 pg/mL) and imaging as above

132

where are most stomatostatinomas located?

head of pancreas

133

is surgery for cure common w/ stomatostatinomas?

No, often have debulking