Flashcards in Pancreas Deck (133):
where is the pancreas?
behind posterior peritoneal membrane at level of L2
where does the head of the pancreas sit?
the duodenal C loop
where does the neck of the pancreas sit
over the superior mesenteric vein
where is the body of the pancreas?
left of the SMV
where is the tail of the pancreas
the distal-most portion and abuts the splenic hilum
_____ 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
main pancreatic duct
Duct of Wirsung
lesser duct that drains the superior portion of the head through the lesser papilla
Duct of Santorini
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
what blood supply goes to the body and tail of the pancreas
Celiac trunk to the splenic artery
where do the veins of the pancreas drain?
likely responsible for high incidence of metastases with pancreatic cancer
abundant and diffuse lymphatic drainage of the pancreas
what is 80-90% of the pancreatic mass?
Secrete fluid and electrolytes and bicarbonate
what are the endocrine portions of the pancreas
Islets of Langerhans - secretes hormones that control glucose homeostasis
2 main causes of acute pancreatitis?
what cells are injuired in acute pancreatitis
acinar cell injury
____________ tends to have a higher mortality rate than alcoholic pancreatitis
the beta cells of the pancreas secrete what?
insulin and amylin
the delta cells of the pancreas secrete what?
what is the Ddx for acute pancreatitis?
Perforated peptic ulcer
what bite can cause acute pancreatitis?
what happens w/ amylase and lipase levels w/ pancreatitis?
will go up then back down
location of acute pancreatitis pain
Epigastric. May radiate to back, LUQ or RUQ
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
associated symptoms w/ acute pancreatitis
N/V. Hematemesis or melena if severe
precipitating factors w/ acute pancreatitis
Large fatty meal if GS pancreatitis. Alcohol ingestion if EtOH pancreatitis
alleviating factors w/ acute pancreatitis?
sitting or standing
if acute pancreatitis is severe what 2 signs can you see?
grey turner's sign
blood around flank (pancreatitis)
grey turner's signs
what will the abdominal exam look like w/ acute pancreatitis
Upper abdominal tenderness with distention +/- guarding and rebound
blood around umbilicus (pancreatitis)
if there a correlation w/ amylase and lipase levels w/ severity of acute pancreatitis
what will you often see on ABG w/ acute pancreatitis
What are the criteria for Ranson's for acute pancreatitis (on admission)
Age >55 years
Blood glucose level >200 mg/dL
Serum LDH level >350 IU/L
AST level >250 IU/L
If the Ranson score is greater than what pancreatitis is likely?
equal to or greater than 3
what is the CT grade for a normal pancreas
what grade on a CT scan is "Inflammation of pancreas or peipancreatic fat"
grade of pancreas on CT with "Focal or diffuse gland enlargement"
Grade on CT scan with "Single ill-defined collection or phlegmon"
Grade of pancreatitis with "Two or more ill-defined collections or the presence of gas in or nearby the pancreas"
what causes gas near or by the pancreas
gas forming bacteria
what are some signs w/ pancratitis on x-ray
cut off sign
what is the tx for mild pancreatitis
most will resolve on own
if a patient has gallstone pancreatitis what should you do?
cholecystectomy same admission
after pancreatitis resolves but before they go home
how do you determine if pancreatitis is resolved?
based on patient
pain better, no nausea
then you can start feeding them
complications that can occur w/ severe pancreatitis
for severe pancreatitis what do you need to monitor?
Central venous catheter
PA catheter (fluid levels)
how do you tx severe pancreatitis?
agressive fluid resuscitation
may need pharmacologic assistance
how do you monitor respiratory for severe pancreatitis
what is one of the main causes of ARDS?
when should you only give antibiotics for pancreatitis?
if you suspect infection
how can you determine infection w/ pancreatitis?
gas on CT scan
CT guided fine needle aspiration to get a culture
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)
when does infected pancreatitis occur?
2-3 weeks into pancreatitis
if pancreatic infection is confirmed what do you do?
necrosectomy- agressive surgical debridement to remove dead tissue (usually multiple OR trips)
A collection of pus adjacent to the pancreas without necrosis
how do you tx a pancreatic abscess?
external drainage (CT guided) or operative drainage
a cyst has what?
epithelial cell wall
what is the most common complication of acute pancreatitis?
Peripancreatic fluid collections
do you treat most Peripancreatic fluid collections?
no they resolve spontaneously- if not they are a pseudocyst
what can a pancreatic pseudocyst cause?
May cause abdominal pain, N/V, early satiety, jaundice
how do you drain a non-communicated Pancreatic pseudocyst?
how do you drain a communicated Pancreatic pseudocyst?
drained internally (can have it drain into stomach)
what is caused by chronic, irreversible inflammation that leads to fibrosis with calcification?
what will someone w/ chronic pancreatitits have?
Chronic abdominal pain and normal or mildly elevated pancreatic enzyme levels
when do endocrine and exocrine insufficiencies occur w/ chornic pancreatitis?
When 90% of gland is replaced with scar
what occur when endocrine and exocrine insufficiencies occur ?
DM and steatorrhea
most common cause of chronic pancreatitis?
excessive alcohol consumption
location of pain w/ chronic pancreatitis and character of pain
epigastric can radiate to back
associated symptoms w/ chronic pancreatitis?
steatorrhea and weight loss
duration of pain w/ chronic pancreatitis?
Initially intermittent lasting hours to days
Becomes constant and unrelenting
precipitating factors for chronic pancreatitis?
food and ETOH
alleviating factors w/ chronic pancreatitis
in advanced chronic pancreatitis how will patients look?
decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition
what will the abdominal exam be like w/ chronic pancreatitis?
Upper abdominal tenderness
Fullness or mass in epigastrium
what is seen on radiography w/ chronic pancreatitis?
Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases
if pain relieved w/ chronic pancreatitis?
what replacements do those w/ chronic pancreatitis need?
how can you allieve pain w/ chronic pancreatitis?
Celiac plexus blockade
what is endoscopic tx for chronic pancreatitis (rarely helps w/ pain)
Decompressing an obstructed pancreatic duct
procedure to drain the pancreatic duct
can only do w/ a dilated pancreatic duct
pain relief in 42%
pancreaticojejunostomy (Puestow procedure)
for unresectable pancreatic cancer what is the median survival?
risks for pancreatitic cancer
smoking and smokeless tobacco
long standing DM
what type are more pancreatitic cancer?
3/4 are in head or neck
most people with pancreatic cancer present how?
painless jaundice due to obstruction of common bile duct
what are associated symptoms w/ pancreatic cancer?
Significant weight loss
if someone presents w/ painless jaundice and signs of malnourishment?
courvoisier's sign- will see on someone w/ pancreatic cancer
palpable gallbladder (non tender)
feels like a balloon
how will someone w/ advanced pancreatic cancer present?
Ascites, palpable abdominal mass, hepatomegaly, splenomegaly
Sister Mary Joseph nodule
Blumer’s shelf ()
Sister Mary Joseph nodule
nodule at belly button)
what is a Blumer’s shelf?
palpable ridge on rectal exam
what is virchow's node
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%
what does an US allow you to see w/ pancreatic cancer?
dilated ductal system
needs to be followed up
mainstay for initial diagnostic modality for pancreatic cancer
may miss small tumors
Patient requires conscious sedation
Better than CT at detecting small tumors (in the right hands)
Can’t detect distant metastases
diagnostic for pancreatic cancer
Can do brush cytology and forcep biopsy
Can’t detect distant metastases
what can be used to stage pancreatic cancer that is a sx procdure?
Preoperative staging laparoscopy
surgical procedure of tumors at head of pancreas
Pancreaticoduodenectomy (Whipple procedure)
what is the dread complication of a whipple?
surgery for for tumor at the body or tail of the pancreas
after surgical resection for pancreatic cancer what is done?
palliative treatment for pancreatic cancer?
celiac axis neurolysis
RT or chemo
palliative tx for jaundice w/ pancreatic cancer
endoscopic or percutaneous stent placement
operative biliary decompression at time of operation for resectability assessment
for a duodenal obstruction w/ pancreatic cancer what can be done?
endoscopic stenting of duodenal obstruction
Usually large (avg 10cm) and well-circumscribed
Frequently at body or tail
Women > men, > 50yo
Abdominal mass or pain or incidental
Most removed for symptoms or to differentiate from other tumors
is the serous cystadenoma multiloculated or not?
Multiloculated w/ clear and serous fluid
potentially lethal pancreatic neoplasm
contain at least a focal area of atypia
unilocaular w/ thick mucous
Mucinous cystadenoma or cystadenocarcinoma
how will mucinous cystadenoma or cystadenocarcinoma present?
abdominal pain or mass
what are the 2 other names for pancreatic endocrine tumors
Pancreatic islet cell tumors
Pancreatic neuroendocrine neoplasms
how to dx a pancreatic endocrine tumor
CT or MRI
octreotide scan (nuclear medicine)
Transhepatic portal venous hormone sampling
Surgical exploration with intraoperative US
most common pancreatic endocrine tumor
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
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)
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)
diagnosis for insulinoma
monitored fast checking serum insulin:glucose ratio q 4 – 6 hr
treament fo rinsulinoma
debulk if there is metastatiic dz
what drugs can be used for non-surgical canidates w/ an insulinoma
Octreotide and diazoxide
what syndrome is caused by gastrinoma?
zollinger and ellison
where are gastrinomas found
found within the gastrinoma triangle
what diagnoses gastrinoma
Fasting gastrin level > 1000 pg/mL while gastric pH < 2
tx for non-surgical canidats for gastinoma
CT (mets and non-surgical canidates)
how will people w/ gastrinoma present?
bad peptic ulcers
tx for gastinoma
how will someone w/ a glucagonoma present
Weight loss, diarrhea, stomatitis, necrolytic migratory erythema, DVT, psychiatric disorders, cachexia, anemia
diagnosis for glucagonoma
Elevated fasting serum glucagon levels (500 – 1000 pg/dL)
where are most glucagonomas?
body or tail
tx for glucagonoma
resection/debulking and octreotide (unresectable).
presents with WDHA (watery diarrhea, hypokalemia and achlorhydria)
will ahve meatbolic acidosis
VIPoma (Verner-Morrison syndrome)
Seen in Pancreas, ampulla, duodenum, jejunum, cystic duct or rectum
Present w/ Steatorrhea, diabetes, hypochlorhydria and cholelethiasis
diagnosis for stomatostatinoma
Diagnosis with fasting serum somatostatin levels (>160 pg/mL) and imaging as above
where are most stomatostatinomas located?
head of pancreas