Pancreas

Question 1

What is the balthazar system?

Answer 1

Staging of pancreatitis

a - normal
b - focal/diffuse enlargement
c - intrinsic pancreatic abnl with peripancreatic inflammation
d - fluid collection/phlegmon
e - 2 or more large phlegmonous collections or peripancreatic gas

Question 2

What are the two main appearances of pancreatitis

Answer 2

Diffuse gland enlargement

Normal sized gland with peripancreatic fluid

Question 3

What is the diagnostic key for pancreatic parenchymal necrosis?

Answer 3

Nonperfusion of a pancreatic segment

Question 4

Which part of the pancreas is most susceptible to necrosis?

Answer 4

The body - doesnt have dedicated blood supply

Question 5

What is the natural progression of peripancreatic fluid collections?

Answer 5

Most resorp in 2-3 weeks

Question 6

What is a pseudocyst? What does it indicate?

Answer 6

A peripancreatic fluid collection with a thick fibrous wall lasting more than 6 weeks

Persistent communication with the pancreatic duct

Question 7

When are pseudocysts usually drained?

Answer 7

4cm

Question 8

Irregular fluid collection within a fluid collection surrounding pancreas suggestS?

Answer 8

Pseudoaneurysm

Question 9

What causes the colon cutoff sign with regards to pancreatitis?

Answer 9

Pancreatic inflammatory fluid occupies the left pararenal space and causes colonic spasm

Question 10

What are the helpful signs that distinguish IPMN and chronic pancreatitis?

Answer 10

IPMN will have mainly ductal dilation

Chronic pancreatitis will have parenchymal atrophy

Question 11

What percentage of pancreatic parenchymal loss must occur for pancreatic insufficiency?

Answer 11

90%

Question 12

Chain of lakes appearance of the pancreatic ducts is seen with what

Answer 12

chronic pancreatitis

Question 13

What are the two types of familial pancreatitis

Answer 13

1) familial occurence associated with hyperlipidemia, hyperparathyroidism, CF, cholelithiasis
2) AD inherited syndrome

Question 14

What is hereditary pancreatitis?

Answer 14

AD inherited

early bouts of pancreatitis as a kid, increased risk of pancreatic cnacncer

Question 15

Subtype of pancreatitis seen in older men, milder symptoms. What is the marker?

Answer 15

Autoimmune pancreatitis

IgG4

Question 16

How are most pancreatic cancers on CT?

Answer 16

hypoattenuating mass

Question 17

What US finding is specific for ductal adenocarcinoma?

Answer 17

Ductal dilation

Question 18

What are the two important phases in detection of pancreatic tumors?

Answer 18

Pancreatic phase (45 seconds) - will have maximal contrast between hypoattenuating mass and parenchyma

Portal venous - detects hepatic mets and lymphadenoapthy

Question 19

How do most pancreatic tumors present on MRI?

Answer 19

Hypo in T1 and hyper on T2

Question 20

What does obliteration of the pancreatic - SMA fat plane suggest?

Answer 20

Pancreatic mass

Question 21

What are the causes of nonresectibility in pancreatic cancer?

Answer 21

Arterial invasion - celiac or SMA
Venous invasion - *limited involvement of SMV and portal can be resected
Regional lymphadenopathy with metastatic tumor
Distant mets

Question 22

Multiple collateral vessels in the upper abdomen in a patient with pancreatic cancer should prompt search for what?

Answer 22

splenic/mesenteric vein occlusion

Question 23

What 3 features help distinguish islet cells tumors?

Answer 23

Hypervascularity
Lack of vascular encasement
Propensity to calcify

Question 24

What are the common hyperfunctioning islet cell tumors?

Answer 24

Insulinoma and gastrinoma

Question 25

Which type of islet cell tumor are worse?

Answer 25

Nonfunctioning because they dont have symptoms and can grow to big sizes before detection

Question 26

What is the gastrinoma triad?

Answer 26

Location of half of gastrinomas (arise out of pancreas) Amuplla vater, junction of cystic duct and CBD, and junction of neck and body of pancreas

Question 27

Gastrinomas are associated with what syndrome?

Answer 27

MEN I

Question 28

What percentage of gastrinoma are malignant?

Answer 28

75%

Question 29

What NM test can detect gastrinoma? Why?

Answer 29

Octreotide scintigraphy High concentration of somatostatin receptiors

Question 30

What is the US difference between primary and metastatic islet cell tumor? Between cavernous hemangioma?

Answer 30

PRimary - hypoechoic Metastatic - hyperechoic with posterior acoustinc shadowing Hemangioma - no shadowing

Question 31

What is the difference between islet cell tumors associated with MEN and those that arise sporadically?

Answer 31

MEN I - tend to be small, multiple, and biologically less aggressive

Question 32

What are the symptoms with glucagonoma

Answer 32

necrolytic erythema migrans, diarrhea, diabetes, glossitis

Question 33

What is unique about hepatic mets in hypervascular primary tumors, such as islet cell?

Answer 33

Can contain fluid air level

Question 34

Intratumoral calcification with solid and cystic elements in a young african woman

Answer 34

Solid and papillary epithelial neoplasm

Question 35

What is the treatment of SPEN

Answer 35

total cure with resection

Question 36

What are the unique features of acinar neoplasm?

Answer 36

Larger than ductal Encapsulated Has metastatic fat necrosis due to systemic release of lipase

Question 37

What tumor causes metastatic fat necrosis

Answer 37

Acinar cell carcinoma

Question 38

Most common met to the pancreas?

Answer 38

Renal cell

Question 39

What are the two main types of cystic pancreatic masses? Which are benign?

Answer 39

Serous - benign Mucinous - pre/malignant

Question 40

Honeycombed appearance, many (>6) small (

Answer 40

Serous "Serous has Several"

Question 41

Few large cysts

Answer 41

Mucinous

Question 42

What is the main differential for a mucinous cystadenoma

Answer 42

Pseudocyst - will have history of pancreatitis

Question 43

What are malignant features of mucinous neoplasms

Answer 43

Thick septation | mural nodules

Question 44

Mucin eminating from the papilla of vater is pathognomonic for what

Answer 44

IMPN

Question 45

What is the imaging in IPMN

Answer 45

pancreatic ductal dilation with filing defects

Question 46

Identification of a dilated side branch is suggestive of what diagnosis?

Answer 46

side branch IPMN

Question 47

What is the size cutoff for resection of side branch IPMN

Answer 47

3cm

Question 48

What is the grandma tumor? mother tumor? daughter tumor?

Answer 48

Grandma - serous Mother - "M"ucinous Daughter - SPEN

Question 49

What are the pancreatic manifestations of VHL?

Answer 49

Numerous cysts Serous cystadenoma Islet cell tumor

Question 50

Where do pancreatic lacerations most often occur

Answer 50

Between the neck and body

Question 51

What is pancreatic divisum?What are the drainage pathways?

Answer 51

Failure of the dorsal and ventral portions of the pancreas to fuse The duct of santorini empties via the accessory papilla

Question 52

What are the two theories of pancreatic annulus forms?

Answer 52

Failure of pancreatic atrophy Ventral portion adheres to duodenum and stretches around it as it rotates into position

Question 53

Calcifications in the pancreas that are not intraductal and without ductal dilation?

Answer 53

Sarcoidosis

Question 54

Where are the calcifications with chronic pancreatitis seen

Answer 54

Intraductal

Question 55

What does a sausage shaped and with an apparent hypoattenuating halo surrounding an enlarged pancreas suggest?

Answer 55

Autoimmune pancreatitis