Pancreas Flashcards
(53 cards)
Severe acute pancreatitis ddx?
- ddx-perf ulcer, boerhaaves sx, cholecystitis, cholangitis, MI, AAA dissection
Severe acute pancreatitis hx?
- Hx- drinking, h/o pancreatitis,
Severe acute pancreatitis PE?
- PE- jaundice, grey turner, cullen si, rectal exam, pulsatile mass
Severe acute pancreatitis note?
- Note- arterial blood gas, 80% will resolve spontaneously
Severe acute pancreatitis ranson score?
- Ranson score
- admit-
- GALAW >200, >55yrs, >350, AST>250, >16
- 48hrs
- CHHOBS Ca10%, PaO2 5, Base def >4, sequestration fluids >6L
- admit-
Severe acute pancreatitis mortality?
- 1-2 =1%, 3-4=15%, 5-6=40%mortality indicates the likelyhood of systemic complications and likelihood of necrosis
Severe acute pancreatitis etiology?
- gallstone panc, ETOH, TG, divisum, trauma
Severe acute pancreatitis management? MDOS? Ext ill?
- r/o other causes
- Cardiac enzymes, CBC, Lipase, amylase, LFTs, CXR, US RUQ (check for stones)
- Flat Upright XR (r/o perf ulcer)
- CT Scan (will show inflammation around pancreas necrotic or ischemic)
- pain ctrl, fluids monitor o2 may need intubation,
- Admit patient +- ICU
- enteral feeding via nasojejunal tube (post pyloric) if ileum isn’t bad
- DVT and GI px
- Foley monitor UOP
- consider central line
- don’t start ABX cuz candida is associated with worse outcomes
- for patients with MODS and sepsis
- then ct guided FNA of necrotic areas to determine bacterial contamination which needs intervention surgical or radiologic drainage.
- in ext ill patients then
- perc drains placed at the time of FNA can sometimes stabilize patient prior to surgery to temporize and even treat definitively
- if possible wait 4 weeks for demarcation prior to necrosectomy minimize resection of viable pancreas and the accompany mortality
Severe acute pancreatitis hemorrhagic?
- check hgb, transfuse, consider angiogram and embolization if doesn’t respond
- If fails then take to OR get proximal and distal control of aorta and open the the hematoma and find bleeder
- poor prognosis
Severe acute pancreatitis patient deteriorates?
- if patient deteriorates after CT guided FNA then proceed with surgical debridement
- access the lesser sac through the gastrocolic ligament or mesocolon
- once pancreas is exposed the capsule is opened and all purulent material and necrotic tissue is removed from the pancreatic bed
- you can do this with irrigation or ring forceps
- inspect the transverse colon to make sure not compromised and if it is the right hemicolectomy
- if you close then leave JP drains to maximize drainage debris or consider closed continuous lavage of retroperitoneum where undoing necrosis is anticipated
- other option is leaving open and re-explore every 48 hrs until no further debridement is needed
- if gallstone pancreatitis cholecystectomy should be deferred to a later date if the gallbladder is not easily accessible
- post op comp -
- MOF, hemorrhage, endocrine comp, fungal, fistula from duct or bowel, pseudocyst, abscess, vascular comp mesenteric or splenic venous thrombosis
- follow with repeat imaging
- consider feeding jejunostomy
- manage pseudocyst with cystogastrostomy
- Management of Gallstone pancreatitis? Mild, severe, infected fluid collections?
- Management of Gallstone pancreatitis
- Mild
- cont supportive care and serial exams
- lap cholecystectomy with IOC w/in 4 days
- Severe
- may wait longer for inflammation to go down
- may need ICU care
- ERCP for evacuation of stones if no improvement in 24 hrs
- If no gallstones, the repeat CT scan in 48hrs to look for necrosis, pseudocyst, abscess, phlegm, or fluid collections
- Mild
- Infected fluid collections
- need large perc drains and if fails with 24 to 48hrs then take to OR for surgical debridement and feed J-tube placement
Cystic lesion hx?
- Hx-back pain, steatorrhea,weight loss (exocrine), new onset diabetes (endocrine)
Cystic lesion rf?
- RF smoking, obesity, family
Cystic lesion PE?
- PE - abdominal mass, lymhadenopathy, cachexia, jaundice
Cystic lesion labs?
- CEA, AFP, LFTs, CA19-9
Cystic lesion imaging diagnosics?
- CT pancreatic protocol
- MRCP- useful for cystic lesions detects small lesions 2/2 to the ductogram gadolinium and secretin injection; motifocalilty in absence h/o pancreatitis suggest IPMN
- EUS- if MRCP CI then use EUS with FNA of cystic fluid, nodules etc (cytopathology is gold std 2/2 to surgical bx most accurate and specific of malignancy, unfort is low sensitive 2/2 low cellularity
Cystic lesion cyst vs bad?
- Pancreatic cyst CEA >192 predicts mucionous lesion but doesn’t determine malignancy, DNA KRAS
- Serum CA19-9adn HgbA1C do correlate with malignancy, serum amylase and lipase can also help determine if a cyst has malignant potential
- Alk phosp predicts biliary obstruction
Cystic lesion ERCP, EUS?
- ERCP less common high risk profile but can use in combo c ductoscopy
- ERCP, EUS (stage and FNA LN), Bx and brushings
- no perc bx (seed)
Cystic lesion ddx?
- inflammatory vs neoplastic;
- pseudocyst (inflam),
- IPMN,
- papillary mucin producing neoplasm arising from main pancreatic duct
- thick mucin exuding from ampulla during ERCP
- mostly proximal and older pts
- use Ca19-9 to distinguish
- if involves main duct needs resection
- Cystadenoma,
- Cystadenocarcinoma,
- serous cystic neoplasm
- usually evenly distributed throughout
- usually only sx when enlarged
- aspirate no mucin and have no malignant potential
- usually nonoperative unless sx
- mucinous cystic neoplasm
- usually body or tail
- increase risk of cancer
- elevated CEA aspirate
- usually nonoperative unless sx
Cystic lesion preop?
- Preop vaccinations
Cystic lesion IPMN?
- Distal pancreatectomy, splenectomy
- IPMN -cause intermittent pancreatic duct obstruction with mucus (MC when main duct involved) exocrine affected (steatorrhea and weight loss) bloating (take oral pancreatic enzymes meds supp)
- if side branch w/o sx and concerning imaging or cytopath then ok to do surveillance and an older patient. younger more chance to mutate
- Main duct elevated rates of invasive cancer 50% Side branch 10%
- imaging mural nodule near cyst higher risk
- Tx segmental resection
- multifocal disease need to weigh affects of leaving some behind and performing surveillance (just take the worst of it ie. distal pancreatectomy) vs doing a total pancreatectomy (endo & exocrine failure)
Cystic lesion distal pancreatectomy?
- Surgery distal pancreatectomy
- preop vaccinations splenectomy possible (try to preserve better )
- explore liver and peritoneum for mets
- take down gastrocolic ligament and enter lesser sac preserve gastroepiploic retract posterior wall of stomach cephlad
- look for splenic artery superior border of pancreas
- establish a plane on the inferior border of pancreas ID and preserve splenic vessels and dissect free from them
- very tricky to preserve in cyst is near hilum
- transect pancreatic parenchyma with a buttressed linear stapler with oversewing of main pancreatic duct
- if you take the splenic vessels sometimes can salvage them based off the short gastrics
- Intraoperative frozens of proximal margin
- if “main duct” or “side branch- High grade” involved reresect, if side branch low grade back off if further resect meant total pancreatectomy.
- Just remove the most threatening lesion and preserve gland
- need negative margins
- drains have no benefit but if placed if output is >50 ml/day check drain amylase to guide timing of removal
- Annual surveillance of negative margins lesions H&P, MRI-MRCP, CT and serum studies
- Semiannual for higher risk lesions and also include EUS-FNA c cytopath and molecular studies to monitor recurrence or progression
Refractory Pain from Chronic Pancreatitis ddx?
- DDx- PUD, hepatitis, biliary
Refractory Pain from Chronic Pancreatitis hx?
acute pancreatitis, ETOH abuse, chronic Abdominal Pain, weight loss, steatorrhea, exocrine and endocrine insufficiency, malnutrition