Pancreas

Question 1

Head blood supply

Answer 1

superior (off GDA) and inferior (off SMA) pancreaticoduodenal arteries (ant/post branches)

Question 2

Body blood supply

Answer 2

great, inferior, and caudal pancreatic artery (off splenic artery)

Question 3

Tail blood supply

Answer 3

splenic, gastroepiploic and dorsal pancreatic arteries

Question 4

Located where

Answer 4

retroperitoneum

Question 5

SMA and SMV

Answer 5

lie behind neck of pancreas

Question 6

Venous drainage

Answer 6

into portal system

Question 7

Portal vein

Answer 7

forms behind neck (SMV and splenic vein)

Question 8

Ductal cells

Answer 8

have carbonic anhydrase and secrete HCO3- ; increase flow leads to increase bicarb and decrease chloride

Question 9

Acinar cells

Answer 9

secrete chloride and digestive enzymes

Question 10

Ventral pancreatic bud

Answer 10

connected to duct of wirsung; migrates posteriorly, to the right and clockwise and fuse with dorsal bud; forms uncinate and inferior portion of head

Question 11

Dorsal pancreatic bud

Answer 11

body, tail, and superior aspect of pancreatic head; duct of santorini

Question 12

Duct of santorini

Answer 12

small accessory pancreatic duct that drains directly into duodenum

Question 13

Duct of wirsung

Answer 13

major pancreatic duct that merges with CBD before entering duodenum

Question 14

Exocrine function

Answer 14

amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase; bicarb

Question 15

Amylase

Answer 15

only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains

Question 16

Enterokinase

Answer 16

released by duodenum; activates trypsinogen to trypsin; trypsin activates other pancreatic enzymes

Question 17

Secretin

Answer 17

released from cells in duodenum; increase bicarb

Question 18

CCK

Answer 18

released from cells in duodenum; increase enzymes

Question 19

Acetylcholine

Answer 19

increase bicarb and enzymes

Question 20

somatostatin and glucagon

Answer 20

decrease exocrine function

Question 21

Endocrine function

Answer 21

glucagon (alpha cells); insulin (beta cells, center of islets); somatostatin (delta cells); pancreatic polypeptide (PP or F cells)

Question 22

Islet cells

Answer 22

also prodce VIP, serotonin, neuropeptide Y, gastrin releasing peptide; receive majority of blood supply

Question 23

Annular Pancreas

Answer 23

2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal xray; assoc with down syndrome; forms from ventral pancreatic bud from failure of clockwise rotation; tx: duodenojejunostomy or duodenoduodenostomy and sphincteroplasty; pancreas not resected

Question 24

Pancreas divisum

Answer 24

failed fusion of pancreatic ducts; can result in pancreatitis from duct of santorini (accessory duct) stenosis; most are asymptomatic; some get pancreatitis; DX: ercp, minor papilla will show long and large duct of Santorini, major papilla will show short duct of Wirsung; tx: sphincteroplasty and stent placement if symptomatic, some may need pancreaticojejunostomy

Question 25

Heterotopic pancreas

Answer 25

most commonly found in duodenum; usually asymptomatic; surgical resection if symptomatic

Question 26

Pancreatic pseudocysts

Answer 26

nonepithelialized sac; expectant management up to 3 months, allows pseudocyst to mature; only need to treat pts with continued symptoms or pseudocysts that are growing; need MRCP / ERCP to check for duct involvemnt; if duct involved need cystogastrostomy; if duct not involved can do perc drainage

Question 27

Puestow procedure

Answer 27

chronic pancreatitis; pancreaticojejunostomy for ducts > 8mm; open along main pancreatic duct

Question 28

Pancreatic adenocarcinoma

Answer 28

tobacco #1 risk factor; lymphatic spread first; 70% in head; 50% invade portal vein, SMV, or retroperitoneum at time of dx; mets to peritoneum, omentum, liver, celiac, SMA nodes unresectable disease; pts with resectable disease do not need biopsy; if appears to have mets then biopsy

Question 29

Whipple

Answer 29

pancreaticoduodenectomy; delayed gastric emptying #1 complication

Question 30

Intraductal Papillary Mucinous Neoplasm

Answer 30

6th-7th decade of life; side branch, main duct, mixed type; tx: partial pancreatectomy for main duct, symptomatic, large branch type > 3c, or invasive component; cyst fluid: mucin stain positive; high amylase; high CEA

Question 31

Mucin cystic neoplasm

Answer 31

cyst fluid: mucin stain positive, low amylase, high CEA

Question 32

Serous cystic neoplasm

Answer 32

cyst fluid: mucin stain negative, low amylase, low CEA

Question 33

Pseudocyst

Answer 33

cyst fluid: mucin stain negative; high amylase; low CEA

Question 34

Pancreatic trauma

Answer 34

Grade I: hematoma - minor contusion without ductal injury laceration - superficial lac w/o ductal injury Grade II: hematoma - major contusion w/o ductal injury laceration - major lac w/o ductal injury Grade III: laceration - distal transection or parenchymal injury with ductal injury Grade IV: laceration - proximal transection or parenchymal injury involving the ampulla Grade V: laceration - massive disruption of pancreatic head

Question 35

Nonfunctional Endocrine Tumors

Answer 35

1/3 pancreatic endocrine tumors; 90% malignant; sxs: pain, weight loss, jaundice; indolent course; tx: resection unless mets; 5FU and streptozocin may be effective; 50% 5 year survival after resection

Question 36

Insulinoma

Answer 36

- most common islet cell tumor and functional neoplasm of pancreas - 90% benign; evenly distributed; 10% assoc with MEN I - sxs: whipples triad 1. fasting hypoglycemia 2. sxs of hypoglycemia (palpitations, tachycardia, sweating, blurry vision, fatigue, seizures) 3. relief with glucose - Dx --> insulin:glucose ratio > 0.4 after fast; increase c-peptide and proinsulin - Tx: enucleate < 2cm; formal resection > 2cm; mets streptozocin, octreotide, 5FU

Question 37

Gastrinoma

Answer 37

- most common islet cell tumor (fxt'l tumor) in MEN-I - 50% malignant / 50% multiple - 75% sporadic / 25% MEN-I - majority in gastrinoma triangle (CBD, neck of pancreas, 3rd portion of duodenum) - Sx: refractory ulcer disease, abd pain, diarrhea - Dx: gastrin > 200, > 1,000 diagnositc; secretin stim test (gastrin > 200, normal pts decrease gastrin); octreotide scan (somatostatin receptor scintigraphy) best study to localize tumor - Tx: enucleation < 2cm; formal resection > 2cm; excise suspicious nodes; can't find tumor perform duodenostomy, look inside duodenum; duodenal tumor resect with primary closure (whipple maybe); debulking can improve

Question 38

Somatostatinoma

Answer 38

- very rare; most malignant / most in head - Sx: DM, gallstones, steatorrhea, hypochlorhydria - Dx: fasting somatostatin level > 100 - tx: perofrm chole with resection; debulk hepatic mets

Question 39

Glucagonoma

Answer 39

- most malignant; distal panc - Sx: DM, stomatitis, dermatitis (necrolytic migratory erythema), weight loss) - Dx: high fasting glucagon level; biopsy skin lesion - Tx: resection (usually distal panc); octreotide useful in controlling symptoms (hyperglycemia, dermatitis); zinc, amino acids or fatty acids for skin rash

Question 40

VIPOMA

Answer 40

- verner-morrison syndrome - most malignant; most distal; 10% extrapancreatic (RP, thorax) - Sxs: watery diarrhea, hypokalemia, achlorhydria (WDHA); decrease K+ from diarrhea (lethargy, muscle weakness, nausea); metabolic acidosis d/t loss of bicarb in diarrhea - Dx: exclude other causes of diarrhea; increase VIP level - Tx: pre op electrolyte correction; distal panc; octreotide as adjunct

Question 41

Functional Endocrine Pancreatic Tumors

Answer 41

``` Insulinoma Gastrinoma Somatostatinoma Glucagonoma VIPoma ```