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Flashcards in Pancreas Deck (58):
1

RUSH--Pancreas

Which of the following vascular relationships is not an important consideration during resection of the head of the pancreas?

A. Arterial supply of the pancreatic head from the splenic artery
B. Confluence of the splenic vein and SMV dorsal to the pancreatic neck
C. Absence of ventral portal vein branches doral to the pancreatic neck
D. Origin of the R hepatic artery from the SMA
E. Origin of the middle colic artery from the SMA

A

Arterial supply to the head of the gland is derived from both from the GDA and SMA via the anterior and posterior pancreaticoduodenal arcades. For the most part, head of the pancrease and duodenum have a shared blood supply so they must be resected together. Techniques for duodenal sparing pancreatetcomy and pancreatic sparing duodenectomy in select circumstances

Body and tail of pancreas receive blood supply from multiple brances of splenic artery, which also connect with superior mesenteric sources.

Variations in major arteries such as origin of R hepatic artery from SMA and origin of middle colic artery from SMA or dorsal pancreatic artery pleave these vessels in close proximity to head and neck of pancreas, where they are subject to injury during pancreatectomy

Junction of splenic vein and SMV to from the portal vein lies behind the neck of the pancreas. Usually these vessel do not have large anterior tributaries in this area.

2

RUSH--Pancreas

Endoscopy demonstrates a 1 cm submucosal nodule with central umbilication in the second portion of the duodenum. This finding is usually associated with which of the following?

A. Peptic ulceration
B. Increased risk for pancreatic cancer
C. Islet cell hyperplasia
D. Absence of symptoms
E. Intussuscption

D

Heterotopic pancreas is pancreatic tissue located at sites other than the normal location of the gland. Ectopic pancreatic tissue has been described at many anatomic locations but is typically found in the stomach, duodenum or Meckel's diverticulum.

Theories of origin include metaplasia and transplantation. Histologic findings range from rudimentary structure to a fully formed gland. Most heterotopic rests contain ducts and both endocine and exocrine elements may be present.

Not uncommon, in 1-2% of autopsies. Usually asymptomatic. When symptoms occurs, they are related to location of the ectopic site and include obstruction (as a results of intussusception), ulceration, and bleeding. Malignancy has been reported, there is no evidence that heterotopic pancreatic tissue is predisposed to cancer.

Typical gross appearance is submucosal nodule, often with central umbilication. Resection is indicated for symptomatic lesions and is appropriate diagnostically for incidental lesions discovered during operations for other reasons

3

RUSH--Pancreas

The embryologic ventral pancreas forms which area of the fully developed gland?

A. Superior head
B. Uncinate process
C. Neck
D. Body
E. None of the above

B

Pancreas is forms from two outpouching of the primitive gut. Dorsal pancreas originates from the duodenum and ventral pancreas begins as a bud from the hepatic diverticulum, which itself is an outpouching of the duodenum. Other outgrowths from the hepatic diverticulum mature into the liver, gallbladder and bile ducts.

During normal fetal development, ventral pancreas rotates along with the primitive gut and fuses with the dorsal component. Ventral pancreas constitutes the uncinate process and the inferior portion of the head of the gland in the fully developed state. The dorsal pancreas forms the remainder of the gland.

Abnormalities in this development process result in recognized congenital anomalies that can be clinically important.

4

RUSH--Pancreas

The uncinate process of the pancreas is adjacent and dorsal to which of the following?

A. Splenic vein
B. IVC
C. SMA
D. Left renal vein
E. 4th portion of the duodenum

C

Pancreas divided into head, uncinate, neck, body and tail.
Uncinate process is the portion of the gland that extends to the left, dorsal to the portal vein and SMA. It lies ventral to the aorta and IVC. Located caudad and ventral to the L renal vein and cephalad to the 4th part of the duodenum.

Blood supply of uncinate is derived from numerous short branches of the SMA and portal vein. When performing a Whipple, these branches must be controlled to prevent bleeding and avoid injury to the SMA and portal vein

5

RUSH--Pancreas

What is the recommended treatment of duodenal obstruction caused by annular pancreas?

A. Endoscopic division of the associated duodenal web
B. Gastrojejunostomy
C. Duodenoduodenostomy
D. Surgical division of the annular tissue
E. Pancreaticoduodenectomy

C

Annular pancreas is a congenital anomaly involving a band of pancreatic tissue encircling the 2nd portion of the duodenum. Appears to originate from the embryologic ventral pancreas. Causal theories include abnormal fixation of the ventral pancreatic primordium before gut rotation, failure of involution of part of the ventral pancreas, and the development of heterotopic pancreatic tissue in the duodenum.

1/2 of these cases are dx in infants and the remainder in adults, with a peak during 4th decade of life. Most patients are asymptomatic. Clinical findings are obstruction in infants & children and obstruction, ulceration, or pancreatitis in adults. Associated anomalies include duodenal stenosis or atresia and Down's syndrome.

Tx of symptomatic patients consists of surgical bypass by duodenoduodenostomy or duodenojejunostomy. Gastrojejunostomy can also alleviate obstruction but risks marginal ulceration.

Resection or division of the annular band is not advised because it risks the develop of a pancreaticfistula and may fail to relieve the obstruction

6

RUSH--Pancreas

Which of the following developmental anomalies best characterizes pancreas divisim?

A. Aplasia of the dorsal pancreatic anlage
B. Aplasia of the ventral pancreatic anlage
C. Incomplete rotation of the ventral pancreatic anlage
D. Failed fusion of the ventral and dorsal pancreatic parenchyma
E. Failed fusion of the ventral and dorsal pancreatic ducts

D

Pancreatic division refers to congenital variation of the pancreatic ducts that result from failed or incomplete fusion of the embryologic ventral and dorsal ductal systems.

There may be complete separation of the ducts, an absent or minimal ventral duct, or only a few meagre connections between systems. As a consequence, most of the pancreatic duct drainage is through the dorsal duct joining the duodenum at the minor papilla. Any existing ventral ducts (Wirsung) drain only the uncinate process and the caudal head of the gland rather than the bulk of the gland at the major papilla, as when normally developed.

Some variation of pancreatic divism is present in 10% of the population. In some individuals, it is clinically significant if the relatively stenotic mior papilla imposes an obstruction to ductal flow. This can potentiall reuslt in recurrent abdominal pain, acute pancreatitis or chronic pancreatitis.

7

RUSH--Pancreas

The diagnosis of pancreas divisim is usually made by which of the following?

A. Laparoscopic exploration
B. Endoscopic U/S
C. CT
D. ERCP
E. Genetic testing

D

Dx of pancreas divisim is usually made by ERCP and cannulation of the minor papilla may be required to image the dorsal duct.

MRCP might also demonstrate this ductal anatomy.

8

RUSH--Pancreas

Which of the following is appropriate treatment of a patient with pancreas divism, chronic abdominal pain, a dilated dorsal pancreatic duct and an enlarged calcified pancreatic head?

A. Pancreaticoduodenectomy
B. Endoscopic dorsal sphincterotomy
C. Operative dorsal sphincterotomy
D. Endoscopic or operative ventral sphincterotomy
E. Sphlanchnic nerve ablation

A

Vast majority of patients with pancreatic divism are asymptomatic. Symptomatic patients with pancreas divism require evaluation of nature of their symptoms and for any other causes of abdo pain or pancreatitis.

WHen it is reasonable to suspect that a stenotic lesser papilla is the cause of recurrent abdo pain or pancreatitis, therapeutic considerations include endoscopic treatments (dilation, stenting, sphinterotomy) or operative sphincterotomy/sphincteroplasty, which may be combind with cholecystectomy and sphincteroplasty of major papilla

Occasionally, there are patients with established findings of chronic pancreatitis and pancreas divism. Sphincter operations are not successful in this setting. Rather, surgical treatment involving resection or decompression of the pancreatic head may be indicated

9

RUSH--Pancreas

Which of the following is not characteristic of pancreatic acinar cells?

A. Zymogen granules
B. Carbonic anhydrase
C. Golgi apparatus
D. Rough endoplasmic reticulum
E. Contractile proteins

B

Twofold function of the exocrine pancreas--secrete bicarbonate rich fluid and to synthesize digestive enzymes.

Acinar cells, which elaborate and secrete digestive enzymes, are designed for protein synthesis. Contain abundant RER, Golgi apparatus and secretory zymogen granules. Contractile proteins are also abundant near the apical membrane of the cell and facilitate exocytosis of the enzyme bundles into the ductal lumen.

The centroacinar cells are part of the ductal system. They secrete bicarbonate and therefore contain carbonic anhydrase, which dissociates carbonic acid into bicarbonate and hydrogen ion. Some ductal cells also contain synthetic and secretory organelles for the production of mucoproteins

10

RUSH--Pancreas

The bicarbonate concentration of pancreatic secretions is:

A. Primarily increased by CCK
B. Primarily decreased by secretin
C. Independent of acinar cell secretion
D. Reciprocally related to the chloride concentration
E. Reciprocally related to the sodium concentration

D

The centroacinar cells secrete a bicarbonate rich solution by an active transport mechanism primarily in response to secretin. CCK is the primary stimulatn in enzume secretion from the acinar cells.

The bicarbonate and chloride contents of pancreatic juice are reciprocally related. As ductal flow rates increase, the bicarbonate concentration increases and the chloride concentration decreases. This is the result of two processes: 1) changes in passive exchange of intraductal bicarbonate for intracellular chloride and 2) changes in the relative contribution of acinar cell secretion. Acinar cells secrete fluid high in chloride in addition to digestive enzymes. In contradistinction to anion concentrations, the concentration of sodium and potassium in pancreatic duct secretions remain relatively constant despite the flow rate and are similar to their concentrations in plasma

11

RUSH--Pancreas

Normally, activation of pancreatic trysinogen involves which of the following?

A. Pancreatic amylase
B. pH greater than 7.0
C. Lysosomal hydrolase
D. Pancreatic enterokinase
E. Duodenal enterokinase

E

Pancreatic acinar cells secrete digestive enzymes for fats, carbohydrates and proteins. Except amylase, these enzymes are secreted in inactive forms to protect the pancreas from autodigestion. Activation of the proenzymes trypsinogen to trypsin is the primary event that leads to activation of the other various proteases and phospholipases. It occurs in the duodenum via the action of enterokinase. Trypsinogen activation can also occur in acidic environments (pH <7.0). With acute pancreatitis, intranglandular activation can take place when the inactive enzymes are exposed to lysosomal hydrolases

12

RUSH--Pancreas

Which pancreatic islet cell type produce a hormonal peptide to stimulate glycogenolysis and gluconeogenesis?

A. Alpha cell
B. Beta cell
C. Delta cell
D. F cell
E. PP cell

A

Endocrine pancreas is composed of various cells located in the islets of Langerhans, approx 1 million of which are interspersed with the acinar and ductal elements throughout the gland.

Primary function of the endocrine pancreas is to regulate glucose homeostasis. Beta cells, which are the most numerous, produce insulin. Insulin promotes glucose transport, stimulates protein synthesis, and inhibits glycogenolysis and lipolysis. Alpha cells secrete glucagon which counterbalances insulin by stimulating hepatic glycogenolysis, guloconeogenesis, ketogenesis, and lipolysis. Glucagon also inhibits intestinal mobility and gastric acid and pancreatic exocrine secretion.

13

Pancreatic delta cells secrete which inhibitory peptide?

A. Bombesin
B. Glucagon
C. Somatostatin
D. Insulin
E. Pancreatic polypeptide

C

Somatostatin produced by delta cells, has a broad range of inhibitory effects on the GI tract including inhibition of secretion of other pancreatitic peptides; inhibition of gastric, biliary, intestinal, and pancreatic exocrine secretions; and inhibitions of GI motility.

PP cells are the source of pancreatic polypeptides. Pancreatic polypeptide inhibits pancreatic exocrine secretion and biliary and gut motility. Clinically, deficiency of pancreatic polypeptide has been linked to diabetes following resection of the pancreatic head or chronic pancreatitis. Because postprandial secretion of pancreatic polypeptide is dependent on vagal innervation, it has been used to assess the completeness of vagotomy

14

RUSH--Pancreas

Which is the principal cell type located at the center of the islets of Langerhans?

A. Alpha cell
B. Beta cell
C. Delta cell
D. F cell
E. Varies according to the location of the islet in the pancreas

B

Each islet of Langerhans is composed of an average of 3000 cells. Beta cells are located at the core and make up about 70% of the islet. The other cell types are located at the periphery of the islet. The cellular anatomy has potential functional implications that are as yet not well understood.

The distribution of cell types within the islet varies in different areas of the gland. Islets in the uncinate process derived from the embryologic ventral pancreas contain PP cells but few alpha cells. Islets in the body and tail of the gland have abundant alpha cells but no PP cells.

15

RUSH--Pancreas

Which of the following statements is true regarding blood flow to the pancreas?

A. Islet cells receive a greater proportion of pancreatic blood flow than do the exocrine elements
B. CCK and secretin regulate secretion by altering blood flow
C. Fragile anastomotic networks predispose the gland to ischemia
D. The blood supply to the islet cells is independent of the acinar supply
E. Pancreatic blood flow is highly sensitive to changes in systemic blood flow

A

Microcirculation of the pancreas is complex and has important correlated with endocrine and exocrine functions of the gland. Rich anastomotic supply from various sources makes pancreatic ischemia unusual

The islets receive is disproportionately large amount of total pancreatic blood flow (10-25%) relative to their mass (1-2%). Both the islets and exocrine tissues have arteriolar blood supply. The acinar tissue is also perfused by blood that drains from the islets, a mechanism referred to as the islet-acinar or insuloacinar portal system. This system is the structural basis for endocrine regulation of exocrine function. Insulin receptors are present on acinar cells, and the density of receptors is highest on acini located near the islets. Because the islets themselves often have a central to peripheral pattern of perfusion, insulin from the centrally located beta cells can influence the other peripheral islet cell types. In addition, some islets are apparently perfused in a peripheral to central pattern.

CCK and secretin have relatively little effect on blood flow and thus exert their stimulatory effects independently.

Pancreatic blood flow is maintained relatively constant despite changes in arterial pressure.

16

RUSH--Pancreas

Which of the following events occurs in acinar cells with acute pancreatitis?

A. Accelerated extrusion of zymogen granules
B. Impaired syntehsis of zymogen granules
C. Fusion of lysosomes and zymogen granules
D. Fusion of mitochondria and zymogen granules
E. Impaired protein synthesis

C

Pathogenesis of pancreatitis involves intra pancreatic activation of digestive enzymes that are normally secreted in inactive form. This results in "autodigestion" of the gland.

Although the mechanism by which the various causes of clinical pancreatitis lead to this state are incompletely understood, experimental observations have identified certain derangements in acinar cell biology that may be the underlying common pathway to pancreatic injury. The primary defects involve blocked extrusion of zymogen granules containing inactive digestive enzymes and alterations in intracellular transport that result in fusion of zymogen granules with lysosomes to form large cytoplasmic vacuoles. This sequence results in co-localization of digestive enzymes and lysosomal hydrolases. Lysosomal enzymes, such as cathepsin B, activate trypsinogen and initiate a cascade of intracellular digestive enzyme activation.

Amino acid uptake and protein synthesis are not impaired during this process.

17

RUSH--Pancreas

The mechanism of alcohol induced acute pancreatitis is thought to involve all of the following except:

A. Pancreatic ductal obstruction
B. Pancreatic exocrine hypersecretion
C. Hypertriglyceridemia
D. Acetaldehyde toxicity
E. Genetic defect in lysosomal membranes

E

EtOH is the prevalent etiologic factor in acute pancreatitis. Several contributory mechanisms by which EtOH induced pancreatic injury occurs. EtOh causes pancreatic ductal HTN by increasing ampullary resistance and by intraductal deposition of stone proteins. Concomitantly, it stimulates gastric acid secretion and increases pancreatic exocrine secretion via release of secretin. The combination of ductal obstruction with stimulated secretion may result in enzyme extravasation.

Acetaldehyde, the metabolic product of ethanol, injures acinar cells by increasing membrane permeability and disrupting the microtubular structure.

The elevated levels of serum triglycerides induced by alcohol are a source of cytotoxic free fatty acids.

Alcohol also impairs normal trypsin inhibition and reduces pancreatic blood flow.

All of these effects may contribute to intraglandular enzyme activation and development of alcholic pancreatitis

18

RUSH--Pancreas

Hyperamylasemia is diagnostic of acute pancreatitis when associated with which of the following lab findings?

A. Hyperlipasemia
B. Increased urinary amylase levels
C. Amylase-creatnine clearance ration (ACCR) >5%
D. Hypocalcemia
E. None of the above

E

The dx of acute pancreatitis is based on signs and symptoms, supported by biochemical findings and morphologic abnormalities seen on imaging studies such as CT

No biochemical feature is pathognomonic of acute pancreatitis. Hyperamylasemia, hyperlipasemia and elevations in urinary-amylase levels and the ACCR are typical of acute pancreatitis but are not specific or sensitive, and they can occur with other abdmoinal and extra-abdominal disorders. There is no absolute level of serum amylase or lipase that is diagnostic of acute pancreatitis. Marked elevations are more indicative of pancreatitis but not themselves diagnostic. Both amylase and lipase levels may be elevated in a number of conditions that can be confused with acute pancreatitis, such as cholecystitis, perforated peptic ulcer, and intestinal infarction. Moreover, severe pancreatitis can occur without substantial elevations in these serum enzymes

Hypocalcemia may occur as a consequence of pancreatitis but it is also non specific

19

RUSH--Pancreas

A patient with abdo pain is found to have a serum amylase of 1200 IU/L, a normal urinary amylase level, and an ACCR of <2%. Based on these findings, the probably diagnosis is which of the following conditions?

A. Acute pancreatitis
B. Chronic pancreatitis
C. Renal failure
D. Choledocholithiasis without pancreatitis
E. Macroamylasemia

E

Elevations of serum and urinary amlyase levels and in the ACCR are typical of acute pancreatitis.

Elevation of amylase-creatnine ratio above normal 2-5% is not specific for pancreatitis, but a normal ratio in the presence of hyperanlyasemia suggests that hyperamylasemia is the result of something other than pancreatitis.

Serum and urinary amylase levels and the ACCR may be normal in patients with chronic pancreatitis or elevated during an acute exacerbation.

Renal disease may be associated with low urinary amylase levels and an elevated ACCR. CBD stones may produce hyperamylasemia without true pancreatitis. Urinary amylase is elevated, although the ACCR may be normal. With macroamylasemia, amylase forms complexes with serum proteins too large for glomerular filtration. The serum amylase level is elevated but urinary amlyase levels and the ACCR are low. The dx can be confirmed by electrophoresis. Abdo pain has been reported in >1/2 of patients with macroamylasemia, although the biochemical abnormality is probably not etiologically related to the pain. Hyperamylasemia predominantly caused by salivary amylase may also be assoc with a low urinary amylase level and ACCR because the salivary isoenzyme is cleared more slowly by the kidneys than the pancreatic isoenzyme

20

RUSH--Pancreas

Which of the following is an unfavorable prognostic factor in patients with acute alcoholic pancreatitis?

A. Initial WBC >16
B. Elevated serum triglycerides during the initial 48 hrs
C. Serum amylase > 1200 on admission
D. Serum lipase more than 3x normal
E. Serum BUN elevated more than 2mg/dL during the initial 48 hrs

A

Ranson critera include 11 parameters determined at the time of admission or during the subsequent 48 hours
Patients with 3 or more criteria have more severe disease and are at increased risk for septic complicaions and death. Criteria reflect the patient's underlying status, severity of retroperitoneal inflammatory process, and effects on renal and respiratory function. The Ranson criteria were originally developed for alcoholic pancreatitis and have been modified for gallstone pancreatitis. A rise in the serum BUN of more than 2 mg/dL is one of the 10 criteria for gallstone pancreatitis but the rise must be more than 5 mg/dL to meet the criteria for alcoholic pancreatitis.

21

RUSH--Pancreas

What is the leading cause of death from acute pancreatitis?

A. Hemorrhage
B. Pseudocyst rupture
C. Secondary pancreatic infection
D. Biliary sepsis
E. Renal failure

C.

Formerly, death from acute pancreatitis often occurred early in the course of the disease as a result of the acute effects of hypovolemia and inadequate resuscitation.

In the current era, about 80% of death are attributed to secondary pancreatic infection, which develops in ~10% of patients with acute pancreatitis. Fatal pancreatic sepsis typically progresses to multisystem organ failure, and deaths occur later in the course of the disease. To have an impact on this disease, therapeutic effects have therefore focused on the prevention and early diagnosis of pancreatic infection and on more effective methods of surgical therapy

22

RUSH--Pancreas

Which of the following complications of acute pancreatitis is associated with the highest mortality rate?

A. Peripancreatic abscess
B. Infected pancreatic pseudocyst
C. Infected pancreatic necrosis
D. Sterile pancreatic necrosis
E. Bile duct obstruction

C

Retroperitoneal infection is a serious, often fatal complication of acute pancreatitis.

Pancreatic abscess best describes a localized collection of drainable pus in or around the pancreas. Pancreatic abscess and infected pseudocyst can be treated effectively by external drainage and the anticipated mortality rate for each is 5%.

Pancreatic necrosis is a manifestation of severe pancreatitis. When accompanies by infection, it has been associated with a mortality rate that may exceed 40% which is higher than noninfected necrosis. Infected pancreatic necrosis is treated by operative debridement and open or closed retroperitoneal drainage. Patient with sterile necrosis may require operative intervention as well but are generally treated nonoperatively with intensive support as long as their condition permits

23

RUSH--Pancreas

A 45M is admitted with severe alcoholic pancreatitis. 40% pancreatic necrosis is estimated on CT .Which of the following statements best describes the current use of antibiotics for this patient?

A. Systemic Abx are not indicated unless his condition deteriorates
B. Systemic Abx are indicated for coverage of gut derived bacteria
C. Systemic Abx are indicated for coverage of gut derived bacteria and fungal organisms
D. Nonabsorbable Abx are indicated for gut decontamination
E. Systemic Abx are not indicated if enteric feeding can be tolerated

B

Risk for infected pancreatic necrosis is related to the clinical severity and duration of disease and to the extent of necrosis. Strategies to decr secondary pancreatic infection focus on patients at higher risk. RCTs of systemic Abx for ppx against secondary infection have yielded conflicting results. Differences are probably b/c of numerous factors, including heterogeneity in the severity of disease, patient characteristics, and concomitant therapy among those studied as well as methodologies.

Current practice favors systemic Abx for patients with severe disease and more extensive (>30%) necrosis based on studies demonstrating fewer septic complications and perhaps decreased mortality. However, not all studies have shown benefit, and the risk for subsequent infection with multiresistant bacteria or fungal organisms may be increased, particularly if ppx abx use is prolonged. B/x the gut is typically the source of the organisms, the use of nonabsorbable enteral abx for selective gut decontamination has some appeal. The effect of this measure remains unclear, and is not typically used. Enteric feeding are beneficial to maintain the gut mucosal barrier to bacterial translocation. However, the efficacy of enteric feeding alone for prevention of secondary pancreatic infection has not been demonstrated

24

RUSH--Pancreas

Which of the following types of abx does not acheive adequate levels in the pancreas?

A. Imipenem
B. 3rd generation cephalosporin
C. Metronidazole
D. Aminoglycosides
E. Fluoroquinolones

D

Early studies of abx ppx in patients with acute pancreatitis showed no efficacy, in part b/c they involved individuals with mild pancreatitis and in part b/c they used abx that did not achieve therapeutic levels in the pancreas and retroperitoneum

Aminoglycosides, 1st generation cephalosporins and amiopenicillins do not adequately penetrate the pancreas.

Drugs with penetration include the other choices listed as well as pip/tazo and mezlocillin

25

RUSH--Pancreas

An alcoholic patient has acute pancreatitis with 5 of the Ranson criteria. He gradually improves over a 14 day hospitalizaion but then a pulse of 120, temp of 39 and abdo distension develop. CT is performed and shows pancreatic necrosis with bubbles of gas. The next most appropriate therapy is which of the following

A. Abx
B. Percutaneous catether drainge
C. Peritoneal lavage
D. Endoscopic cyst gastrostomy
E. Operative drainage

E...but that seems crazy. Would personally start with A

Pancreatic infection complicating acute pancreatitis should be suspected in any patient who fails to improve following supportive medical therapy or improves but then deteriorates.

Pancreatic infection occasionally occurs ealry during chronologic course of disease, but it typically occurs later. CT is the best method for imaging the pancreas. The results demonstrate air in the pancreas, which is characteristic of pancreatic infectio. Technique of dynamic pancreatography can identigy ischemic areas of the pancreas and is useful for evaluating patients who amy have pancreatic necrosis. Permed by serially imaging the pancreas after bolus injection of an IV contrast agent.

Percutaneous needle aspiration of fluid collection or nerotic areas found on CT can be performed to identify the presence of infection adn guide therapeutic decision s about the need for drainage. When pancreatic infection is present, operative drainage and debridement are indicated. Interest has focused on the selection of closed or open methods of oeprative drainage. Minimal access operative approaches are also used to drain and debride pancreatic necrosis in the hope of lowering morbidity in ill patients, Percutaneous catheters can drain thin fluid but are usually inadequate for the management of infected pancreatic necrosis. Pertioneal lavage has been used early in the course of patients with severe acute pancreatitis. Endoscopic cyst gastroscopy may be appropriate for some patient with pancreatic pseudocysts. These latter two modalites have no reols in the management of infected pancreatic necrosis

Don't agree with Rush. Recent rounds discussed used percutaneous drains as a guide for VARDS procedure and endoscopic debridement. Also mentioned that operating early leads to increased mortality.

26

RUSH--Pancreas

Acute gallstone pancreatitis is diagnoses in a 54M. Which of the following is considered standard treatment?

A. Urgent (within 24hrs) chole and CBD exploration
B. Urgent ERCP and subsequent lap chole
C Initial supportive therapy with chole performed during the same admission
D. Initial supportive therapy with chole performed in 6-8 wks
E. Initial supportive therapy with chole performed only if symptoms recur

C

Gallstone pancreatitis is related to the passage of stones through the ampulla of Vater. Patients w/smaller stones have an increased risk for the development of this manifestation. Chole is indicated b/c gallstone pancreatitis is a recurrent problem in 30-50% of patients if surgery is not performed. Traditional controversy has involved the timing of the surgery. Proponents of immediate intervention have found a higher incidence of choledocholithiasis but have not demonstrated that this approach is safer than delayed surgery of that it is necessary for most patients. Most surgeons advise initial nonoperative therapy until the patient's signs and symptoms subside (most do within 2-3 days) followed by elective chole with intraop imaging of the CBD by cholangiography or intra op u/s during the same hospitalization.

Role of ERCP and endoscopic sphincterotomy for the management of biliary pancreatitis has been controversial. 97% of patients with gallstone pancreatitis have mild pancreatitis that improves rapidely. ERCP finds common duct stones in only a small percentage of patients and is not indicated routinely. Some trials have suggested benefit in severe pancreatitis but this has not been consistently observed. ERCP is indicated for patients with concomitant obstructive jaundice, and biliary sepsis

MRCP or EUS might be useful in patients with an intermediate risk for choledocholithiasis but is not necessary for most with biliary pancreatitis.

For the small proportion of patients with severe biliary pancreatitis, early chole should be avoided. Tx in this group is directed at resolution of pancreatitis and its complications. When the pancreatitis has subsided, delayed chole is indicated

27

Which of the following is the preferred nutritional support for a patient with severe pancreatitis?

A. NG feeding
B. Feeding via percutaneous endoscopic gastrostomy
C. NJ feeding
D. Parenteral amino acids and glucose
E. Parenteral amino acids and lipids

C

Nutritional support is a critical component of the successful management of patients with severe pancreatitis. Mortality is reduced by positive nitrogen balance. Direct delivery of nutrients into the jejunum is the preferred route. Enteral jejunal feeding does not stimulate the pancreatic exocrine secretion and helps maintain the intestinal mucosal barrier. Jejunal feeding is associated with a lower risk of infection and shorter hospital stay than parenteral nutrition. Morever, enteric feeding avoid catheter related sepsis and other complications of central venous lines. Peeding intot eh stomach does stimulate the pancreas and is not usually tolerated b/c of retrogastric inflammation and delayed gastric emptying. NJ tubes may require radiologically guided or endoscopic placement.

If nutritional goals cannot be met within a few days of initiation, parenteral nutritional support may also be necessary. IV lipids are not determental and prevent essential fatty acid deficiency.

28

RUSH--Pancreas

In North America, chronic pancreatitis is most commonly related to chornic alcohol ingestion. Which of the following is the second most common cause?

A. Gallstones
B. Drugs
C. Infection
D. Malnutrition
E. Idiopathic

E

In the Western world, alcohol accounts for 75% of cases of chronic pancreatitis. ~20% of cases are considered idiopathic.

In parts of Africa and Asia, protein malnutirtion is an important etiology. Other less common causes of chronic pancreatitis include pancreatic duct obstruction (secondary to stenosis or pancreas divism), hyperparathyroidism, trauma, CF, and hereditary causes.

Unlike acute pancreatitis, calculous biliary diseae is not a typical cause of chronic pancreatitis. Certain infections (particularly viral) and drugs are among the many factors that can produce acute rather than chronic pancreatitis

29

RUSH--Pancreas

With regard to the histologic characteristics of chronic pancreatitis, all but which of the following is observed?

A. Increased interstitial connect tissue
B. Loss of acinar cells
C. Loss of islet cells
D. Neural hypertrophy
E. Damaged perineurium

C

Chronic pancreatitis is characterized on histologic exam by the loss of exocrine acinar cells and marked increase in interstitial fibrous connective tissue. Islets of Langerhans are preserved and constitute a relatively greater proportion of the pancreatic tissue. Hyperplasia of islet cells is also seen.

The sizes and number of nerves are increased but the protective perineural sheath is damages and nerves are found in proximity to inflammatory foci. There appear to be selective increases in certain peptidergic nerves. These histologic observations may be related to the cause of pain in chronic pancreatitis

30

RUSH--Pancreas

Pain is the predominant clinical manifestation of chronic alcoholic pancreatitis. Most patients also have which of the following associated manifestations?

A. Clinical diabetes mellitus
B. Hypoglycemia
C. Steatorrhea
D. Subclinical fat malabsorption
E. Hepatic cirrhosis

D

Recurrent or persistent abdo pain is the predominant symptom of chronic pancreatitis. Varying degrees of nausea, anorexia and wt loss. Mechanism that may contribute to pain include ductal obstruction, parenchymal HTN, acute inflam, and perineural inflam.

2/3 of patients have abN glucose tolerance test results and subclinical fat malabsorption, whereas overt diabetes is present in 30-50% and frank steatorrhea in only 10-15%. Endocrine and exocrine insufficiency progresses during the course of the disease. Diabetes mellitus may be related to impaired insulin release b/c the islet cells themselves are relatively preserved. Despte the common etiologic factor of EtOH, most patients with chronic pancreatitis do no have hepatic cirrhosis.

31

RUSH--Pancreas

Which of the following would not be appropriate for the management of steatorrhea in a patient with chronic pancreatitis?

A. Restriction of fat to 75g/day
B. Encapsulated pancreatic enzymes
C. Encapsulated pancreatic enzymes and a PPI
D. Nonencapsulated pancreatic enzymes
E. Nonencapsulated pancreatic enzymes and a PPI

C

Gross steatorrhea and diarrhea occur when pancreatic exocrine function is <10% of normal. Therapy involves limitation of fat intake and administration of adequate amounts of exogenous pancreatic enzyme preparations to provide at least 10% of normal lipolytic activity in the duodenum at the time the food substrate is present.

Nonencapsulated forms may improve malabsorption but can be ineffective b/c of inactivation in the stomach when the pH falls below 4. Addition of H2 blockers may then be useful.

Enteric coated preparations release their enzymes at a pH >5. Therefore, they are useful for patients whose gastric pH remains low to ensure that the enzyme is not released until it reaches the duodenum. The use of encapsulated forms with H2 blockers is counterproductive b/c the enzyme is release in the stomach and is then inactivated if the pH falls. In addition, enteric coated preparations are microspheres of varying sizes and the larger ones do not empty into the duodenum until after the food substrate does

32

RUSH--Pancreas

58F with jaundice underwent ERCP as part of her diagnostic work up. On the basis of this radiograph (showing a double duct sign), what diagnosis is considered the most likely?

A. Chronic pancreatitis
B. Pancreatic cancer
C. Cholangiocarcinoma
D. Pancreas divism
E. Ectopic pancreas

B

ERCP shoes double duct sign= dilation of the biliary system above an area of abrupt narrowing and abrupt termination of the main pancreatic duct. These findings place primary abnormality in the pancreatic head and it is not uncommon for a pancreatic neoplasm to involve both ducts.

Chronic pancreatitis may cause biliary obstruction but the obstruction in the biliary system is more distal. No coexistent changes in this patient, such as irregular beading of the pancreatic duct to suggest chronic pancreatitis is present.

Cholangiocarcinoma may be responsible for stenosis in the biliary system but cholangiocarcinomas are rarely large enough to involve the pancreatic duct.

With pancreas divism, injection of the major papilla opacified only a short, tapering ventral duct draining the caudal portion of the pancreatic head and uncinate process. Injection of the minor papilla demonstrates the dorsal duct draining the major portion of the gland.

33

RUSH--Pancreas

45 nondiabetic patient with chronic alcoholic pancreatitis and intractable abdo pain has a 10 mm pancreatic duct. Which of the following choices constitutes the best treatment?

A. Sphincteroplasty
B. Lateral pancreaticojejunostomy
C. Caudal (tail) pancreatectomy
D. Total pancreatectomy
E. Continued non operative therapy

B

Pain is the primary indication for surgery in chronic pancreatitis. Selection of the best operation for a particular patient must include consideration of the anatomy of the gland, preexisting endocrine or exocrine dysfunction, compliance and rehabilitative capacity of of the patient, post op endocrine or exocrine deficiency and the likelihood of post op pain relief.

Patients with a dilated duct (>6 mm) are candidates for ductal drainage, with lateral pancreaticojejunostomy being the best choice of these procedures. It is important to achieve adequate decompression of the enlarged pancreatic head and uncinate during drainage procedures. Variations such as the Frey or Beger procedure are intended to accomplish this. Sphincteroplasty does not play a role in the management of patients with established chronic pancreatitis.

Patients with small ducts disease are tx by resection if surgery is necessary. Resection of the pancreatic head in properly selected patients has generally yielded better long term results for pain relief than has tail resections. The head of the pancreas is often enlarged and bulky in chronic pancreatitis and has been considered to be the "pacemaker" of the disease. Total or near total (95%) resection have higher long term morbidity and mortality rates relates to post op endocrine insufficiency. Although endocrine and exocrine function tends to deteriorate over time in patients with chronic pancreatitis, some evidence suggests that pancreaticojejunostomy halts or delays this decline better than non operative therapy.

34

RUSH--Pancreas

Ascites develops in a 60y.o. patient with acute pancreatitis. Paracentesis demonstrates that the ascitic fluid amylase is higher than the serum amylase and that the fluid protein level is higher than 3g/dL. Which of the following best explains the ascites?

A. Pancreatic duct leak
B. Secondary bacterial peritonitis
C. Portal vein thrombosis
D. Underlying pancreatic cancer
E. Resuscitative fluid overload

A

Pancreatic ascites can be differentiated from ascites of other causes by the high amylase and protein content of the fluid. Pancreatic ascites and pleural effusions are the result of disruption in the pancreatic duct, usually consequent to pancreatitis.

Ascites may resolve with conservative mgmt consisting of paracentesis (thoracentesis), TPN, and administration of somatostatin analogue to inhibit pancreatic exocrine secretion. Otherwise an operataion may be required for internal drainage of the pancreatic duct fistula or pseudocyst.

35

RUSH--Pancreas

CT demonstrates a 5 cm peripancreatic fluid collection in a patient 3 weeks after an episode of acute pancreatitis. The patient is eating and does not have clinical signs of infection. What is the recommended treatment?

A. Expectant management without intervention
B. NPO and TPN
C. Percutaneous catheter drainage of fluid collection
D. Endoscopic drainage
E. Re-imaging in 3 to 6 weeks and surgery for internal drainage if the collection persists

A

Peripancreatic fluid collections in 20% of pts with acute pancreatitis. May resolve spontaneously and should not be mistaken for pancreatic pseudocysts. If patient is stable, can eat and does not have clinical evidence of infection or other complications, expectant mgmt is indicated. Fluid collection can be monitored with US or CT in 1-3 months.

If patient has persistent pain and is unable to eat, nutrition by post pyloric enteral feeding or parenteral nutrition if necessary, may be instituted for several wks to allow resolution or maturation of the collection into a pseudocyst.

If patient has a symptomatic or complicated fluid collection that requires early intervention, some method of external drainage must be used. If the fluid is thin, endoscopic or percutaneous catheter drainage may suffice. Operative drainage is preferred if there is substantial necrotic debris, as there often is, or if there is concern about infection. Operative drainage may be accomplished with minimal access approaches.

36

RUSH--Pancreas

Which of the following is the most important determinant of the need for drainage of a pancreatic pseudocyst?

A. Pseudocyst symptoms
B. Pseudocyst size
C. Pseudocyst duration
D. Associated chronic pancreatitis
E. Patient age

A

Historically, pancreatic pseudocysts >5-6 cm and present for >6 weeks were thought to have a low rate of spontaneous resolution and a high rate of complications. They were tx by operative drainage.

Current understanding of natural hx of pseudocysts is that the rate of spontaneous resolution is higher and the rate of complications is lower then prev thought. Pseudocyst size and duration are no longer absolute criteria for intervention. Rather pseudocyst related symptoms are the primary indication for treatment. Large pseudocysts are more likely to be symptomatic and less likely to resolve than small pseudocysts. In addition, pseudocysts in patients with chronic pancreatitis are unlkely to resolve but may not require intervention if they are stable, asymptomatic and uncomplicated

37

RUSH--Pancreas

A patient with chronic pancreatitis is unable to eat b/c of persistent postprandial pain. CT is performed showing large pseudocyst. What is the recommended treatment?

A. NPO and TPN for 4-6 wks
B. Percutaneous catheter drainage
C. Endoscopic drainage
D. Operative internal drainege
E. Operative external drainage

D

Pseudocysts that develop in patients with chronic pancreatitis can be considered mature when they are discovered unless there has also been a recent episode of acute pancreatitis.

Indications for treatment of a pancreatic pseudocyst are 1) persistent symp (pain, inability to eat, or biliary or GI obstruction), 2) enlargement or 3) onset of a pseudocyst related complication (infection, hemorrhage, or rupture).

Operative internal pseudocyst drainage into the stomach, jejunum, or duodenum is generally the preferred treatment, depending on the location of the pseudocyst.

For patients with chronic pancreatitis, it is critical to evaluate the pancreatic duct to determine whether a concomitant duct drainage procedure is necessary.

Pseudocyst drainage can be accomplished laparoscopically in some situations. Pseudocysts in the tail of the gland are sometimes best tx by distal pancreatectomy. Percutaneous or endoscopic drainage of established pseudocysts is still being debated. Can sucessfully treat pseudocysts in some circumstances but have definite limitations and potential complications

38

RUSH--Pancreas

Which of the following risk factors is most strongly associated with ductal adenocarcinoma of the pancreas?

A. Chronic pancreatitis
B. Diabetes mellitus
C. Cigarette smoking
D. Coffee consumption
E. Alcohol consumption

C

The most firmly establish risk factor for pancreatic cancer is cigarette smoking. Experimentally nitrosoamines have been found to be carcinogenic. In addition, the carcinogens in cigarettes have been related to K-ras oncogene mutations, which are frequent in pancreatic cancer.

Alcohol has not been demonstrated conclusively to be a risk factor independent of cigarettes. Previously reported association of pancreatic cancer with coffee consumption is questionable. Diets high in fat and meat may be associated with pancreatic cancer whereas diets high in fruits and vegetables may be protective.

Certain occupational and industrial exposures have an increased risk. There may be some association with diabetes mellitus and certain forms of chronic pancreatitis but the relationship is not considered causal. Prev gastrectomy has been associated with increased risk whereas tonsillectomy has been observed to be protective

39

RUSH--Pancreas

A jaundiced otherwise healthy patient is noted to have a 3 cm mass in the head of the pancreas on CT. EUD guided FNA shows cancer. The mass abuts the portal vein but there is no clear evidence of vessel involvement or metastatic disease. Which of the following is the most appropriate next step?

A. MRCP to better assess vascular involvement
B. Direct angiography to better assess vascular involvement
C. Operative exploration and potential resection
D. Endoscopic placement of a biliary stent
E. Chemo and radiation

C

When clinical situation suggests a resectable pancreatic neoplasm in a good risk patient with biliary obstruction, surgery for potential resection is generally indicated without additional tests.

Routine preop biliary decompression is not advantageous in this setting b/c it does not improve operative outcomes and may increase the morbidity associated with resection. Endoscopic biliary decompression is invaluable for palliation of obstruction in unresectable patients or if the operation is to be delayed.

Accuracy of angio for pre-op resectability staging has limitations and adds little to good quality CT or MRI. EUS is extremely useful for identifying small tumors that are inapparent on CT, for obtaining cytologic material and somewhat for assessing vascular invasion.

Neoadjuvatn chemo with radiation is increasingly being used before surgery for patients whose imaging studies suggest borderline resectability. Imaging criteria for what constitutes a boderline resectable tumor would commonly include: tumors that abut a substantial (>1/2) circumference of adjacent vessels (hepatic artery, SMA, portal vein) or that narrow portal-splenic vein confluence

40

RUSH--Pancreas

In which of the following situations is resection of a ductal carcinoma of the pancreas contraindicated?

A. Age >80
B. Tumor located in the body of the pancreas
C. Inability to verify malignancy histologically before resection
D. Presence of small peritoneal metastases
E. Tumor invading the portal vein

D

Resection of malignancy offer the only chance for cure. Most commonly, resection of ductal carcinomas involve Whipple b/c most potentially resectable tumors are located in the head or uncinate process of the gland. Tumors originating in the body or tail are often not diagnosed until they are beyond the confines of surgical resection. Location alone does not contraindicate resection b/c stage for stage, tumors in the body have the same survival as tumors in the head.

Resection is indicated for physiologically fit patients (age alone is not a contraindication) who do not have mets beyond the field of resection. Histologic or cytologic confirmation of malignancy can often be obtained intraop but is not necessary before resection if the clinical circumstances suggest cancer.

For some tumors with local vascular invasion, en bloc resection with reconstruction of the involved vessels is appropriate if a tumor free resection can be accomplished. Positive LNs outside the resection field, peritoneal mets, and liver mets generally contraindicated resection for adenocarcinoma of the exocrine pancreas. However, tumor debulking and resection of liver mets can be beneficial in patients with functioning tumors of the endocrine pancreas

41

RUSH--Pancreas

Which of the following operations could be appropriate for a 2 cm ductal adenocarcinoma in the head of the pancreas?

A. Whipple with preservation of the stomach and pylorus
B. Duodenum sparing pancreatectomy
C. Total pancreaticoduodenectomy
D. Laparoscopic enucleation
E. All are potentially appropriate

A

Whipple is indicated for resectable ductal cancer in the head of the pancreas. 5 year survival rate of 15-20%. Higher incidence of intially delayed gastric emptying with pyloric preserving operations. Long term studies demonstrate normal emptying and good nutritional outcomes. Postprandial gastrin and acid responses are normal despite the loss of duodenal inhibitory factors and marignal ulcer has not been a prohibitive problem. Shorter operative time and lower blood loss. Preservation of stomach and most proximal portion of duodenum is not appropriate in patients with tumors cin close proximity if the margins would be compromised.

Duodenum sparing resection of the panc head has been used in some centers for patients with chronic pancreatitis and has been reported to better maintain enteropancreatic hormonal relationships and glucose homeostasis. This procedure is not indicated for cancer

Total pancreaticoduodenectomy is not advocated for pancreatic cancers that can otherwise be resected. Has been used bsed on the ground that it produces better clearance of LNs and possible multicentric disease and avoids a pancreatic anastomosis. However long term survival is not improved, and total pancreatectomy is assoc with a higher rate of both early and late complications.

Extended pancreatectomy involves removal of more RP soft tissue and regional LNs. Have not demonstrated improve survival with this approach and rate of operative complications may be higher. Pancreatic resections can be accomplished laparoscopically but enucleation is never an appropriate method of removing a pancreatic ductal cancer

42

RUSH--Pancreas

At laparotomy, a jaundiced patient is found to have an unresectable pancreatic cancer obstructing the bile duct. Which of the following statements regarding biliary decompression is correct?

A. The preferred management is to close the patient and place an endoscopic stent post op
B. Chole plus T tube placement is the preferred management
C. Choledochoduodenostomy is contraindicated
D. Cholecystojejunostomy should not be performed if the patient has cholelithiasis
E. Roux en Y choledochojejunostomy is not appropriate b/c of limited life expectancy

D

Palliative treatment is directed to relieve obstruction of bile duct and duodenum and to alleviate pain. For lesions demonstrated to be unresectable before laparotomy, nonoperative relief of biliary obstruction can be achieved by endoscopic (preferred) or transhepatic route. Surgical bypass with some form of biliary enteric anast generally provides more durable releife with less need for further intervention. It is preferred for patients when unresectability is determined at the time of laparotomy. Cholecystojejunostomy, choledocho or hepaticojejunostomy and choledochoduodenostomy are appropriate for the management of distal bile duct obstruction.

Choledochojejunostomy usually provides the most durable relief. A roux en y configuration is preferred although a simple loop also suffices.

Cholecystojejunostomy is relatively simple but should be avoided if the gallbladder is diseases or when cystic duct patency cannot be demonstrated or may be jeopardized by tumor proximity. It is sometimes taught that choledochoduodenostomy should be avoided with malignant obstruction b/c of possible tumor growth and eventual reobstruction. In reality, choledochoduodenostomy can be effective provided that the CBD is sufficiently dilated and the duodenum is plaible and unobstructed.

43

RUSH--Pancreas

When should gastrojejunostomy be performed at the time of biliary bypass in a patient with unresectable pancreatic cancer?

A. Always
B. Never
C. If the tumor is locally unresectable and there are no peritoneal mets
D. Only if symptomatic duodenal obstruction is present at the time of surgery.
E. Only if endoscopic stent placement is not available

C... in real life, we do A...

Panc Ca can obstruct the duodenum or the proximal jejunum near the ligament of Treitz. Traditionally, many surgeons have favored routine " double bypass" for operative patients b/c the rate of duodenal obstruction that develops later in patient treated by biliary bypass alone has been cited to be 5%-30%.

Duodenal obstruction does not develop in most patients and gastrojej is sometimes assoc w/problems such as bleeding or delayed gastric emptying. The selective approach is more appropriate.

Patients with obstructive symptoms or impending obstruction as a result of tumor location should undergo gastrojej. Gastrojej is also advisable for patients with an anticipated longer survival, such as those whose lesions are not resected b/c of local tumor invasion rather than b/c of hepatic or peritoneal mets. Endoscopic duodenal stent placement is another option

44

RUSH--Pancreas

44F who is not an alcoholic has a septated 10 cm cystic mass in the head of the pancreas. Which of the following statements constitutes appropriate advice?

A. The lesion is benign and requires no intervention
B. The lesion is malignant and probably incurable
C. Whipple is indicated
D. Percutaneous needle biopsy is indicated
E. Drainage by Roux-en-Y cystjejunostomy is indicated

C

Cystadenoma or cystadenocarcinoma are cystic neoplasms of the pancreas that are most commonly manifested as mass lesions in middle aged women.

Serous and mucinous types are recognized and risk for malignancy is significant with the mucinous variety. Cystadenoma is more common than its malignant counterpart but malignant transformation may occur. EUS with sampling for cytology, mucin and CEA can be usfeul for gauging the likelihood of cancer.

Without resection, exclusion of malignancy can be difficult. Internal drainage of cystic neoplasms is not appropriate therapy.

5 yr survival rate after resection of cystadenocarcinoma is ~50%. Occasionally, islet cell tumors, ductal adenocarcinomas, or other unusual tumors (e.g. papillary and cystic pancreatic neoplasms) have cystic components

45

RUSH--Pancreas

64M is evaluated for abdo pain. CT shows segmental dilation of main pancreatic duct to >10 mm in the head of the gland with mural nodules. Which of the following is the next most appropriate recommendation?

A. EUS
B. ERCP
C. Serum Ca 19-9
D. Total pancreatectomy
E. Abstinence of alcohol and CT repeated in 3 months

A

Intraductal papillary mucinous neoplasm of the pancreas (IMPN) is a premalignant condition characterized by papillary projections of mucin secreting epithelial cells, excessive mucin production and cystic dilation of the pancreatic duct. Patient may already have cancer when initially seen or may be at some other stage along the process of malignant transformation, which occurs relatively slowly.

Divided into main duct and branch duct type, depending on the areas of the pancreatic ducts that are involved. Goals of evaluation are to identify factors associated with a higher risk for malignancy and to determine the anatomic extent of disease.

EUS is the next step in evaluation with IPMN is suspected. Can identify diffuse or segmental dilation of the pancreatic duct and the size of cystic lesions or mural nodules and can guide FNA to assess cytology and molecular tumor markers.

ERCP shows duct dilation without strictures, filling defects from mucus or nodules, and commonly a patulous papillary orifice with mucus. Also permits sampling of mucus and therapeutic clearance if obstruction is a problem. If available, direct pancreatoscopy and intraductal US can be adjuncts to ERCP

46

RUSH--Pancreas

Which of the following is features of IPMN is associated with the lowest risk for cancer?

A. Branch duct type with mural nodularity
B. Branch duct type < 3 cm
C. Main duct type with diffuse dilation to > 10 mm
D. Main duct type with segmental dilation
E. Multifocal IPMN

B

Progression of IPMN through the adenoma carcinoma sequence is considered a slow process that requires 10-20 yrs.

Main duct type have a greater risk for malignancy than the branch duct type

Sendai Consensus Guidelines identified the following RF for cancer and as general indicators for resection: main duct dilation to >10 mm, cyst size > 3 cm, presence of mural nodules, atypical cytology. Additional RF include high grade dysplasia, multifocal or synchronous tumors and increasing cyst size during follow up, In branch type, mural nodularity or atypical cytology may be more important determinants than size

47

RUSH--Pancreas

Which of the following would you recommend to a 60F with an established dx of IPMN?

A. Mammography
B. Transvaginal US
C. Colonoscopy
D. Genetic testing
E. Screening CT for 1st degree relatives

C

Extrapancreatic malignancies observed more commonly in patients with IPMN than in those with ductal cncaer of the pancreas or other cystic pancreatic neoplasms. Reason unknown.

No particular genetic predisposition for IPMN has been identified. Extrapancreatic cancer has been reported in 1/3 of patients with IPMN. No specific guidelines exist but based on these findings, screening EGD and colonoscopy would be appropriate.

48

RUSH--Pancreas

Which of the following is true regarding the dx of insulinoma?

A. Whipple triad is pathognomonic
B. Serum insulin to glucose ratio is < 0.3
C. Oral glucose tolerance test permits differentiation from reactive hypoglycemia
D. Tolbutamide test is useful for excluding factitious hyperinsulinemia
E. CT is the most accurate preop method for tumor localization

C

Whipple triad (fasting hypoglycemia, symp of hypoglycemia and relief of symp following the administration of glucose) clinically establishes hypoglycemia. Ddx requires further evaluation

Biochemical dx of insulinoma is based on findings of fasting hypoglycemia (<50 mg/dL) and hyperinsulinemia (>20 microU/mL) that yield and insulin to glucose ration of >0.3.

Use of tolbutamide or leucine as a provocative test to release insulin may be dangerous is not required. C peptide is cleaved from insulin before its release and determination of C peptide levels for excluding facitious hyperinsulinemia.

In the case of organic hyperinsulinism, serial blood sampling results following oral glucose administration and subsequent fasting will demonstrate persistent hypoglycemia and hyperinsulinemia. When reactive hypoglycemia is present, insulin levels initially rise and glucose levels fall but the levels become normal after several hours

Most insulinomas are small. Arteriography or selective venous sampling may provide useful pre-op locatization. EUS and intraop u/scan also aid in identification

49

RUSH--Pancreas

Which of the following statements is true regarding the treatment of insulinoma?

A. Diazoxide is the preferred initial method of management
B. Enucleation is acceptable for localized pancreatic lesions
C. B/c most lesions are multiple or diffuse, total or nearly total pancreatectomy is generally necessary
D. B/C most lesions are malignant, adjuvant streptozocin is usually indicated
E. Parathyroid adenoma should be excluded or treated before pancreatic resection

B

Insulinomas are usually single and benign and rarely ectopic. Localization can be difficult and preop imaging along with mobilization and exploration of pancreas are mandatory. Intraop U/S is indispensable.

For localized lesions, simple enucleation is the preferred treatment, but the integrity of pancreatic duct must be ascertained.

If the lesion cannot be identified and biochemical dx is firm, blind distal pancreatic resection with careful histologic exam of the specimen may be necessary. Intraop monitoring of glucose has also been used

Diazoxide inhibits insulin release from beta cells and is occasionally used for perop control or for patients with recurrent post op hypoglycemia. For patients with metastatic malignant insulinoma, tumor debulking may be benefical, as is the use of streptozocin and 5-FU.

Gastrinoma is the most common pancreatic adenoma associated with MEN I. Parathyroid disease should be excluded or treated before surgical intervention for gastrinoma

50

RUSH--Pancreas

Which of the following features is characteristic of Zollinger Ellison syndrome but not of Verner Morrison syndrome?

A. Diarrhea
B. Hypercalcemia
C. Hypocalcermia
D. Increased gastric acid secretion
E. Malignancy

D

Zollinger Ellison syndrome is cause by gastrin producing islet cell tumor. Verner Morrison syndrome is caused by an islet cell tumor that produces vasoactive intestinal peptide.

ZES is assoc with marked incr in gastric acid secretion and with diarrhea. Hypercalcemia may occur b/c of assoc parathyroid abN.

Verner Morrison is characterized by watery diarrhea, hypokalemia, and achlorhydria. Hypercalcemia may occur but the parathyroids are usually N.

Both syndromes are frequently the result of malignant islet cell tumors.

51

RUSH--Pancreas

Which of the following is not a feature of the clinical syndrome assoc with a glucagon producing islet cell tumor?

A. Rash
B. Diabetes
C. Seizures
D. Glossitis
E. Anemia

C

Patients with glucagon secreting tumors have diabetes, anemia, wt loss, DVT, glossitis and a characteristic cutaneous lesion aka necrolytic migratory erythema.
4D syndrome consists of diabetes, dermatitis, DVT (deep vein thrombosis), and depression.

Rare and often metastatic at time of dx.

Tx directed at acheiving as complete a resection as possible. Post op, chemo with dacarbazine or stroptozocin may be useful for residual or recurrent disease

52

RUSH--Pancreas

Which of the following statements is true about pancreatic trauma?

A. Blunt trauma is the most common mechanism of injury
B. Trauma is the most common cause of pancreatic pseudocyst
C. Hyperamylasemia following penetrating abdominal trauma is pathognomonic
D. Negative peritoneal lavage findings following blunt trauma usually exclude pancreatic injury
E. Central retroperitoneal hematomas should be explored to exclude pancreatic injury

A

Most pancreatic injuries are the result of penetrating trauma, although the gland is vulnerable to blunt trauma b/c of its fixed position anteriorly over the vertebral column. Presence of significant pancreatic injury following blunt trauma is often not initially apparent.
Hyperamylasemia in serum or peritoneal fluid suggests the dx, but a neg peritoneal lavage does not exclude RP injury. RP hematomas in the upper part of the abdo should be explored to exclude panc duct injury. Pancreatitis is the most common cause of pseudocyt, although 25% occur as a result of trauma

53

RUSH--Pancreas

At operative exploration following blunt abdominal trauma, complete transection of the pancreatic neck is identified. There are no associated organ injuries. Which of the following treatments is most appropriate?

A. Placement of drains and closure of abdo
B. Distal pancreatectomy with ligation of proximal duct
C. Roux en Y pancreaticojej to the distal panc with ligation of proximal duct
D. Roux en Y pancreaticojeuj to both the prox and distal segments of pancreas
E. Whipple with Roux en Y pancreaticojej to distal duct

B

Pancreatic contusions or lacerations without ductal disruption are managed by drainage alone.

Pancreatic neck is a freq site of injury when it occurs with blunt trauma. Distal pancreatectomy with identification and closure of proximal duct and drainage is safe and resections involving up to 80% of an otherwise normal gland can be accomplished without subsequent endocrine insufficiency.

In theory Roux en Y pancreaticojej may be desirable to preserve pancreatic tissue but it is not recommended for the mgmt of acute injuries b/c of the risk assoc with a panc anast and need to open the gut. Whipple is indicated for patients with severe combined duodenal, pancreatic and bile duct injuries

54

PANCREAS

Annular pancreas is associated with:

A. Duodenal atresia
B. Ampullary obstruction causes jaundice
C. Failure to pass meconium
D. Always associated with duodenal ulcer when presents in adulthood
E. Associated with poor prognosis in childhood

A

Annular pancreas results from incomplete rotation of ventral pancreatic bud resulting in circumferential or near circumferential pancreas tissue surrounding the 2nd part of the duodenum

Assoc with maternal polyhydramnios and congenital abN such as Down's syndrome, esophageal and duodenal atresia, cardiac malformations, imperforate anus and Meckel's diverticulum

2/3 children present during neonatal period with features of GOO including feeding intolerance, bilious vomiting and abdo distension. If obstruction, bypass with duodenojejunostomy

Adults may present with abdo pain, n/v, post prandial fullness, upper GI bleed (from peptic ulceration), acute or chronic pancreatitis and rarely biliary obstruction

55

Pancreas

Which best describes the anatomy of pancreas divism?

A. Duct of santorini is the main drainage of the pancreas
B. Ventral analogue fails to migrate and join the dorsal analogue
C. Duct of wirsung drains the head, uncinate process and body of the pancreas
D. Accessory duct of santorini does not drain into the duodenum
E. Accessory duct of santorini drains into duct of wirsung

B

Dorsal = Santorini
Ventral = Wirsung

Ducts fail to fuse during embryogenesis resulting in a ventral (Wirsung) and CBD which enter the duodenum via the major papilla and the dorsal (Santorini) pancreatic duct entering through a minor papilla

56

Pancreas

Pancreas divism most frequently presents with:

A. Pancreatitis
B. Jaundice
C. Malignancy
E. Pseudocysts

A

57

Pancreas

Pancreatitis is associated with all except:

A. Beta hemolytic strep
B. Staph
C. Actinomycosis
D. Ascaris lumbricoides
E. Mumps

A?

Organisms assoc w/pancreatitis

Viruses-- mumps, coxsackie, hep b, CMV, varicella zoster, HSV, HIV
Bacteria--mycoplasma, legionella, leptospira, salmonella
Fungi--aspergillus
Parasites--toxoplasma, crytosporidium, ascaris

Group D streptococcus and S aureus have been seens in pancreatic abscesses. But not beta hemolytic strep

58

Pancreas

Which organism would not be seen with pancreatic abscess

A. E coli
B. Clostridium
C. Enterococcus
D. Staph aureus
E. Streptococcus

Answer says E

Group D streptococcus is found in pancreatic abscess. but less commonly

Usually polymicrobial and involves enteric flora (E. coli, enterococcus, klebsiella, pseudomonas, staph aureus, bacteroides fragilis, and clostridium perfringens).