Pancreas

Question 1

MC cause acute panc

Answer 1

alcohol gallstones

Question 2

Gallstone Panc tx

Answer 2

Clear duct - ERCP, IC

Cholecystectomy in same admission

Question 3

Atlanta classification

Answer 3

Non-nec: < 4 wks (acute peri-panc fluid collection), > 4 wks (pancreatic pseudocyst)

Nec: < 4 wks (acute nec collection, > 4 wks (walled off necrosis)

Question 4

Nec panc tx with abx or not

Answer 4

No, only if have subsequent infection

F, Inc WBC, CT guided FNA

Question 5

What abx for infected nec panc

Answer 5

Imipenem

Question 6

Step up approach

Answer 6

1) Admit to ICU: Fluids, nutrition, support
2) Abx and percutaneous drain
3) Upsize drain
4) Video assisted retroperitoneal drainage

Question 7

MC cause chronic panc

Answer 7

Alcohol
Biliary tract disease
Autoimmune
Idiopathic

Question 8

S/S of chronic panc

Answer 8

Persistent abd pain
Weightloss
Malabsorption/steatorrhea/DM
>= 1 bout of acute panc

Question 9

Dx: CT

Answer 9

Fibrosis, atrophy, calcification of gland

Question 10

Chronic pain inc risk of cancer?

Answer 10

Yes

Question 11

Tx

Answer 11

Non op mgmt
Abstain from alcohol
Panc enzyme replacement

Question 12

Surgical mgmt of chronic pain

Answer 12

Decompress duct: Puestow

Resection of dz tissue: Beggar, Fray

Question 13

Puestow

Answer 13

Longitudinal pancreaticojejunostomy
Large duct pancreatitis > 6 mm duct
W/ Normal panc head

Question 14

Beggar

Answer 14

Resection of pancreatic head, pancreaticojejunostomy

Panc head dominant pancreatitis

Question 15

Fray

Answer 15

Lat longitudinal pancreaticojejunostomy, core out head of panc

Question 16

Distal panc

Answer 16

For mostly distal strictured disease

Question 17

Minimal change panc

Answer 17

Resection/drainage won’t help
Need denervation
Bilateral thoracoscopic splantenectomy

Question 18

Panc pseudocyst

Answer 18

Non nec > 4 wks
More common in chronic panc patients
Manage expectantly for 6 wks -> mature or resolve
If enlarging, symptomatic or > 6 cm then intervene

Question 19

Panc pseudocyst surgical intervention

Answer 19

1st: Pre-op ERCP or MRCP to assess duct
2nd: Transpapillary endoscopic stenting, Endoscopic transluminal drainage, Open cystgastromstomy, Lap cystgastrostomy

Question 20

PNETs

Answer 20

Most found incidentally on CT, then need panc triple phase CT or MRI
EUS -> FNA -> Analyze for CEA and amylase levels

Question 21

Mucinous cyst

Answer 21

CEA > 190

Question 22

Pseudocyst

Answer 22

Amylase high -> ductal communication

Question 23

Serocystadenoma

Answer 23

Low CEA
Benign
Well circumscribed, central stellate scar
Do not need resection

Question 24

Mucinous cystic neoplasm

Answer 24

Malignant potential
Thick walled
Cyst with internal septations
CEA > 190, mucin in aspirate
Tx: Must resect

Question 25

IPMN

Answer 25

3 groups Main duct Branch duct Mixed type

Question 26

Main duct IPMN

Answer 26

Higher risk of malignancy Fishmouth papilla on endoscopy Must resect Tx mixed type the same

Question 27

Branch duct IPMN

Answer 27

Lower risk of malignancy Decision to resect: Fitness of patient, Cyst > 3 cm, Thickened wall, non-enhancing mural nodules, lymphadenopathy, main duct > 10 cm

Question 28

Daughter Mother Grandaughter

Answer 28

Daughter: Solid pseudopapillary Mother: Mucinous Grandmother: Serous

Question 29

MC PNET

Answer 29

Non functional tumor

Question 30

MC functional PNET

Answer 30

Insulinoma

Question 31

Non function PNET

Answer 31

Malignant Discovered late due to asymptomatic Usually large, in head of panc and having some mass effect when found

Question 32

Insulinoma

Answer 32

Benign Throughout panc - even distribution Whipple's triad

Question 33

Whipple's triad

Answer 33

Neuroglycopenic symptoms High insulin Resolution of symptoms with administration of glucose

Question 34

Dx of insulinoma

Answer 34

``` S/S Insulin > 18 Glucose < 55 C-peptide > 6 B hydroxy biutyrate < 2.7 Inc plasma glucose by 25 with glucagon Negative urine test for oral hypoglycemic ```

Question 35

Tx:

Answer 35

Localize: Triphasic panc CT or MRI, EUS, or if cannot localize -> Intrarterial Ca injection and hepatic vein sampling. Somatostatin scintography is not helpful Solitary/Benign -> enucleate Distal -> Distal panc/splenectomy

Question 36

Gastrinom

Answer 36

Mostly malignant | In gastrinoma triangle