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PANCREAS Flashcards

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1
Q

relationship of the duodenum to the pancreas

A

head of the pancreas is surrounded by loop of the duodenum

Retroperitoneal

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2
Q

Relationship of pancreas to vasculature

A

Head of the pancreas extends to be right of the superior mesenteric VEIN
Anterior to this is gastroduodenal artery

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3
Q

Origin and course of gastroduodenal artery

A

Common HEPATIC artery
junction marked the beginning of the PROPER hepatic artery
gastroduodenal artery runs posterior to duodenum (massive bleeding)
Divides to form posterior superior pancreaticoduodenal arteries
Anastomosis with anterior and posterior INFERIOR pancreaticoduodenal arteries (these arise from superior mesenteric artery)

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4
Q

list right to left vascular structures related to the pancreas

A

far right: superior mesenteric vein
2 the left colon
at neck-the superior mesenteric artery
Cephalad at tail-splenic artery
Caudad at tail-dorsal pancreatic artery
Posterior and longitudinal 2 tail- splenic vein
Cephalad at head-gastroduodenal artery and superior anterior pancreaticoduodenal artery and superior posterior pancreaticoduodenal artery
Caudad at head-inferior anterior pancreaticoduodenal artery

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5
Q

pancreatic divisum

A

dorsal and ventral blood filter fuse the duct causing separate ductal drainage into duodenum
The accessory duct of Santorini drains through minor papilla
The major ampulla always drains the common bile duct and duct Wirsung

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6
Q

Normal pancreatic duct anatomy

A

Duct of Wirsung - major duct-major papilla (“ ampula of Vater”)-second portion of the duodenum-common bile duct off informs common channel with the main pancreatic duct before it enters the ampulla and sphincter of Oddi

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7
Q

Venous drainage of pancreas

A

Anterior venous arcade drains into superior mesenteric vein

Posterior venous arteriogram into portal vein

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8
Q

Enzymes is agreed to by the pancreas as inactive precursor

A

Trypsinogen
Chymotrypsinogen
activated by duodenum

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9
Q

alpha cells

A

Glucagon

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10
Q

Beta cells

A

Insulin

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11
Q

Delta cells

A

Somatostatin

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12
Q

Most common cause of pancreatitis

A

Cholelithiasis

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13
Q

List causes of pancreatitis

A 
Cholelithiasis
Alcohol
Hyperlipoproteinemia/hypercalcemia
Duodenal obstruction
Cardiopulmonary bypass (ischemia)-this is most common abdominal  problem post bypass
Mumps
Coxsackie B.
Cytomegalovirus
Cryptococcus
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14
Q

Drugs that cause pancreatitis

A 
Steroids
Dyazide
Furosemide
Estrogen
Azathioprine
Dideoxyinosine
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15
Q

Most common cause of mechanical etiology acute pancreatitis

A

gallstones

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16
Q

Gray Turner sign

A

Flank

TURN on side

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17
Q

Cullen sign

A

periumbilical ecchymosis

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18
Q

Fox sign

A

inguinal

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19
Q

Ranson criteria On admission

A 
GA  LAW
 glucose greater than 200 and
AST greater than 250
LDH greater than 350
Age greater than 55
White count greater than 16
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20
Q

Ranson criteria at 48 hours after admission

A 
C HOBBS
 calcium greater than 8
Hematocrit more than 10 point decrease
PaO2 less than 60 on room air
BUN greater than 5
Base deficit less than for
Sec restoration greater than 6 L
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21
Q

Clinical management based on ransom criteria

A

3 or greater criteria ICU
3 or greater criteria 15% mortality
Ranson criteria not used for gallstone pancreatitis

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22
Q

Management of common duct stone

A

MRCP 90% negative and stone-little utility
do not perform early ERCP
cholecystectomy same hospital admission with intraoperative cholangiogram-try to flush/glucagon
If still stuck postoperative ERCP
Do not wait for amylase/lipase normalized

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23
Q

Antibiotics for pancreatitis

A

Imipenem

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24
Q

management of pancreatic pseudocyst

A

Majority resolved spontaneously
Pancreatic rest
TPN and avoid oral intake that stimulates pancreatic secretion
a does not resolve within 4-6 weeks and still symptomatic pseudocyst that communicate with the pancreatic duct on ERCP should be drained surgically
The pseudocyst does not communicate with the pancreatic duct Endoscopic Cyst Gastrostomy
Alternative pseudocyst anastomosis to limb of jejunum and Roux-en-Y cyst jejunostomy

External drainage: Offer require a second operation because of pancreatic fistula
BIOPSY cyst wall
AVOID external drainage-fistula infection

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25
Pulmonary disease or causes pancreatitis
cystic fibrosis
26
The splenic vein thrombosis
-year-old bleed with erosion in the splenic artery cannot band Cannot decompress with tips (independent of portal vein flow) SPLENECTOMY
27
chain of lakes
segmental ductal obstruction and alternating areas of obstruction and dilation Best treated with lateral pancreaticojejunostomy or modified Puestow
28
utility of celiac block for chronic pancreatitis pain
not very helpful
29
risk factors for pancreatic adenocarcinoma
Age Smoking double the risk Possible diabetes/alcohol most common site head
30
Most common cancer of the pancreas
Adenocarcinoma with ductal epithelium origin
31
Other cancer the pancreas beside adenocarcinoma
Islet cell tumor Cystadenocarcinoma Lymphoma- rare-treated with chemotherapy and radiation!
32
what is expected mortality from Whipple
2-4% based on hospital volume
33
advantage of pylorus preserving Whipple
no survival advantage | May decrease dumping
34
utility of neoadjuvant chemotherapy for adenocarcinoma of the pancreas
no survival advantage | May improve resectability
35
workup for adenocarcinoma pancreas
preoperative CTA | DO NOT BIOPSY preop
36
procedures performed during a Whipple
``` #1 pancreaticoduodenectomy #2 antrectomy (is not pylorus-preserving) with vagotomy (to avoid acid from burning the bowel) #3 cholecystectomy #4 distal common bile duct resection #5 pancreaticojejunostomy #6 choledochojejunostomy #7 gastroenterostomy ```
37
Gastrinoma triangle
``` #1 common bile duct #2 portion the duodenum #3 pancreatic neck ```
38
What is considered incurable disease with adenocarcinoma pancreas
Liver metastases Peritoneal seeding Invasion of mesenteric root, celiac axis, mesenteric vessels
39
Treatment of unresectable pancreatic adenocarcinoma
Papillae with biliary drainage endoscopic stenting in most cases Gastric outlet obstruction management gastrojejunostomy Back pain is improved with the celiac axis block
40
Management of pancreaticojejunostomy leak after Whipple
Amylase rich drainage or abscess formation Adequate drainage of secretions Nutrition often TPN Nonoperative therapy
41
Most common cystic tumor of the pancreas
Cystadenoma- Serous or mucinous -more common
42
mucinous cystic neoplasm of the pancreas
``` Women Early age-50 Tall columnar cell Treatment WHIPPLE! Better prognosis than adenocarcinoma 50% 5 year survival rate ```
43
Cystic papillary neoplasm of the pancreas
Young women in their 20s | Resection!
44
islet cell tumor of the pancreas
``` Includes: insulinoma Gastrinoma Glucagon, Somatostatin, VIP, N ```
45
Most common eyelid cell tumor of the pancreas
NON-functional
46
Insulinoma
90% benign Distended throughout pancreas Diagnosis is confirmed out of proportion with glucose ratio Whipple's triad: Symptoms known or likely to be caused by hypoglycemia A low plasma glucose measured at the time of the symptoms Relief of symptoms when the glucose is raised to normal
47
Treatment of insulinoma
ENUCLEATION | If patient not a candidate they alleviate with streptozotocin or diazoxide
48
Zollinger-Ellison syndrome
Peptic ulcer disease caused by gastrin secreting islet cell tumor ulcers in unusual locations distal duodenum or jejunum Watery diarrhea Fasting serum gastrin greater than 750
49
Gastrinoma triangle
common bile duct Second/third portion of duodenum Neck of the pancreas
50
Extrapancreatic sites of gastrinoma
``` Gastrinoma triangle bile duct Heart Liver Lungs Ovary Kidney Mesentery Bones ```
51
Most common false positive elevations in increased serum gastrin
atrophic gastritis the | achlorhydria
52
Workup for gastrinoma
Fasting serum gastrin greater than 750 Secretary and stimulation test confirms diagnosis of positive doubling fasting level or absolute increase of 200 octreotide scan
53
treatment of gastrinoma
Simple enucleation for many May be multicentric Bile duct, pancreatic duct, and vessels, and duodenum Pregnancies blind pancreatic resection rarely indicated) ( total gastrectomy no longer performed given acid secretion inhibiting medication) His poor risk patient or bulky mass then cannulated with PPI
54
tropical pancreatitis
``` Young Trypsinogen inhibitor gene Casava root Emilio Treat with medications digestive enzymes May require endoscopy decompression Increased risk of cancer ```
55
Treatment of large chronic pancreatic pseudocyst
INTERNAL drainage Communicates with the pancreatic duct system 80% Endoscopic approach we'll fail with major duct disruption or stenosis seen on ERCP or cholangiopancreatography
56
New onset diabetes with skin rash and pancreatic mass in tail
glucagon, Medical lytic migratory erythema Usually does not present with jaundiced because and tail
57
Greasy floating stool, gallstones, pancreatic head mass
``` somatostatinoma exocrine insufficiency: steatorrhea and gallstones easily metastatic at presentation Diagnoses somatostatin level ```
58
Diagnosis with watery diarrhea and electrolyte abnormalities mass in the pancreas extension into the superior mesenteric vein and organs
VIPoma Vasoactive intestinal peptide WDHA (watery diarrhea, hypokalemia, achlorhydria) “Verner-Morison syndrome” Diagnosis CT scan Tumors and tail 3 with tumor debulking even with metastases! Adjunct hepatic artery embolization, radiofrequency ablation for liver metastases Octreotide (somatostatin analog) for symptoms next she'll
59
Possible risk factors for pancreatic cancer
``` Obesity Atypical multiple small melanoma Hereditary pancreatitis Familial adenomatous polyposis Her dietary non-polyposis colon cancer Peutz-Jeghers syndrome Alcohol is debatable as a risk factor ```
60
Most common pancreatic functional endocrine neoplasm
``` insulinoma Whipple triad: Elevated C-peptide level diagnostic Localizing CT and ultrasound Even distribution pancreas 90% benign Treatment the nucleation ```
61
which pancreatic endocrine tumor is octreotide scan used for
gastrinoma -Confined tumors less than 1 cm | Also useful for carcinoid tumors
62
Gallstone pancreatitis ERCP
Differential severe pancreatitis: Early cholecystectomy associated increased mortality ERCP performed with concomitant cholangitis or clear evidence of biliary obstruction (jaundice, persistent total bili greater than 4)
63
Best predictor of retained common duct stone
persistently elevated total bili
64
Pseudohyponatremia
seen with severe hypertriglyceridemia water displaced by lipids causing air and measurement Pancreatitis
65
hereditary pancreatitis
defect in trypsin inactivation Although nondominant Results in uncontrolled proteolytic auto destruction of pancreas Presents in childhood/adolescence Calcifications of the pancreas Risk of pancreatic carcinoma 40%! Typically presents first 2 decades of life
66
pancreatic divisum
ducts of Wirsung and Santorini failed to fuse Majority of pancreas drained throughSantorini and LESSER papilla inferior portion of pancreatic head and uncinate process is drained via Wirsung major papilla considered normal anatomic variant and 10% Increased for pancreatitis by overwhelming minor papilla no color change he is to
67
Pancreatic lesion associated with persistent skin rash and glucose of 160
GLUCOGONoma
68
findings with glucagonoma
necrolytic migratory erythema Increased glucagon level NO jaundice because lesions usually tail of pancreas
69
clinical findings with exocrine insufficiency
steatorrhea gallstones (seen with somatostatin Oma)
70
treatment with VIP Oma
even with distant metastases tumor debulk, embolized, radiofrequency ablation for liver, octreotide
71
familial syndromes associated with pancreatic cancer
``` FAP hereditary non-polyposis colon cancer Peutz-Jegher's syndrome BRCA II melanoma-atypical ```
72
Which pancreatic tumor it octreotide scan use for
GASTRINoma
73
when preoperative ERCP be performed for gallstone pancreatitis
``` and common cholangitis Or Clear evidence of biliary obstruction: Jaundice Total bilirubin greater than 4 ```
74
pseudohyponatremia
caused by hypertriglycerides | seen with pancreatitis
75
and pancreatic divisum where do the head and uncinate drain
Duct of Wirsung major papilla
76
treatment for recurrent acute pancreatitis due to pancreatic divisum
minor papilla sphincterotomy
77
where do the majority of adenocarcinomas arise in the pancreas
main pancreatic DUCT | head or uncinate process
78
workup for obstructive jaundice acholic stool weight loss and mass in the head of the pancreas on CT scan with no signs of distant metastases or vascular involvement
done | NO biopsy
79
First study to perform a patient with obstructive jaundice
ultrasound
80
we did a biopsy performed for pancreatic adenocarcinoma working diagnosis
paradoxically was appears unresectable: helpful to guide chemotherapy with tissue also rule out pancreatic lymphoma
81
Effects of alcohol and the pancreas and producing pancreatitis
``` #1 spasm of the sphincter over the #2 toxin acinar cells #3 increase his ductal permeability #4 decrease his pancreatic blood flow #5 and appropriately activates pancreatic trypsin ```
82
Drinking habits associated with alcoholic pancreatitis
18 ys mend | 11 ys womne
83
type 3 diabetes
``` diabetes that develops in the setting of chronic pancreatitis or after pancreatic resection Associated with decreased glucagon Decreased PP level Decrease insulin Difficult to control INCREASED peripheral insulin SENSITIVITY DECREASED hepatic and common sensitivity Patient prone to develop HYPOglycemia marked hyperglycemia rare ```
84
PP enzyme
``` HEPATIC insulin receptor PP cells (F-cells) located proximal pancreas ```
85
Characteristics of serous cystadenoma
CENTRAL SCAR septations Calcification (careful: also seen in mucinous)
86
characteristic of mucinous cystadenoma
peripheral eggshell calcification
87
workup for pancreatic ascites
paracentesis- Elevated serum amylase Protein greater than 25
88
Management of pancreatic ascites
Bowel rest TPN n.p.o. ERCP with stent Surgery distal duct-distal pancreatectomy Surgery pancreatic body Roux-en-Y pancreaticojejunostomy
89
Diagnosis with compression of intrapancreatic common duct and biopsy with diffuse fibrosis plasma and lymphocytic infiltrate increased IgG
``` autoimmune pancreatitis Can be confused lymphoma Hypoechoic pancreas Often presents diabetes Treatment steroids ```
90
Diagnosis of factitious hypoglycemia
C-peptide low | In fundus C-peptide ratio greater than one
91
treatment of pancreatic lymphoma
CHEMOTHERAPY
92
Diagnosis of pancreatic lymphoma
one other rare case of the FNA should be done
93
Most common cause of chronic pancreatitis worldwide
alcohol and

PANCREAS (1 decks)

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