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PANCREAS Flashcards

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1
Q

Absolute C/I endoscopic drainage of panc pseudocyst

A

pseudocyst c/b pseudoaneurysm

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2
Q

Ranson’s criteria components (on admission) - severity

A 
WBC >16
Age >55
glucose >200
AST >250
LDH >250
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3
Q

Ranson’s criteria components (48hrs into admission) - severity

A 
Hct drop >10%
BUN increase >5
Ca<8 within 48hrs
PaO2 <60mmHg
Base deficit (24-bicarb) >4
Fluid needs >6L within 48hrs
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4
Q

Size cut-off in which pseudocysts unlikely to resolve spontaneously

A

> 6cm

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5
Q

STEP-UP approach for mgmt necrotic pancreatitis

A

better prognosis if prolong surgical intervention

  1. ICU support, NPO, IVF, TPN/distal feeding tube
  2. if failing or sign of infection -> IV Abx, possible perQ drain
  3. Re-scan after perQ and still have fluid -> upsize drain, re-placement
  4. If worsening still -> video-assisted RP debridement (via flank)
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6
Q

Ranson criteria score that predicts 100% mortality

A

8

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7
Q

Atlanta classification system

A
  1. necrotizing vs. interstitial edematous

2. fluid vs. no fluid collection (and for how long?)

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8
Q

Puestow procedure; indications?

A

longitudinal pancreaticojejunostomy (decompressive operation); for large-duct chronic pancreatitis (>6mm) + normal panc head

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9
Q

Beger procedure

A

duodenal-preserving panc head resection

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10
Q

Frey procedure; indications?

A

lateral longitudinal pancreaticojejunostomy w/ excavation of panc head wo transection of pancreas (decompressive + resection of disease); for primary panc head involvement w/ or w/o duct dilation

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11
Q

Mgmt minimal change pancreatitis

A
  • total pancreatectomy

- if high surgical risk, then denervation via bilateral thoracoscopic splanctenectomy

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12
Q

Dx cystic pancreatic neoplasms

A
  • most found incidentally
  • further characterization w/ MRCP
  • EUS + FNA will differentiate type
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13
Q

FNA of cystic pancreatic neoplasms

A
  • high CEA (>190) -> mucinous

- high amylase -> ductal communication (ie. pseudocyst, IPMN)

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14
Q

Demographics of cystic pancreatic neoplasms

A

F>M

  • younger -> think solitary pseudopapillary lesions
  • middle-aged -> think mucinous
  • elderly -> think serous
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15
Q

Imaging characteristic: serous cystadenoma

A

well-circumscribed; multicystic, lobulated mass (“bunch of grapes”) +/- central stellate scar

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16
Q

Imaging characteristics: mucinous cystadenoma

A

thick-walled, single cyst with internal septations +/- peripheral calcifications

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17
Q

Pathognomonic endoscopic finding for main duct IPMN

A

fish-mouth papilla

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18
Q

Worrisome EUS findings for branch duct IPMN

A
  • cyst >3cm (for young pts, <2cm)
  • thickened cyst wall
  • non-enhancing mural nodules
  • lymphadenopathy
  • main duct >10mm
  • abrupt change in main duct size w/ distal atrophy
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19
Q

MC PNET

A

nonfunctional

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20
Q

MC functional PNET

A

insulinoma

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21
Q

MC PNET associated with MEN1

A

gastrinoma

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22
Q

Nonfunctional PNET (malignancy? location? sxs?)

A
  • majority malignant
  • MC head of panc
  • dx late bc incidentally found or mass effect
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23
Q

Insulinoma (malignancy? location? sxs?)

A
  • most benign
  • evenly distributed throughout panc
  • Whipple’s triad
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24
Q

Whipple’s triad

A
  • fasting hypoglycemia
  • neuroglycopenic sxs
  • relief sxs w/ glucose
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25
Labs: Insulinoma
- plasma glucose <55 - insulin >18 - C-peptide > 0.6 - pro-insulin >5 - beta-hydroxybuterate <2.7 - increase plasma glucose >25 after glucose admin - neg urine test for oral hypoglycemic
26
Mgmt insulinoma
depends on location, suspicion for malignancy + presence of other tumors - solitary benign -> enucleation - distal -> distal spleen preserving pancreatectomy - malignant -> formal resection
27
Gastrinoma (malignancy? location? sxs?)
- most malignant - located gastrinoma triangle - abd pain + diarrhea + weight loss + peptic ulcer disease
28
Gastrinoma triangle
- jxn CBD + CD - jxn neck/body panc - jxn 2nd/3rd duodenum
29
If cannot localize gastrinoma, go to OR and do...
1. intra-op US 2. transduodenal palpation 3. intra-op upper endoscopy w/ transduo illumination 4. duodenotomy, then palpate head of panc
30
Mgmt gastrinoma
- if small in duodenal mucosa -> enucleation + paraduo LN dissection - if noninvasive, <5cm at head -> (same as above) - if invasive or >5cm, at head -> Whipple - if in body/tail -> distal panc
31
Glucagonoma (malignancy? location? sxs?)
- most malignant - MC tail of panc - sxs: dermatitis, DM, depression, DVT + necrolytic migratory erythema
32
Mgmt glucagnoma
NO enucleation, need resection w/ regional lymphadenectomy (bc high malignant potential) + cholecystectomy (bc need somatostatin adjuvant)
33
Somatostatinoma (malignancy? location? sxs?)
- most malignant - MC head of panc, can be at 2nd duo - sxs: cholecystitis, DM, malabsorption, steatorrhea
34
Mgmt somatostatinoma
NO enucleation, need resection w/ regional lymphadenectomy + cholecystectomy
35
VIPoma (malignancy? location? sxs?)
- most malignant - MC body/tail panc (extrapanc also possible @ adrenal, RP, mediastinum) - sxs: WDHA
36
Mgmt VIPoma
NO enucleation, need resection w/ regional lymphadenectomy + cholecystectomy (bc somatostatin adjuvant)
37
Characteristics of resectable panc adenocarcinoma
- no arterial contact - <180 degree contact SMV or portal vein - wo vein contour irregularity (which would indicate invasion into vasculature structure)
38
Characteristics of unresectable panc adenocarcinoma
- distant mets - >180 degree contact w/ SMA or celiac - unresectable involvement with SMV or portal vein
39
What is / who gets adjuvant for panc adenocarcinoma?
everyone; folinic acid (leucovorin) + 5FU + irinotecan + oxaliplatin
40
hx pancreatitis + hematemesis, think...?
gastric varices 2/2 splenic vein thrombosis
41
2-cm branch IPMN incidental + microcytic anemia, also need w/u for...?
colonoscopy; bc IPMN pts have higher incidence extra-panc malignancy (MC colonic adenocarcinoma)
42
Mutations associated w/ panc adenocarcinoma
- KRAS - p53 - CDKN2A - SMAD4
43
Mgmt pancreatic fistula
- most will close spontaneously 4-6 wks - ERCP w/ stent if still signif output (will close 85% pts) - somatostatin analog NOT helpful and is expensive
44
If choose to do dx lap for borderline panc adeno, must do what during procedure?
divide gastrocolic omentum to access lesser sac -> direct inspection of pancreas and peripanc LN burden + washing of lesser sac (for cytologic eval)
45
MC serious Cx following Whipple
post-op pancreatic fistula
46
Sxs post-op pancreatic fistula s/p Whipple
range from - asympt: leak from cut end panc -> self-limiting pseudocyst formation; to - complete disruption pancreatoJ, requiring emergency lap
47
Mets from pancreatic ductal adenoCA MC where?
liver
48
Imaging for preop determination of resectability for panc ductal adenoCA
3-phase pancreatic protocol CT
49
Best blood biomarker for PNET
chromogranin A (CgA)
50
ChemoRx used for metastatic PNET
everolimus (mTOR inhibitor), streptozocin, sunitinib
51
Surveillance interval of BD-IPMN wo worrisome features <2cm
yearly CT/MRI
52
Surveillance interval of BD-IPMN wo worrisome features >2cm
CT/MRI imaging alternating with endoscopic US q3-6mo
53
If BD-IPMN with worrisome features, next step is...?
endoscopic US
54
Worrisome features of BD-IPMN
- cysts >3cm - thickened or enhancing cyst wall - main duct 5-9mm - nonenhancing mural nodule
55
High-risk stigmata of BD-IPMN
- obstructive jaundice - enhancing solid component within cyst - main duct >10mm
56
Mgmt mature cyst abutting stomach on imaging, not resolved with conservative mgmt
endoscopic cystgastrostomy (drain into stomach via opening made through posterior stomach to collection)
57
MCC death after Beger and Frey procedures
CV disease 2/2 endocrine insufficiency
58
MC post-op Cx of distal pancreatectomy
leak from cut edge of pancreas
59
Most reliable method to reduce pancreatic leak from distal pancreatectomy
direct suture ligation of the duct
60
Direct retroperitoneal debridement AKA? Can be used for?
Direct perQ endoscopic debridement - can be used for walled-off pancreatic necrosis
61
Which malignancies require dx lap for accurate dx of stage?
- stomach - esophagus - pancreas (if >3cm, in body/tail, elevated CA19-9 >100, or uncertain CT findings)
62
Cationic trypsinogen gene (PRSS1) mutation results in...?
hereditary pancreatitis - suspect in <35-yo with unexplained pancreatitis
63
Smoking independently increases risk for ?? in chronic pancreatitis pts
pancreatic adenocarcinoma
64
What type of pseudocysts are likely to resolve?
- =/< 6cm | - present for <6 weeks
65
Cause of pancreas divisum
from failure of fusion of ventral and dorsal pancreatic ducts
66
Mgmt symptomatic pancreas divisum
ERCP + sphincteroplasty with stent placement
67
What is Duct of Wirsung?
major pancreatic duct - drains uncinate process and part of head
68
What is Duct of Santorini?
lessor papilla - drains head/body/tail of pancreas
69
Cause of annular pancreas?
incomplete rotation of ventral pancreatic bud -> ring of panc tissue surrounding descending portion of duodenum
70
Imaging finding for annular pancreas on XR?
double bubble sign
71
Annular pancreas can result in ?? for duodenum
duodenal atresia
72
Imaging dx for pancreas divisum
ERCP - see two papilla
73
Most important predictor of overall survival for pancreatic adenoCA
tumor stage
74
Indications for early ERCP for gallstone pancreatitis
- CBD stone US - clinical ascending cholangitis - bilirubin >4 - both dilated CBD >6mm + bili 1.4-4
75
What pancreatic neoplasm associated with ovarian type of stroma?
Mucinous cystic neoplasms
76
Three phases of exocrine pancreatic response + respective mediators
1. Cephalic - sight/smell; vagus 2. Gastric - food entering stomach; somatostatin primary inhibitor; vagus 3. Intestinal - food entering duodenum; majority panc secretion here; vagus/CCK/secretin
77
Most potent stimulator of pancreatic enzyme secretion
CCK
78
Most potent stimulator of pancreatic bicarbonate
Secretin
79
Tx for annular pancreas
Duodenojejunostomy (NO resection of obstructing pancreas)
80
Tx pancreatic divisum
ERCP + sphincteroplasty with stent placement
81
Medical (initial) Tx for chronic pancreatitis
- anagelsic - stop EtOH and smoking - oral enzyme therapy - selective use of anti secretory therapy (somatostatin) - +/- PPI (assist in preventing inactivation of panc enzyme)
82
Borders of where to open pancreatic duct - Puestow procedure
Anterior: open along its length Medial: to level of GDA Lateral: into tail beyond all pancreatic duct strictures
83
Complications of pancreatic cyst
- splenic vein thrombosis (bc compression of vein by cyst) - pseudoaneurysm (bc erosion into visceral arteries) - peritonitis
84
Patho of chronic pancreatitis
Irreversible pancreatic fibrosis + loss of functional pancreatic exocrine/endocrine tissue
85
Action of trypsin
Breakdown of proteins into AA
86
Dx mass at ampulla of Vater
- biopsy to determine if carcinoma | - EUS to identify duodenal invasion
87
Which ampullary mass can be managed endoscopically?
- no invasion - benign daemons - =/<2cm *can be excised endoscopically or via transship approach with 2-3mm margins
88
Which ampullary masses should be considered of pancreaticoduodenectomy?
- pre-op dx of carcinoma | - >2cm
89
Dx hereditary pancreatitis (PRSS1)
- 2+ first degree relatives with unexplained pancreatitis - 3+ second degree relatives - over 2+ generations
90
What enzyme actives trypsinogen to its active form (trypsin)?
Enterokinase
91
Which of the pancreatic digestive enzymes are synthesized and secreted in their active forms?
- amylase - lipase - ribonuclease - deoxyribonuclease
92
Tx flare of chronic autoimmune pancreatitis
Steroids
93
MC presentation of autoimmune pancreatitis
Jaundice
94
Dx autoimmune pancreatitis
- clinical (jaundice, pain) - elevated IgG4 - imaging (enlarged peripanc LN; usually no intrapanc calcifications)
95
Which pancreatic pseudocysts can be managed conservatively?
- present <6 weeks | - 6cm and smaller
96
Presentation and Dx of pancreatic lymphoma
- B-symptoms (fever, night sweats, weight loss) - N/V + abdominal pain - CT: bulky pancreatic mass
97
Tx pancreatic lymphoma
Cytotoxic chemotherapy - cyclophosphamide - doxorubicin (adriamycin) - vincristine - prednisone
98
Action of pancreatic polypeptide
Suppress bile secretion, GB contraction, and exocrine pancreatic function
99
Pancreatitis in pt with pancreas divisum likely due to...?
Alcohol or gallstones. Rare that pancreas divisum is primary cause of pancreatitis - but if it is, thought to be 2/2 minor papilla being insuff to drain pancreatic secretions (obstruction)
100
Dx for pancreas divisum
ERCP
101
Mgmt pancreatic divisum if refractory to endoscopic minor papillotomy and pancreatic duct stenting?
Surgical longitudinal duodenotomy + minor sphincteroplasty
102
If presumed case of autoimmune pancreatitis does not completely respond to steroids, then consider possibility of...?
Pancreatic adenocarcinoma
103
Which genetic change associated with pancreatic endocrine neoplasms (PEN) is associated with improved prognosis?
Microsatellite instability from hypermethylation of hMLH1
104
Secretin stim test panc: end-stage pancreatitis
- low total volume - low bicarb - low enzymes
105
Secretin stim test panc: panc cancer
- low total volume - nl bicarb - nl enzymes
106
Secretin stim test panc: chronic pancreatitis
- nl total volume - low bicarb - nl enzymes
107
Secretin stim test panc: malnutrition
- nl total volume - nl bicarb - low enzymes
108
What basal acid output is necessary to confirm dx gastrinoma?
>15 basal acid output
109
VHL (von Hippel-Lindau) is associated with...?
- hemangioblastomas of CNS and retina (bilateral, multiple) - pheo - clear cell renal cell CA (bilateral, multifocal) - cystadenomas and neuroendocrine tumors of pancreas

QUESTION NOTES (28 decks)

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