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Section II General Surgery P203Surgical Recall Sixth > Pancreas, C55 P382-398 > Flashcards

Pancreas, C55 P382-398 Flashcards

1
Q

Identify the regions of the
pancreas:
P382 (picture)

A
  1. Head
  2. Neck (in front of the SMV)
  3. Uncinate process
  4. Body
  5. Tail
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2
Q

What structure is the tail of
the pancreas said to “tickle”?
P382

A

Spleen

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3
Q

Name the two pancreatic
ducts.
P382

A
  1. Wirsung duct

2. Santorini duct

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4
Q

Which duct is the main
duct?
P382

A

Duct of Wirsung is the major duct

Think: Santorini = Small duct

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5
Q

How is blood supplied to the
head of the pancreas?
P382

A 
1. Celiac trunk → gastroduodenal →
    Anterior superior pancreaticoduodenal
       artery
Posterior superior pancreaticoduodenal
       artery
2. Superior mesenteric artery →
    Anterior inferior pancreaticoduodenal
       artery
    Posterior inferior pancreaticoduodenal
       artery
3. Splenic artery →
    Dorsal pancreatic artery
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6
Q

Why must the duodenum be
removed if the head of the
pancreas is removed?
P382

A

They share the same blood supply

gastroduodenal artery

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7
Q 
What is the endocrine
function of the pancreas?
P383
A

Islets of Langerhans:
-cells: glucagon
-cells: insulin

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8
Q

What is the exocrine
function of the pancreas?
P383

A

Digestive enzymes: amylase, lipase,

trypsin, chymotrypsin, carboxypeptidase

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9
Q 
What maneuver is used to
mobilize the duodenum and
pancreas and evaluate the
entire pancreas?
P383
A

Kocher maneuver: Incise the lateral
attachments of the duodenum and then
lift the pancreas to examine the posterior
surface

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10
Q

PANCREATITIS
ACUTE PANCREATITIS
What is it?
P383

A

Inflammation of the pancreas

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11
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the most common
etiologies in the United
States?
P383
A
  1. Alcohol abuse (50%)
  2. Gallstones (30%)
  3. Idiopathic (10%)
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12
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the acronym to
remember all of the causes
of pancreatitis?
P383
A

“I GET SMASHED”:
Idiopathic

Gallstones
Ethanol
Trauma
    Scorpion bite
    Mumps (viruses)
    Autoimmune
    Steroids
    Hyperlipidemia
    ERCP
    Drugs
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13
Q

PANCREATITIS
ACUTE PANCREATITIS
What are the symptoms?
P383

A 
Epigastric pain (frequently radiates to
back); nausea and vomiting
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14
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the signs of
pancreatitis?
P383
A 
Epigastric tenderness
Diffuse abdominal tenderness
Decreased bowel sounds (adynamic ileus)
Fever
Dehydration/shock
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15
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the differential
diagnosis?
P384
A 
Gastritis/PUD
Perforated viscus
Acute cholecystitis
SBO
Mesenteric ischemia/infarction
Ruptured AAA
Biliary colic
Inferior MI/pneumonia
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16
Q 
PANCREATITIS
ACUTE PANCREATITIS
What lab tests should be
ordered?
P384
A 
CBC
LFT
Amylase/lipase
Type and cross
ABG
Calcium
Chemistry
Coags
Serum lipids
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17
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the associated
diagnostic findings?
P384
A 
Lab—High amylase, high lipase, high
    WBC
AXR—Sentinel loop, colon cutoff,
    possibly gallstones (only 10% visible
    on x-ray)
U/S—Phlegmon, cholelithiasis
CT—Phlegmon, pancreatic necrosis
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18
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the most common
sign of pancreatitis on AXR?
P384
A

Sentinel loop(s)

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19
Q

PANCREATITIS
ACUTE PANCREATITIS
What is the treatment?
P384

A 
NPO
IVF
NGT if vomiting
\+/– TPN vs. postpyloric tube feeds
H(2) blocker/PPI
Analgesia (Demerol®, not morphine—
less sphincter of Oddi spasm)
Correction of coags/electrolytes
\+/– Alcohol withdrawal prophylaxis
“Tincture of time”
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20
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the possible
complications?
P385
A 
Pseudocyst
Abscess/infection
Pancreatic necrosis
Splenic/mesenteric/portal vessel rupture
     or thrombosis
Pancreatic ascites/pancreatic pleural
    effusion
Diabetes
ARDS/sepsis/MOF
Coagulopathy/DIC
Encephalopathy
Severe hypocalcemia
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21
Q

PANCREATITIS
ACUTE PANCREATITIS
What is the prognosis?
P385

A

Based on Ranson’s criteria

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22
Q 
PANCREATITIS
ACUTE PANCREATITIS
Are postpyloric tube feeds
safe in acute pancreatitis?
P385
A

YES

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23
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are Ranson’s criteria for the following stages:
At presentation?
P385
A
  1. Age >55
  2. WBC >16,000
  3. Glc >200
  4. AST >250
  5. LDH >350
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24
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are Ranson’s criteria for the following stages:
During the initial
48 hours?
P385
A
  1. Base deficit > 4
  2. BUN increase > 5 mg/dL
  3. Fluid sequestration > 6 L
  4. Serum Ca⁺ < 8
  5. Hct decrease > 10%
  6. PO(2) (ABG) < 60 mm Hg
    (Amylase value is NOT one of
    Ranson’s criteria!)
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25
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the mortality per
positive criteria:
0 to 2?
3 to 4?
5 to 6?
7 to 8?
P385
A

0 to 2? < 5%
3 to 4? ≈ 15%
5 to 6? ≈ 40%
7 to 8? ≈ 100%

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26
Q 
PANCREATITIS
ACUTE PANCREATITIS
How can the admission
Ranson criteria be
remembered?
P386
A

“GA LAW (Georgia law)”:
Glucose >200
Age >55

    LDH >350
    AST >250
    WBC >16,000
    (“Don’t mess with the pancreas and
don’t mess with the Georgia law”)
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27
Q 
PANCREATITIS
ACUTE PANCREATITIS
How can Ranson’s criteria
at less than 48 hours be
remembered?
P386
A 
“C HOBBS (Calvin and Hobbes)”:
Calcium 10%
O(2) 4
Bun >5 increase
Sequestration >6 L
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28
Q 
PANCREATITIS
ACUTE PANCREATITIS
How can the AST versus
LDH values in Ranson’s
criteria be remembered?
P386
A

Alphabetically and numerically: A before
L and 250 before 350
Therefore, AST >250 and LDH >350

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29
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the etiology of
hypocalcemia with
pancreatitis?
P386
A

Fat saponification: fat necrosis binds to

calcium

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30
Q 
PANCREATITIS
ACUTE PANCREATITIS
What complication is
associated with splenic vein
thrombosis?
P386
A 
Gastric varices (treatment with
splenectomy)
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31
Q 
PANCREATITIS
ACUTE PANCREATITIS
Can TPN with lipids be given
to a patient with pancreatitis?
P386
A

Yes, if the patient does not suffer from

hyperlipidemia (triglycerides <300)

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32
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the least common
cause of acute pancreatitis
(and possibly the most
commonly asked cause on
rounds!)
P386
A 
Scorpion bite (found on the island of
Trinidad)
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33
Q

PANCREATITIS
CHRONIC PANCREATITIS
What is it?
P387

A 
Chronic inflammation of the pancreas
region causing destruction of the
parenchyma, fibrosis, and calcification,
resulting in loss of endocrine and
exocrine tissue
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34
Q

PANCREATITIS
CHRONIC PANCREATITIS
What are the subtypes?
P387

A
  1. Chronic calcific pancreatitis

2. Chronic obstructive pancreatitis (5%)

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35
Q

PANCREATITIS
CHRONIC PANCREATITIS
What are the causes?
P387

A 
Alcohol abuse (most common; 70% of cases)
Idiopathic (15%)
Hypercalcemia (hyperparathyroidism)
Hyperlipidemia
Familial (found in families without any
    other risk factors)
Trauma
Iatrogenic
Gallstones
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36
Q

PANCREATITIS
CHRONIC PANCREATITIS
What are the symptoms?
P387

A

Epigastric and/or back pain, weight loss,

steatorrhea

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37
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the associated
signs?
P387
A

Type 1 diabetes mellitus (up to one third)

Steatorrhea (up to one fourth), weight loss

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38
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the signs of
pancreatic exocrine
insufficiency?
P387
A

Steatorrhea (fat malabsorption from lipase
insufficiency—stools float in water)
Malnutrition

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39
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the signs of
pancreatic endocrine
insufficiency?
P387
A

Diabetes (glucose intolerance)

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40
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the common pain
patterns?
P387
A

Unrelenting pain

Recurrent pain

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41
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What is the differential
diagnosis?
P387
A

PUD, biliary tract disease, AAA,

pancreatic cancer, angina

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42
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What percentage of patients
with chronic pancreatitis have
or will develop pancreatic
cancer?
P387
A

≈2%

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43
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the appropriate
lab tests?
P388
A

Amylase/lipase
72-hour fecal fat analysis
Glc tolerance test (IDDM)

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44
Q 
PANCREATITIS
CHRONIC PANCREATITIS
Why may amylase/lipase be
normal in a patient with
chronic pancreatitis?
P388
A

Because of extensive pancreatic tissue

loss (“burned-out pancreas”)

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45
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What radiographic tests
should be performed?
P388
A 
CT—Has greatest sensitivity for gland
    enlargement/atrophy, calcifications,
    masses, pseudocysts
KUB—Calcification in the pancreas
ERCP—Ductal irregularities with
    dilation and stenosis (Chain of Lakes),
    pseudocysts
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46
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What is the medical
treatment?
P388
A 
Discontinuation of alcohol use—can
    reduce attacks, though parenchymal
    damage continues secondary to ductal
    obstruction and fibrosis
Insulin for type 1 diabetes mellitus
Pancreatic enzyme replacement
Narcotics for pain
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47
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What is the surgical
treatment?
P388
A

Puestow—longitudinal pancreaticojejunostomy
(pancreatic duct must be dilated)
Duval—distal pancreaticojejunostomy
Near-total pancreatectomy

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48
Q

PANCREATITIS
CHRONIC PANCREATITIS
What is the Frey procedure?
P388

A

Longitudinal pancreaticojejunostomy with

core resection of the pancreatic head

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49
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What is the indication for
surgical treatment of
chronic pancreatitis?
P388
A

Severe, prolonged/refractory pain

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50
Q 
PANCREATITIS
CHRONIC PANCREATITIS
What are the possible
complications of chronic
pancreatitis?
P388
A 
Insulin dependent diabetes mellitus
Steatorrhea
Malnutrition
Biliary obstruction
Splenic vein thrombosis
Gastric varices
Pancreatic pseudocyst/abscess
Narcotic addiction
Pancreatic ascites/pleural effusion
Splenic artery aneurysm
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51
Q

PANCREATITIS
GALLSTONE PANCREATITIS
What is it?
P389

A

Acute pancreatitis from a gallstone in or
passing through the ampulla of Vater (the
exact mechanism is unknown)

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52
Q

PANCREATITIS
GALLSTONE PANCREATITIS
How is the diagnosis made?
P389

A

Acute pancreatitis and cholelithiasis
and/or choledocholithiasis and no other
cause of pancreatitis (e.g., no history of
alcohol abuse)

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53
Q 
PANCREATITIS
GALLSTONE PANCREATITIS
What radiologic tests should
be performed?
P389
A

U/S to look for gallstones
CT to look at the pancreas, if symptoms
are severe

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54
Q

PANCREATITIS
GALLSTONE PANCREATITIS
What is the treatment?
P389

A

Conservative measures and early
interval cholecystectomy (laparoscopic
cholecystectomy or open cholecystectomy)
and intraoperative cholangiogram (IOC) 3 to
5 days (after pancreatic inflammation resolves)

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55
Q 
PANCREATITIS
GALLSTONE PANCREATITIS
Why should early interval
cholecystectomy be
performed on patients with
gallstone pancreatitis?
P389
A 
Pancreatitis will recur in ≈33% of
patients within 8 weeks (so always
perform early interval cholecystectomy
and IOC in 3 to 5 days when pancreatitis
resolves)
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56
Q

PANCREATITIS
GALLSTONE PANCREATITIS
What is the role of ERCP?
P389

A
  1. Cholangitis

2. Refractory choledocholithiasis

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57
Q

PANCREATITIS
HEMORRHAGIC PANCREATITIS
What is it?
P389

A

Bleeding into the parenchyma and
retroperitoneal structures with extensive
pancreatic necrosis

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58
Q

PANCREATITIS
HEMORRHAGIC PANCREATITIS
What are the signs?
P389

A

Abdominal pain, shock/ARDS, Cullen’s

sign, Grey Turner’s sign, Fox’s sign

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59
Q 
PANCREATITIS
HEMORRHAGIC PANCREATITIS
Define the following terms:
Cullen’s sign
P389
A 
Bluish discoloration of the
periumbilical area from retroperitoneal
hemorrhage tracking around to the
anterior abdominal wall through fascial
planes
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60
Q 
PANCREATITIS
HEMORRHAGIC PANCREATITIS
Define the following terms:
Grey Turner’s sign
P390
A 
Ecchymosis or discoloration of the
flank in patients with retroperitoneal
hemorrhage from dissecting blood from
the retroperitoneum (Think: Grey
TURNer = TURN side to side = flank
[side] hematoma)
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61
Q

PANCREATITIS
HEMORRHAGIC PANCREATITIS
Fox’s sign
P390

A

Ecchymosis of the inguinal ligament
from blood tracking from the
retroperitoneum and collecting at the
inguinal ligament

62
Q 
PANCREATITIS
HEMORRHAGIC PANCREATITIS
What are the significant lab
values?
P390
A

Increased amylase/lipase
Decreased Hct
Decreased calcium levels

63
Q 
PANCREATITIS
HEMORRHAGIC PANCREATITIS
What radiologic test should
be performed?
P390
A

CT scan with IV contrast

64
Q

PANCREATIC ABSCESS
What is it?
P390

A

Infected peripancreatic purulent fluid

collection

65
Q

PANCREATIC ABSCESS
What are the signs/
symptoms?
P390

A

Fever, unresolving pancreatitis, epigastric

mass

66
Q

PANCREATIC ABSCESS
What radiographic tests
should be performed?
P390

A

Abdominal CT with needle aspiration →

send for Gram stain/culture

67
Q

PANCREATIC ABSCESS
What are the associated lab
findings?
P390

A

Positive Gram stain and culture of

bacteria

68
Q

PANCREATIC ABSCESS
Which organisms are found
in pancreatic abscesses?
P390

A 
Gram negative (most common):
    Escherichia coli, Pseudomonas,
    Klebsiella
Gram positive: Staphylococcus aureus,
    Candida
69
Q

PANCREATIC ABSCESS
What is the treatment?
P390

A

Antibiotics and percutaneous drain
placement or operative débridement
and placement of drains

70
Q

PANCREATIC NECROSIS
What is it?
P391

A

Dead pancreatic tissue, usually following

acute pancreatitis

71
Q

PANCREATIC NECROSIS
How is the diagnosis made?
P391

A

Abdominal CT with IV contrast; dead
pancreatic tissue does not take up IV
contrast and is not enhanced on CT scan
(i.e., doesn’t “light up”)

72
Q

PANCREATIC NECROSIS
What is the treatment:
Sterile?
P391

A

Medical management

73
Q

PANCREATIC NECROSIS
What is the treatment:
Suspicious of infection?
P391

A

CT-guided FNA

74
Q

PANCREATIC NECROSIS
What is the treatment:
Toxic, hypotensive?
P391

A

Operative débridement

75
Q

PANCREATIC PSEUDOCYST
What is it?
P391 (picture)

A

Encapsulated collection of pancreatic

fluid

76
Q

PANCREATIC PSEUDOCYST
What makes it a “pseudo”
cyst?
P391

A

Wall is formed by inflammatory fibrosis,

NOT epithelial cell lining

77
Q

PANCREATIC PSEUDOCYST
What is the incidence?
P391

A

≈1 in 10 after alcoholic pancreatitis

78
Q

PANCREATIC PSEUDOCYST
What are the associated risk
factors?
P391

A

Acute pancreatitis < chronic

pancreatitis from alcohol

79
Q 
PANCREATIC PSEUDOCYST
What is the most common
cause of pancreatic
pseudocyst in the United
States?
P391
A

Chronic alcoholic pancreatitis

80
Q

PANCREATIC PSEUDOCYST
What are the symptoms?
P392

A 
Epigastric pain/mass
Emesis
Mild fever
Weight loss
Note: Should be suspected when a
    patient with acute pancreatitis fails to
    resolve pain
81
Q

PANCREATIC PSEUDOCYST
What are the signs?
P392

A

Palpable epigastric mass, tender

epigastrium, ileus

82
Q

PANCREATIC PSEUDOCYST
What lab tests should be
performed?
P392

A

Amylase/lipase
Bilirubin
CBC

83
Q

PANCREATIC PSEUDOCYST
What are the diagnostic
findings?
P392

A 
Lab—High amylase, leukocytosis, high
bilirubin (if there is obstruction)
U/S—Fluid-filled mass
CT—Fluid-filled mass, good for showing
multiple cysts
ERCP—Radiopaque contrast material
fills cyst if there is a communicating
pseudocyst (i.e., pancreatic duct
communicates with pseudocyst)
84
Q

PANCREATIC PSEUDOCYST
What is the differential
diagnosis of a pseudocyst?
P392

A

Cystadenocarcinoma, cystadenoma

85
Q 
PANCREATIC PSEUDOCYST
What are the possible
complications of a
pancreatic pseudocyst?
P392
A

Infection, bleeding into the cyst, fistula,
pancreatic ascites, gastric outlet
obstruction, SBO, biliary obstruction

86
Q

PANCREATIC PSEUDOCYST
What is the treatment?
P392

A

Drainage of the cyst or observation

87
Q 
PANCREATIC PSEUDOCYST
What is the waiting period
before a pseudocyst should
be drained?
P392
A

It takes 6 weeks for pseudocyst walls to
“mature” or become firm enough to hold
sutures and most will resolve in this
period of time if they are going to

88
Q 
PANCREATIC PSEUDOCYST
What percentage of
pseudocysts resolve
spontaneously?
P392
A

≈50%

89
Q 
PANCREATIC PSEUDOCYST
What is the treatment for
pseudocyst with bleeding
into cyst?
P392
A

Angiogram amd embolization

90
Q

PANCREATIC PSEUDOCYST
What is the treatment for
pseudocyst with infection?
P393

A

Percutaneous external drainage/

IV antibiotics

91
Q

PANCREATIC PSEUDOCYST
What size pseudocyst should
be drained?
P393

A 
Most experts say:
    Pseudocysts larger than 5 cm have a
       small chance of resolving and have
       a higher chance of complications
    Calcified cyst wall
    Thick cyst wall
92
Q 
PANCREATIC PSEUDOCYST
What are three treatment
options for pancreatic
pseudocyst?
P393
A
  1. Percutaneous aspiration/drain
  2. Operative drainage
  3. Transpapillary stent via ERCP
    (pseudocyst must communicate with
    pancreatic duct)
93
Q 
PANCREATIC PSEUDOCYST
What are the surgical options for the following
conditions:
Pseudocyst adherent to the stomach?
P393
A

Cystogastrostomy (drain into the

stomach)

94
Q 
PANCREATIC PSEUDOCYST
What are the surgical options for the following
conditions:
Pseudocyst adherent to
the duodenum?
P393
A

Cystoduodenostomy (drain into the

duodenum)

95
Q 
PANCREATIC PSEUDOCYST
What are the surgical options for the following
conditions:
Pseudocyst not adherent
to the stomach or
duodenum?
P393
A

Roux-en-Y cystojejunostomy (drain into

the Roux limb of the jejunum)

96
Q 
PANCREATIC PSEUDOCYST
What are the surgical options for the following
conditions:
Pseudocyst in the tail of
the pancreas?
P393
A

Resection of the pancreatic tail with the

pseudocyst

97
Q 
PANCREATIC PSEUDOCYST
What is an endoscopic
option for drainage of a
pseudocyst?
P393
A

Endoscopic cystogastrostomy

98
Q 
PANCREATIC PSEUDOCYST
What must be done during a
surgical drainage procedure
for a pancreatic pseudocyst?
P393
A

Biopsy of the cyst wall to rule out a cystic

carcinoma (e.g., cystadenocarcinoma)

99
Q 
PANCREATIC PSEUDOCYST
What is the most common
cause of death due to
pancreatic pseudocyst?
P393
A

Massive hemorrhage into the pseudocyst

100
Q

PANCREATIC CARCINOMA
What is it?
P394

A

Adenocarcinoma of the pancreas arising

from duct cells

101
Q

PANCREATIC CARCINOMA
What are the associated risk
factors?
P394

A

Smoking 3X risk, diabetes mellitus, heavy
alcohol use, chronic pancreatitis, diet high
in fried meats, previous gastrectomy

102
Q

PANCREATIC CARCINOMA
What is the male to female
ratio?
P394

A

3:2

103
Q

PANCREATIC CARCINOMA
What is the African American
to white ratio?
P394

A

2:1

104
Q

PANCREATIC CARCINOMA
What is the average age?
P394

A

>60 years

105
Q

PANCREATIC CARCINOMA
What are the different
types?
P394

A

>80% are duct cell adenocarcinomas;
other types include cystadenocarcinoma
and acinar cell carcinoma

106
Q

PANCREATIC CARCINOMA
What percentage arise in
the pancreatic head?
P394

A

66% arise in the pancreatic head; 33%

arise in the body and tail

107
Q 
PANCREATIC CARCINOMA
Why are most pancreatic
cancers in the tail
nonresectable?
P394
A

These tumors grow without symptoms until
it is too late and they have already spread—
head of the pancreas tumors draw attention
earlier because of biliary obstruction

108
Q 
PANCREATIC CARCINOMA
What are the signs/ symptoms of tumors based
on location:
Head of the pancreas?
P394
A

Painless jaundice from obstruction of
common bile duct; weight loss; abdominal
pain; back pain; weakness; pruritus from
bile salts in skin; anorexia; Courvoisier’s
sign; acholic stools; dark urine; diabetes

109
Q 
PANCREATIC CARCINOMA
What are the signs/ symptoms of tumors based
on location:
Body or tail?
P394
A

Weight loss and pain (90%); migratory
thrombophlebitis (10%); jaundice
(<10%); nausea and vomiting; fatigue

110
Q 
PANCREATIC CARCINOMA
What are the most common
symptoms of cancer of the
pancreatic HEAD?
P394
A
  1. Weight loss (90%)
  2. Pain (75%)
  3. Jaundice (70%)
111
Q

PANCREATIC CARCINOMA
What is “Courvoisier’s sign”?
P395

A

Palpable, nontender, distended gallbladder

112
Q 
PANCREATIC CARCINOMA
What percentage of patients
with cancers of the pancreatic
HEAD have Courvoisier’s
sign?
P395
A

33%

113
Q 
PANCREATIC CARCINOMA
What is the classic
presentation of pancreatic
cancer in the head of the
pancreas?
P395
A

Painless jaundice

114
Q 
PANCREATIC CARCINOMA
What metastatic lymph nodes
described classically for
gastric cancer can be found
with metastatic pancreatic
cancer?
P395
A

Virchow’s node; Sister Mary Joseph’s

nodule

115
Q

PANCREATIC CARCINOMA
What are the associated lab
findings?
P395

A 
Increased direct bilirubin and alkaline
    phosphatase (as a result of biliary
    obstruction)
Increased LFTs
Elevated pancreatic tumor markers
116
Q 
PANCREATIC CARCINOMA
Which tumor markers are
associated with pancreatic
cancer?
P395
A

CA-19-9

117
Q

PANCREATIC CARCINOMA
What does CA-19-9 stand for?
P395

A

Carbohydrate Antigen 19-9

118
Q

PANCREATIC CARCINOMA
What diagnostic studies are
performed?
P395

A

Abdominal CT, U/S, cholangiography
(ERCP to rule out choledocholithiasis and
cell brushings), endoscopic U/S with biopsy

119
Q

PANCREATIC CARCINOMA
What are the pancreatic cancer STAGES:
Stage I?
P395

A

Tumor is limited to pancreas, with no

nodes or metastases

120
Q

PANCREATIC CARCINOMA
What are the pancreatic cancer STAGES:
Stage II?
P395

A

Tumor extends into bile duct,
peripancreatic tissues, or duodenum;
there are no nodes or metastases

121
Q

PANCREATIC CARCINOMA
What are the pancreatic cancer STAGES:
Stage III?
P395

A

Same findings as stage II plus positive

nodes or celiac or SMA involvement

122
Q

PANCREATIC CARCINOMA
What are the pancreatic cancer STAGES:
Stage IV?
P396

A

Tumor extends to stomach, colon, spleen,
or major vessels, with any nodal status
and no distant metastases

123
Q

PANCREATIC CARCINOMA
What are the pancreatic cancer STAGES:
Stage IVB?
P396

A 
Distant metastases (any nodal status,
any tumor size) are found
124
Q

PANCREATIC CARCINOMA
What is the treatment based on location:
Head of the pancreas?
P396

A

Whipple procedure

pancreaticoduodenectomy

125
Q

PANCREATIC CARCINOMA
What is the treatment based on location:
Body or tail?
P396

A

Distal resection

126
Q

PANCREATIC CARCINOMA
What factors signify
inoperability?
P396

A 
Vascular encasement (SMA, hepatic artery)
Liver metastasis
Peritoneal implants
Distant lymph node metastasis
    (periaortic/celiac nodes)
Distant metastasis
Malignant ascites
127
Q 
PANCREATIC CARCINOMA
Is portal vein or SMV
involvement an absolute
contraindication for
resection?
P396
A

No—can be resected and reconstructed
with vein interposition graft at some
centers

128
Q 
PANCREATIC CARCINOMA
Should patients undergo
preoperative biliary
drainage (e.g., ERCP)?
P396
A

No (exceptions for symptoms/

preoperative XRT, trials, etc.)

129
Q

PANCREATIC CARCINOMA
Define the Whipple procedure
(pancreaticoduodenectomy).
P396

A 
Cholecystectomy
Truncal vagotomy
Antrectomy
Pancreaticoduodenectomy—removal of
    head of pancreas and duodenum
Choledochojejunostomy—anastomosis of
    common bile duct to jejunum
Pancreaticojejunostomy—anastomosis of
    distal pancreas remnant to jejunum
Gastrojejunostomy—anastomosis of
    stomach to jejunum
130
Q

PANCREATIC CARCINOMA
What is the complication rate
after a Whipple procedure?
P396

A

≈25%

131
Q 
PANCREATIC CARCINOMA
What mortality rate is
associated with a Whipple
procedure?
P397
A

<5% at busy centers

132
Q

PANCREATIC CARCINOMA
What is the “pyloruspreserving
Whipple”?
P397

A

No antrectomy; anastomose duodenum

to jejunum

133
Q

PANCREATIC CARCINOMA
What are the possible
post-Whipple complications?
P397

A

Delayed gastric emptying (if antrectomy
is performed); anastomotic leak (from
the bile duct or pancreatic anastomosis),
causing pancreatic/biliary fistula; wound
infection; postgastrectomy syndromes;
sepsis; pancreatitis

134
Q 
PANCREATIC CARCINOMA
Why must the duodenum be
removed if the head of the
pancreas is resected?
P397
A

They share the same blood supply

135
Q

PANCREATIC CARCINOMA
What is the postoperative
adjuvant therapy?
P397

A

Chemotherapy +/– XRT

136
Q 
PANCREATIC CARCINOMA
What is the palliative
treatment if the tumor is
inoperable and biliary
obstruction is present?
P397
A

PTC or ERCP and placement of stent

across obstruction

137
Q

PANCREATIC CARCINOMA
What is the prognosis at
1 year after diagnosis?
P397

A

Dismal; 90% of patients die within 1 year

of diagnosis

138
Q

PANCREATIC CARCINOMA
What is the survival rate at
5 years after resection?
P397

A

20%

139
Q

MISCELLANEOUS
What is an annular
pancreas?
P397

A

Pancreas encircling the duodenum; if
obstruction is present, bypass, do not
resect

140
Q

MISCELLANEOUS
What is pancreatic divisum?
P397

A 
Failure of the two pancreatic ducts to
fuse; the normally small duct (Small 
Santorini) of Santorini acts as the main
duct in pancreatic divisum (Think: the
two pancreatic ducts are Divided 
Divisum)
141
Q

MISCELLANEOUS
What is heterotopic
pancreatic tissue?
P398

A

Heterotopic pancreatic tissue usually
found in the stomach, intestine,
duodenum

142
Q

MISCELLANEOUS
What is a Puestow
procedure?
P398

A

Longitudinal filleting of the pancreas/
pancreatic duct with a side-to-side
anastomosis with the small bowel

143
Q 
MISCELLANEOUS
What medication decreases
output from a pancreatic
fistula?
P398
A

Somatostatin (GI-inhibitory hormone)

144
Q

MISCELLANEOUS
Which has a longer half-life:
amylase or lipase?
P398

A

Lipase; therefore, amylase may be normal

and lipase will remain elevated longer

145
Q

MISCELLANEOUS
What is the WDHA syndrome?
P398

A 
Pancreatic VIPoma (Vasoactive Intestinal
    Polypeptide tumor)
Also known as Verner-Morrison syndrome
Tumor secretes VIP, which causes:
    Watery
    Diarrhea
    Hypokalemia
    Achlorhydria (inhibits gastric acid
       secretion)
146
Q

MISCELLANEOUS
What is the Whipple triad of
pancreatic insulinoma?
P398

A
  1. Hypoglycemia (Glc <50)
  2. Symptoms of hypoglycemia: mental
    status changes/vasomotor instability
  3. Relief of symptoms with
    administration of glucose
147
Q

MISCELLANEOUS
What is the most common
islet cell tumor?
P398

A

Insulinoma

148
Q 
MISCELLANEOUS
What pancreatic tumor is
associated with gallstone
formation?
P398
A

Somatostatinoma (inhibits gallbladder

contraction)

149
Q 
MISCELLANEOUS
What is the triad found with
pancreatic somatostatinoma
tumor?
P398
A
  1. Gallstones
  2. Diabetes
  3. Steatorrhea
150
Q 
MISCELLANEOUS
What are the two classic
findings with pancreatic
glucagonoma tumors?
P398
A
  1. Diabetes
  2. Dermatitis/rash (necrotizing migratory
    erythema)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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