First Aid For Surgery - Pancreas

Front 1

Pancreas divisum

Back 1

Due to a failure of the ventral and dorsal ducts to fuse, the majority of pancreatic drainage is accomplished via the accessory papilla and duct of Santorini. This is the most common congenital anomaly of the pancreas (5% of population) but is usually asymptomatic. Rarely, however, chronic pain and recurrent pancreatitis may result from inadequate drainage.

Front 2

Annular pancreas

Back 2

Usually presents in infancy with duodenal obstruction (postprandial vomiting). Caused by malrotation of the ventral pancreas leading to a ring of pancreatic tissue around the second portion of the duodenum. Pancreatitis and peptic ulcers may also result.

Front 3

Heterotopic pancreas

Back 3

Pancreatic tissue in an abnormal location such as the stomach, duodenum, or Meckel's diverticulum

Front 4

Why does resection of the head of the pancreas require resection of duodenum?

Back 4

Because they have a shared blood supple, the gastroduodenal artery

Front 5

Pancreatic Ducts

Back 5

The duct of Wirsung is the main duct; runs entire length of pancreas. It joins the common bile duct and empties into the second part of the duodenum at the ampulla of Vater. The duct of Santorini (small duct) is an accessory duct often joining the duodenum more proximally than the ampulla of Vater.

Front 6

Blood supply of pancreas

Back 6

HEAD: anterior and posterior superior pancreaticoduodenal arteries - branches of gastroduodenal artery; anterior and posterior inferior pancreaticoduodenal arteries - branches of SMA. NECK, BODY, and TAIL: splenic artery and branches (dorsal pancreatic artery)

Front 7

Exocrine Physiology of Pancreas

Back 7

Secretion of 1-2L/day of clear, isomotic alkaline fluid containing digestive enzymes. The exocrine pancreas makes up 85% of pancreatic volume; the endocrine pancreas accounts for only 2%, with the rest composed of extracellular matrix and vessels or ducts.

Front 8

What kind of block can be done for pain control in pancreatic disease?

Back 8

Celiac plexus block

Front 9

Secretin

Back 9

Most potent endogenous stimulant of bicarbonate secretion

Front 10

Endocrine function of pancreas

Back 10

Islets of Langerhans make up 2% of pancreas by weight; (1) Insulin: from beta cells in islets of Langerhans (glucose absorption and storage); (2) Glucagon: From islet alpha cells (glycogenolysis and release of glucose); (3) Somatostatin: From islet delta cells (generally causes inhibitory function of GI tract)

Front 11

Uses of Somatostatin

Back 11

(1) Treat symptoms of neuroendocrine tumors (islet cell, carcinoid, gastrinoma, VIPoma, and acromegaly); (2) Convert high-output fistulae to low-output fistula (because of its antimotility and antisecretory effects)

Front 12

Acute Pancreatitis

Back 12

Inflammation of pancreas due to parenchymal autodigestion by proteolytic enzymes; CAUSES: (1) Alcohol abuse (40-50%); (2) Gallstones (40%)

Front 13

Less common causes of acute pancreatitis

Back 13

(1) Hyperlipidemia; (2) Hypercalcemia - 2/2 hyperPTH; (3) Trauma; (4) Postop and post-ERCP; (5) Pancreatic duct obstruction (tumor, pancreatic divisum); (6) Vasculitis; (7) Scorpion venom; (8) Viral imfections; (9) Drugs (azathioprine, INH, cimetidine)

Front 14

S&S of acute pancreatitis

Back 14

(1) Severe, constant epigastric pain radiating to the back. Pain may be improved by sitting forward or standing; (2) Nausea/vomiting; (3) Low-grade fever, trachypnea, tachycardia, upper abdominal tenderness with guarding but no rebound. Bowel sounds may be absent due to adynamic ileus. Signs of hypovolemic shock may also be present due to massive retroperitoneal fluid sequestration and dehydration

Front 15

Cullen's sign

Back 15

Bluish discoloration of the periumbilicus

Front 16

Grey-Turner's sign

Back 16

Bluish discoloration of the flank

Front 17

Fox's sign

Back 17

Bluish discoloration of the inguinal ligament

Front 18

Cullen's sign, Grey-Turner's sign, and Fox's sign

Back 18

Indicative of severe, hemorrhagic pancreatitis

Front 19

MEDVIPS: drug-induced pancreatitis

Back 19

(1) Methyldopa/Metronidazole; (2) Estrogen; (3) Didanosine; (4) Valproate; (5) INH; (6) Pentamidine; (7) Sulfonamides

Front 20

Elevated lipase

Back 20

Only found in gastric and intestinal mucosa and liver, in addition to pancreas, so is more specific for pancreatitis than amylase

Front 21

Elevated amylase

Back 21

Also found in salivary, glands, small bowel, ovaries, testes, and skeletal muscle, so is not specific marker for pancreatitis

Front 22

Ranson's criteria: on admission

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(1) Age >55; (2) BGL >200; (3) AST > 250; (4) LDH > 350; (5) WBC >16k

Front 23

Ranson's criteria: after 48 hours

Back 23

(1) Base deficit > 4; (2) Increase in BUN >5; (3) Fluid deficit >6L; (4) Calcium <8; (5) Drop in Hct >10%; (6) PO2 <60mmHg

Front 24

Diagnostic choice for acute pancreatitis

Back 24

CT scan; 90% sensitive, 100% specific. Demonstrates pseudocysts, phlegmon, abscesses, or pancreatic necrosis

Front 25

Causes of elevated amylase levels

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High amylase levels are seen in intestinal disease, perforated ulcer, ruptured ectopic pregnancy, salpingitis, salivary gland disorders, renal failure, and diabetic ketoacidosis

Front 26

Treatment of acute pancreatitis

Back 26

(1) Aggressive hydration w/ electrolyte monitoring to maintain adequate intravascular volume; (2) NG tube if vomiting; (3) Antibiotics if infection identified; (4) NPO with nutritional support via post-pyloric feeding or TPN; (5) Avoid morphine - possible spasm of sphincter of Oddi; (6) Surgery indicated for either infected necrosis of panceras or correction of associated viliary tract disease

Front 27

Chronic pancreatitis

Back 27

Chronic inflammation or recurrent acute pancreatitis causes irreversible parenchymal fibrosis, destruction, and calcification, leading to loss of endocrine and exocrine function

Front 28

Causes of chronic pancreatitis

Back 28

(1) EtOH abuse [70%]; (2) Idiopathic [20%]; (3) Other [10%] - hyperPTH, HLD, congenital pancreatic abnormalities, hereditary, obstruction

Front 29

S&S of chronic pancreatitis

Back 29

(1) Recurrent or constant epigastric/back pain; (2) malabsorption/malnutrition [exocrine dysfunction]; (3) Steatorrhea [exocrine dysfunction] - fat soluble vitamin difficiency; (4) T1DM; (5) Polyuria

Front 30

Diagnosis of chronic pancreatitis

Back 30

(1) Pancreatic calcifications; (2) Chain-of-lakes pattern on ERCP with ductal irregularities/dilatation/stenosis; (3) Pseudocysts with gland enlargement/atrophy, masses

Front 31

Pseudocysts

Back 31

Nonepithelialized, encapsulated pancreatic fluid collections. Up to 30% of pseudocysts resolve on their own with bowel rest (TPN and NPO). If after 6 weeks they have not resolved and are > 6 cm in size, internal drainage of the mature cyst is indicated via cyst gastrostomy or Roux-en-Y cyst jejunostomy.

Front 32

Pancreatic adenocarcinoma

Back 32

(1) Originate in the exocrine pancreas (ductal cells); (2) two-thirds occur in the head of the pancreas. Risk factors: (1) male; (2) african american; (3) tobacco user

Front 33

Courvoisier’s sign

Back 33

Jaundice with a palpable gallbladder that is nontender

Front 34

S&S of pancreatic adenocarcinoma

Back 34

(1) Weight loss; (2) Jaundice; (3) Posterior epigastric pain radiating to the back; (4) Migratory thrombophlebitis - Trousseau's syndrome seen especially in tumors of the body or tail

Front 35

Diagnosis of pancreatic adenocarcinoma

Back 35

(1) Elevated CEA or CA19-9; (2) CT scan is study of choice; (3) PTC and ERCP useful in periampullary lesions

Front 36

Treatment of pancreatic adenocarcinoma

Back 36

(1) Tumors of head: Whipple procedure [pancreaticoduodenectomy]; (2) Tumors of body/tail: distal near-total pancreatectomy; (3) If unresectable 2/2 liver or peritoneal mets, nodal mets beyond zone of resection, or tumor invasion of SMA, palliative procedures are considered

Front 37

Whipple procedure

Back 37

"Removal of gallbladder, common bile duct (CBD), antrum of stomach, duodenum, proximal jejunum and head of pancreas (en bloc); Reconstruction with pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy.

Front 38

Prognosis for pancreatic adenocarcinoma

Back 38

The median survival for patients who undergo successful resection is approximately 12–19 months, with a 5-year survival rate of 15–20%.

Front 39

Pancreatic cystadenocarcinoma

Back 39

(1) Commonly seen in females age 40-60yo; (2) occurs in body/tail; (3) accounts for <2% of all pancreatic exocrine tumors; (4) prognosis is better than adenocarcinoma; (5) TREATMENT: distal/total pancreatectomy

Front 40

Pancreatic cystadenoma

Back 40

(1) Seen in older/middle-aged women - two types: [a] serous = benign; [b] mucinous = generally benign, but potential to be malignant; (2) TREATMENT: surgical resection

Front 41

Insulinoma

Back 41

Beta cell neoplasm with overproduction of insulin. (1) MC islet cell tumor; (2) 90% are benign; (3) Most are solitary lesions with even distribution in head/body/tail of pancreas; (3) If associated with MEN I [<10% of all cases], then multiple insulinomas may be present

Front 42

Diagnosis of insulinoma

Back 42

(1) Fasting serum insulin level >10uU/mL [nl is <6uU/ml]; (2) Fasting insulin-to-glucose ratio >0.3; (3) Proinsulin or C-peptide levels should be measured to rule out surreptitious exogenous insulin administration

Front 43

Treatment for insulinoma

Back 43

(1) Surgical enucleation/resection is usually curative; (2) Diazoxide can improve hypoglycemic symptoms by inhibiting pancreatic insulin release

Front 44

What is Whipple's triad?

Back 44

Characterizes insulinoma: (1) Symptoms of hypoglycemia with fasting; (2) Fasting glucose <50mg/dL; (3) Relief of symptoms after eating

Front 45

Gastrinoma

Back 45

Neoplasm associated with overproduction of gastrin; aka Zollinger-Ellison syndrome

Front 46

Epidemiology of gastrinomas

Back 46

(1) Second most common islet cell tumor; (2) 90% are located in the gastrinoma triangle bordered by the junction of the second and third part of duodenum, the cystic duct, and the SMA under the neck of the pancreas. (3) 25% of gastrinomas are associated with MEN-1

Front 47

Signs and Symptoms of gastrinomas

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(1) Signs mimicking peptic ulcer disease; (2) Epigastric pain most prominent after eating; (3) Profuse, watery diarrhea

Front 48

Diagnosis of gastrinoma

Back 48

(1) Fasting serum gastrin level >500pg/mL [nl: <100pg/mL]; (2) Secretin stimulation test will cause paradoxical increase in gastrin in patients with Zollinger-Ellison syndrome; (3) Ulcers in unusual locations [i.e, 3rd part of duodenum or jejunum] is highly suggestive; (4) Octreotide scan to localize tumor

Front 49

Treatment of gastrinoma

Back 49

(1) PPI; (2) Surgical resection; (3) Chemotherapy

Front 50

VIPoma

Back 50

Overproduction of VIP; aka Verner-Morrison Syndrome or WDHA syndrome (Watery Diarrhea, Hypokalemia, Achlorhydria); Most are malignant and majority have metastasized to lymph nodes and the liver at time of diagnosis; 10% are extrapancreatic

Front 51

S&S of VIPoma

Back 51

(1) Severe, watery diarrhea; (2) Signs of hypokalemia - palpitations/arrhythymias, muscle fasciculations/tetany, paresthesias

Front 52

Treatment of VIPoma

Back 52

Fasting serum VIP level > 800 pg/mL (normal: < 200 pg/mL) with exclusion of other causes of diarrhea.

Front 53

Glucagonoma

Back 53

Rare alpha cell neoplasm resulting in overproduction of glucagon

Front 54

S&S of Glucagonoma

Back 54

(1) Mild diabetes [hyperglycemia]; (2) Anemia; (3) Mucositis; (4) Weight loss due to low amino acid levels; (5) Severe dermatitis - often a red psoriatic like rash with serpiginous borders over trunk and lower limbs

Front 55

Skin condition associated with glucagonoma

Back 55

Necrolytic migratory erythema is the skin condition associated with glucagonoma.

Front 56

Diagnosis of glucagonoma

Back 56

(1) Fasting serum level >1000pg/ml; (2) Skin biopsy to confirm presence of necrolytic migratory erythema