General Surgery: Pancreas & Spleen

Front 1

Whipple's Triad

Back 1

1) Symptomatic HYPOglycemia during fasting
2) Serum glucose less than 50mg/dl
3) Relief of symptoms with glucose administration
**Associated with insulinomas

Front 2

Presentation of Glucagonoma

Back 2

1) Severe dermatitis - Necrolytic Migratory Erythema
2) Mild diabetes

**Pts often first treated by dermatologist

Front 3

Failure of normal clockwise rotation of the ventral pouch results in...

Back 3

Annular pancreas → Double bubble sign, bilious vomiting

Front 4

The main pancreatic duct

Back 4

Duct of Wirsung

Front 5

Pancreatic Divisum

Back 5

Occurs when the ducts do not fuse → unfused proximal dorsal is accessory duct of Sanrorini

Front 6

Contents of pancreatic acincar cells

Back 6

Digestive enzymes (i.e., amylase, lipase, phospholipase A2, trypsin, elastase)

Front 7

Function of pancreatic ductal cells

Back 7

Secrete electrolyte solution high in bicarbonate

Front 8

Products of pancreatic endocrine cells

Back 8

Alpha cells – glucagon
Beta cells – insulin
Delta cells – somatostatin
F cells – pancreatic polypeptide
Islets – VIP, serotonin, etc

Front 9

2 MCC of acute pancreatitis

Back 9

1) Alcohol abuse
2) Gallstones
*Others: ERCP, trauma, HLD, hypercalcemia, Ascaris lumbricoides, medications)

Front 10

Medications known to cause pancreatitis

Back 10

1) Azathioprine
2) Furosemide
3) Glucocorticoids
4) Cimetidine

Front 11

Signs & Symptoms of acute pancreatitis

Back 11

1) Abdominal pain
2) Nausea / Vomiting
3) Anorexia

Front 12

Signs of hemorrhagic pancreatitis

Back 12

1) Grey Turner sign – retroperitoneal hemorrhage of the flank
2) Cullen sign – hemorrhage around the umbilicus
3) Fox sign – hemorrhage around the inguinal ligament

Front 13

Ranson’s Criteria

Back 13

Prognostic indicator in pancreatitis
Patients with more than 3 Ranson’s criteria are at high risk of complicated pancreatitis
Mortality sharply rises with more than 3 Ranson’s criteria

Front 14

Parameters of Ranson’s criteria

Back 14

1) Age
2) WBCs
3) LDH
4) Aspartate aminotransferase (AST)
5) Glucose

*Clinical prediction rule for predicting the severity of acute pancreatitis

Front 15

Treatment of acute pancreatitis

Back 15

*Nonoperative, unless complications develop (i.e., necrosis or infection)
1) Aggressive fluid resuscitation
2) Intubation and mechanical ventilation → if pulmonary dysfunction occurs
3) Nasogastric decompression
4) Nutritional support (usually TPN)
5) ERCP with endoscopic sphincterectomy → if gallstone pancreatitis or biliary obstruction
6) Prophylactic antibiotics (i.e., imipenem – cilastin)

Front 16

Gallstone pancreatitis

Back 16

Pancreatitis in the setting of cholelithiasis

Front 17

Intraoperative cholangiography (IOC)

Back 17

Done during laproscopic cholecystectomy to confirm the absence of common bile duct obstruction

Front 18

Pancreatic abscesses

Back 18

Well-cirumscribed, polymicrobial abscesses
Should be drained percutaneously (operatively if attempts fail or there is necrosis)

Front 19

Why are patients with sterile necrotizing pancreatitis treated nonoperatively for several weeks?

Back 19

To better delineate viable and nonviable pancreatic tissue
*Imipenem-cilastatin decreases the infection rate in these patients

Front 20

Treatment of infected necrotizing pancreatitis

Back 20

Necrosectomy (debridement of necrotic tissue) and operative drainage
IV antibiotics once organism sensitivity is known

Front 21

Chronic pancreatitis

Back 21

Irreversible parenchymal fibrosis

Front 22

Presentation of chronic pancreatitis

Back 22

1) Recurrent acute pancreatitis
2) Chronic abdominal pain
3) Anorexia and weight loss
4) Malabsorption and steatorrhea
5) DIABETES

Front 23

MCC of chronic pancreatitis in US

Back 23

Alcohol abuse

Front 24

CT findings of chronic pancreatitis

Back 24

1) Atrophied gland
2) Dilated pancreatic duct
3) CALCIFICATIONS

Front 25

Relative indications for surgery of chronic pancreatitis

Back 25

1) Refractory, disabling pain
2) Concomitant malignancy
3) Biliary obstruction
4) Complications of pseudocysts

Front 26

Operative techniques for chronic pancreatitis

Back 26

1) Drainage procedures – Duval, Peustow, Frey
2) Resection procedures – Distal pancreatectomy, Whipple procedure, Total pancreatectomy
3) Splanchnicectomy – celiac ganglion ablation for pain control

Front 27

Pancreatic Pseudocyst

Back 27

Non-epithelialized, encapsulated pancreatic fluid collection
*Usually seen several weeks after bouts of acute pancreatitis

Front 28

Symptoms of pseudocysts

Back 28

1) Pain
2) Fever
3) Weight loss
4) Bowel obstruction

Front 29

Diagnosis of pseudocyst

Back 29

CT scan

Front 30

Size of pseudocysts that resolve spontaneously

Back 30

<5 cm

Front 31

Size of pseudocyst that requires drainage

Back 31

>6 cm

Front 32

Symptoms of pancreatic insufficiency

Back 32

Malabsorption and steatorrhea

Front 33

Diagnosis of pancreatic insufficiency

Back 33

1) Fecal fat testing
2) Secretin or CCK test

Front 34

Treatment of pancreatic insufficiency

Back 34

HIGH CARB, HIGH PROTEIN diet with pancreatic enzyme replacement

Front 35

% of pancreatic carcinoma of ductal cell origin

Back 35

90%

Front 36

% of pancreatic adenocarcinomas arising in the head of the pancreas

Back 36

67%

Front 37

Sites of metastasis of pancreatic adenocarcinomas

Back 37

1) Lymph nodes
2) Liver
3) Peritoneal surfaces

Front 38

Five-year survival rates of pancreatic cancer in US

Back 38

0 – 10%

Front 39

Mucinous Cystadenoma

Back 39

Often contains malignant cells
60% 5-year survival after surgery

Front 40

Tumor-Node-Metastasis (TNM) Staging of Pancreatic Cancer

Back 40

Stage 1 – Limited or no extension beyond pancreas
Stage 2 – Extension incompatible with resection
Stage 3 – Regional nodal disease
Stage 4 – Distant metastasis

Front 41

Presentation of pancreatic cancer

Back 41

1) Weight loss
2) Jaundice
3) Abdominal pain
4) Nausea and anorexia
5) Hepatomegaly
6) Vomiting due to duodenal obstruction
*ELEVATED DIRECT BILIRUBIN, alk phos, and amylase

Front 42

Contraindications to curative resection of pancreatic cancer

Back 42

1) Liver metastasis
2) Peritoneal metastases
3) Nodal metastases beyond zone of resection (e.g., periaortic)
4) Tumor invasion of SMA

Front 43

Pre- or postoperative adjuvant chemoradiotherapy for pancreatic cancer

Back 43

5-fluorouracil and external beam radiation

Front 44

Complications of pancreaticoduodenectomy

Back 44

1) Delayed gastric emptying
2) Pancreatic fistula (10 – 20%)
3) Infection
4) Bile leak
5) Pancreatitis

Front 45

MC endocrine tumor of the pancreas

Back 45

Insulinoma
*90% are benign

Front 46

Symptoms of insulinoma

Back 46

1) Catecholamine surge-related symptoms: Palpitations, diaphoresis, tachycardia
2) Whipple’s Triad

Front 47

Whipple’s Triad

Back 47

1) Symptomatic HYPOglycemia during fasting
2) Serum glucose less than 50mg/dl
3) Relief of symptoms with glucose administration
**Associated with insulinomas

Front 48

Diagnosis of insulinoma

Back 48

Concomitant measurement of insulin and glucose levels during fasting period of 12-18 hours
*Measuring proinsulin or C-peptide excludes surreptitious insulin

Front 49

Presentation of Gastrinomas

Back 49

1) Abdominal pain
2) Intractable peptic ulcer disease (PUD)

Front 50

Chromosomal abnormality associated with Gastrinomas

Back 50

HER-2/neu proto-onogene amplification

Front 51

Diagnosis of gastrinoma

Back 51

Secretin test

Front 52

% of gastrinomas that are malignant

Back 52

50%

Front 53

Presentation of Vasoactive Intestinal Peptide Tumors (VIPomas)

Back 53

WDHA syndrome – Watery Diarrhea, Hypokalemia, Achlorhydria
*Aka Verner-Morrison syndrome

Front 54

% of VIPomas with metastatic disease to LNs of liver

Back 54

50%

Front 55

Presentation of Glucagonomas

Back 55

1) Severe dermatitis → Necrolytic Migratory Erythema
2) Diabetes
3) Stomatitis
4) Weight loss

Front 56

Necrolytic Migratory Erythema

Back 56

Red, blistering rash that spreads across the skin, particularly the lower abdomen, buttocks, perineum, and groin

Front 57

Treatment of all pancreatic endocrine tumors

Back 57

Resection, unless there’s metastatic disease

Front 58

Resection of insulinomas

Back 58

Enucleation

Front 59

Resection of VIPomas and glucagonomas

Back 59

Distal pancreatectomy (tail of pancreas)
*Octreotide may help ameliorate symptoms

Front 60

Incurable pancreatic endocrine tumor

Back 60

Somatostatinoma

Front 61

MC location of accessory spleens

Back 61

Splenic hilum

Front 62

Primary indication for splenectomy

Back 62

Splenic trauma

Front 63

Indications for surgical intervention after splenic trauma

Back 63

1) Hemodynamic instability
2) Arterial “blushing” or pooling of contrast on abdominal CT
3) >2 units PRBC

Front 64

Autosomal dominant disease treated with splenectomy

Back 64

Hereditary Spherocytosis (HS)
*RBC membranes are deformed; RBCs sequestered and destroyed by spleen

Front 65

At which age should splenectomy be performed for Hereditary spherocytosis?

Back 65

After age 4

Front 66

Clinical manifestations of ITP

Back 66

Thrombocytopenia → Purpura, Ecchymoses, Bleeding from mucosal surfaces, Hematuria

Front 67

Treatment of ITP

Back 67

1) Corticosteroids and IV gamma globulin
2) Vinca alkaloids, cyclophosphamide, danazol, plasmapheresis
3) Splenectomy
4) Platelet transfusions POST-OP

Front 68

Pentad of TTP

Back 68

1) Fever
2) Purpura
3) Hemolytic anemia
4) Hematuria
5) Neurologic changes

Front 69

Treatment of TTP

Back 69

1) Plasmapheresis
2) Splenectomy (refractory disease)

Front 70

MCC of splenic abscess

Back 70

Hematogenous spread of bacterial infection (endocarditis and IV drug abuse)

Front 71

Hypersplenism

Back 71

Splenomegaly, decreased dysfunctional circulating platelets, & responsive BM hypertrophy

Front 72

Mortality of Overwhelming Postsplenectomy Infection (OPSI)

Back 72

80 – 90%

Front 73

Causes of OPSI

Back 73

Encapsulated organisms (Pneumococcus, Meningococcus, Haemophilus influenza B)

Front 74

When should vaccinations be given before splenectomy?

Back 74

10 days before surgery