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132 Cards in this Set
- Front
- Back
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common bile forms in which pancreatic bud
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ventral
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which pancreatic bud migrates to fuse with the other
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ventral
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what does ventral pancreatic bud form in adult
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uncinate process and inferior aspect of pancreatic head
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what does dorsal bud form
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superior aspect of head, body and tail
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from which pancreatic bud does small accessory pancreatic duct of santorini form
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from dorsal bud
main duct of Wirsung forms from entire ventral pancreatic duct, which fuses with the distal pancreatic duct of dursal bud |
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what abnormality arises if ventral pancreatic bud migrates posteriorly AND anteriorly to fuse with dorsal pancreatic bud
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annular pancreas
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name parts of pancreas
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head, neck, body, tail
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on what structure does pancreatic head rest
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IVC, renal vessels
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on what structure does uncinate process rest
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aorta
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what likes behind pancreatic neck
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SMA
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how is blood supplied to head of the pancreas from celiac axis
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gastroduodenal artery branches into the SUPERIOR post and ant pancreaticoduodenal
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how is blood supplied to the pancreatic head from the celiac axis
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SMA branches into INFERIOR posterion and anterior branches of pancreaticoduodenal
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which arteries supply the body and tail of the pancreas
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Splenic to dorsal pancreatic to
joining branch from SMA to forming inferior pancreatic also multiple branches from splenic + inferior pancreatic supply tail |
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into which veins do pancreatic veins drain
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splenic vein into portal vein
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which nodal groups drain pancreas
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Head - subpyloric, portal, mesocolic, aortocaval
body and tail - retroperitoneal in splenic hilum to mesocolic, mesenteric, aortocaval |
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what do islet cells make
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insulin (beta)
glucagon (alpha) somatostatin (delta) |
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type of cells in exocrine pancreas
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acinar
centroacinar intercalated ductal ductal |
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pH of pancreatic secretions
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8
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enzymes from pancreas
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peptidases
trypsin chymotrypsin elastase kallikrein carboxypeptidase A and B |
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what stimulates exocrine secretion
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bicarb: vagal efferents and secretin
enzymes: cholecystokinina nd acetylcholine |
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what GI hormone is structurally similar to CCK
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gastrin
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what activates peptidases
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enterokinase
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what portion of acute pancreatitis is idiopathic
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10
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metabolic causes of pancreatitis
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hyperlipidemia
hypercalcemia |
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other surgical diseases causing pancreatitis
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perforating peptic ulcer
Crohn disease of duodenum |
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diagnositc GI test that can cause pancreatitits
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ERCP
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arachnid bite that can cause pancreatitis
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scorpion
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worms that can cause obstructive pancreatitis
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ascaris
clonorchis sinensis |
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tests for diagnosing acute pancreatitis
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- amylase in serum, peritoneal fluid and urinary amylase
serum lipase, WBC, T bilirubin, LFT, ab xray, US, CT |
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what is a sentinel loop?
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adynamic, dilated loop of small bowel associated with a focal area of inflammation initially described in relation to pancreatitis-associated ileus
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when can patients with pancreatitis be fed?
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NOT early -- this causes reactivation
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should antibiotics be used in the treatment of acute pancreatitis
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necrotizing pancreatitis
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which antibiotics to use for necrotizing pancreatitis
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imipenem/cilastatin
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how many patients with acute pancreatitis need surgery
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10%
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does early use of minidose heparin prevent intravascular thrombosis during acute pancreatitis or alter the course of the pancreatitis
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probably not
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does peritoneal lavage alter clinical course of severe or necrotizing pancreatitis
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controversial
recent study showed that patients with five or more of Ranson's criterial had reduced sepsis/death |
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how should patients with severe pancreatitis be nourished
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TPN
but when peristalsis returns, nasoenteric or enteric feeding tubes may offer better nutrition without worsening pancreatities (beyond ligament of Treitz) |
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what causes gallstone pancreatitis
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- bile reflux into pancreas
- reflux of duodenal succus from a loose sphincter of Oddi - stone blockage of pancreatic duct |
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if surgically untreated, what percentage of patients with gallstone pancreatitis will have a recurrence within 8 weeks
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33%
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what other causes of pancreatitis must be ruled out in a patient with gallstones?
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alcohol abuse
medications hyperlipidemia hypercalcemia |
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appropriate treatment of mild gallstone pancreatitis
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laparoscopic chole
intraoperative cholangiogram on HD 3-5 IF pancreatitis resolves |
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definition of chronic pancreatitis
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recurrent bouts of acute
chronic pain exocrine and endocrine dysfunction irreversible parenchymal fibrosis |
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signs and symptoms of chronic pancreatitis
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abdominal pain
diabetes steatorrhea pancreatic calcification |
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anatomic pancreatic changes in chronic pancreatitis
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sclerosis with duct stenosis and dilatation
loss of acinar tissue |
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most common cause of chronic pancreatitis
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alcohol abuse
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CT findings with chronic pancreatitis
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dilated pancreatic duct
calcifications parenchymal atrophy (psyeudocytstt) |
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finding associated with chronic pancreatitis on CT
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chain of lakes
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most sensitive test for chronic pancreatitis
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ERCP
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factors indicating surgery for chronic pancreatitis
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refractory, disabling pain
frequent recurrent acute exacerbations possible malignancy GI or biliary obstruction splenic vein thrombosis with portal HTN |
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how are patients with chronic pancreatitis managed nonoperatively
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tx of pain
pancreatic exocrine replacement insulin therapy |
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what are pseudocysts
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pancreatic juice enclosed by a false capsule of fibrous or granulation tissue that arises as a consequence of pancreatitis or trauma
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percentage of patients with acute pancreatitis form pseudocysts
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20%
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what percent of patients with chronic pancreatitis develop pseudocysts
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20 to 40
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what percentage of people with acute develop persistent pseudocysts
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4
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most common cause of pancreatic pseudocysts in kids
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trauma
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signs/symptoms of pancreatic pseudocysts
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persistent pain
persistent N/V weight loss abdominal mass persistent amylase elevation jaundice distention |
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percent of patients with pseudocysts that have persistent abdominal pain
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more than 90
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percent of patietns with pseudocysts that have abdominal mass
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up to 50
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appropriate treatment of an infected pseudocyst
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external drainage
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average time for 4cm pseudocyst to resolve
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2-3 mos
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complications associated with pseudocyst
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hemorrhage
infection leak gastric otulet obstruction bile duct obstruction |
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treatment of an unstable patient with hemorrhage into a pseudocyst
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surgery
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appropriate treatment of a stable patietn with hemorrhage into a pseudocyst
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arteriorgram and possible embolization
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what portion of pancreas gets carcinoma
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exocrine
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% of pop with pancreatic divisum
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6-10
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risk factors for pancreatic carcinoma
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advanced age adn smoking
diabetes mellitus (esp in women) heavy alcohol use exposure to benzidine and naphthylamine partial gastrectomy |
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most common type of pancreatic carcinoma
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90% adeno
others are cystadenoma and acinar |
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most common location of pancreatic carcinoma
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2/3 in head
1/3 in body/tail |
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signs/symptoms of pancreatic carcinoma
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pain
weight loss nausea anorexia painless jaundice |
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tumor markers for pancreatic cancer
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Ca19-9
Ca50 |
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diagnositc test for pancreatic carcinoma
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CT
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diagnositc tests for patients with jaundice
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ERCP
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why is tissue diagnosis important for pancreatic carcinoma
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DD includes:
lymphoma sarcoidosis TB choledocholithiasis pancreatitis |
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what is disadvantage of FNA
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seeding
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when should tissue diagnosis of potentially resectable tumors be performed
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in OR (FNA)
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which patients are the best candidates for percutaneous needle biopsy of a periampullary tumor
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nonoperative candidates
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which primary tumor location is associated with the most major vessel tumor involvement
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head of pancreas
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what are main sites of mets
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liver
peritoneum |
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what contraindicates resection in pancreatic cancer
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mets, even just to local nodes
tumor involvement o fSMA, SMV |
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goal of pacreas surgery for carcinoma
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cure
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Kocher maneuver
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to determine if SMA is involved in pancreatic carcinoma
hand needs to be able to identify a normal tissue plane between pancreas and SMA |
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what intraoperative maneuvers simplify visualization of the portal vein
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cholecystectomy
transection of common hepatic duct |
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what is appropriate treatment of distal pancreatic cancer
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distal pancreatectomy with splenectomy
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what is appropriate treatment of cancer of head
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Whipple, if resectable
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what is treatmetn option of unresectable pancreatic cancer
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radiation AND 5 fluoro
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what is an option for postop adjuvant treatment
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5 fluoro and radiation
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is pylorus preserving Whipple associated with any survival disadvantage
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no
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what is current operative mortality rate with a Whipple
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<3
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what is most common postop complication of Whipple
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delayed gastric emptying
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appropriate treatmetn of delayed gastric emptying
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metoclopramide
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percent of patients who develop a postop pancreatic fistula
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up to 20
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appropriate treatment of pancreatic fistula
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controlled drainage, with or without somatostatin
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potential complications associated with standard Whipple
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delayed gastric emptying (1/3)
pancreatic fistula (1/5) abcess (1/10) wound infection (1/12) bile leak (1/20) pancreatitis (1/20) |
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what is prognosis for pancreatic cancer patients after resection
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up to 20% are alive after 5 years
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what are most important postresection prognostic factors
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positive lymph nodes
need for blood transfusions clear margins vascular invasion by histology |
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various endocrine tumors of pancreas
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insulinoma
glucagonoma VIPoma somatostatinoma gastrinoma calcitonina nd neurotensin secreting tumors |
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what is most common pancreatic endocrine tumor
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insulinoma
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fasting blood sugar less than 50
symptoms of hypoglycemia when fasting symptomatic relief following glucose replacement |
Whipples triad for insulinomas
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diagnosing insulinoma
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72 hour fast with blod glucose and insulin levels
insulin/glucose ration greater than 0.4 elevated C-protein and proinsulin |
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do you image for pancreatic endocrine tumors
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yes
CT with contrast |
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location for insulinomas
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1/3 in each part of pancreas
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how to treat insulinomas
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resection
(enucleation for small lesions) |
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role of diazoxide for patients with unresectable disease
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can attenuate hypoglycemia
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Zollinger-Ellison?
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pancreatic endocrine tumor that secretes gastrin
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how to diagnose a gastrinoma
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secretin stimulation test
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where are gastrinomas usually located
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triangle
1) confluence of cystic and CBD 2) jnxtn of 2nd and 3rd portions of duodenum 3) jnxtn of neck and body of pancreas |
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what percentage of gastrinomas are malignant
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60% at time of diagnosis
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treatment for gastrinoma
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resection with medical anti-acid production therapy
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how to localize gastrinomas
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CT with contrast
intraoperative ultrasound duodenotomy somatostatin indium scan |
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Watery diarrhea
hypokalemia Achlorhydria |
Verner-Morrison syndrome
WDHA associated with VIPomas |
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where are VIPomas usually
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body and tail
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should VIPomas be resected
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yes, although half have metasticized
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what action should be taken if no tumor is identified in a patient with watery diarrhea, hypokalemia, achlorhydria syndrome
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subtotal pancreatectomy, because there can be diffuse islet-cell hyperplasia
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what condition would a paitnet with diabetes and a migratory rash be likely to develop
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glucagonoma
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which enzyme, when activated, is though to initiate many of the deleterios events associated with pancreatitis
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trypsin
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which lipolytic enzyme causes pancreatic necrosis in presence of bile
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phospholipase A
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which enzyme is responbislbe for creating intrapancreatic hemorrhage
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elastase
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what caues fat necrosis in pancreatitis
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lipase, especially in presence of bile
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most important risk factor for severe necrotizing pancreatitis
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obesity (= more lipase)
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% patients with cholelithiasis that develop gallstone pancreatities
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4-8%
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peritoneal tap findins associated with severe necrotizing pancreatitis
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dark brown, sterile, nonfoulsmelling fluid
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do NG tubes reduce the length of hospital stay or decrease pain in cases of acute pancreatitis
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no
just use for vomiting/ileus |
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is somatostatin helpful in acute pancreatitis
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no
but does decrease pancreatic fistula output |
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cause of coagulopathy in pancreatitis
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released proteases
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appropriate treatment for coagulopathies
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fresh frozen plasma as required
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mechanism for pulmonary dysfunction during pancreatities
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digestion of surfactant by phospholipase A
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appropriate treatment for pulmonary problems in acute pancreatities
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mechanical ventilation
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most ocmmon bacteria that infect necrotic pancreatic tissue
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gram negative rods
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appropriate treatment of infected pancreatic tissue?
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surgical debridement
antibiotics |
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presentation of acute pancreatitis
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epigastric pain and tenderness
abdominal distension fever tachycardia jaundice (when ass w gallstone pancreatitis) |
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most common causes of acute pancreatitis
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alcholism
gallstone |
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Ranson's criteria
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mortality
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