The Pancreas

Front 1

Embryologic development of the pancreas

Back 1

dorsal and ventral buds -> ventral swings around to join the dorsal bud -> they fuse and the duct of santorini (of the dorsal bud) usually fuses with them main duct of Wirsong

Front 2

Blood supply of the pancreas

Back 2

head and uncinate: gastroduodenal and superior mesenteric arteries ; body and tail: splenic artery

Front 3

Action of secretin

Back 3

produced by duodenum in response to fatty acids -> stimulates water and bicarbonate secretion by the pancreas

Front 4

Action of cholecystokinin

Back 4

produced by duodenum -> stimulates secretion of digestive proenzymes by the pancreas

Front 5

Pancreatic enzymes produced in active form

Back 5

don't need trypsin: amylase and lipase

Front 6

Action of VIP

Back 6

induces glycogenolysis and hyperglycemia, stimulates GI fluid secretion

Front 7

Annular pancreas

Back 7

malrotation of the ventral bud of the pancreas that can lead to duodenal obstruction

Front 8

Pancreas divisum

Back 8

5-7 % of pop has no fusion of duct of wirsong and santorini, the bulk of the pancreas exits via the duct of santorini and the minor papilla, often get obstruction and recurrent pancreatitis

Front 9

Complication of atypically shaped/distributed pancreas

Back 9

asymptomatic unless accidentally taken out in surgery from not expecting it to be there

Front 10

Most common causes of acute and chronic pancreatitis

Back 10

acoholism and biliary tract obstruction

Front 11

Morphology of acute pancreatitis

Back 11

edema from microvascular leakage, fat necrosis from release of lipolytic enzymes that possibly spreads to other structures, typically no involvment of inflammatory cells, proteolytic digestion of pancreatic parenchyma, usually reversible

Front 12

Clinical manifestation of acute pancreatitis

Back 12

sudden, epigastric pain radiating to the back, elevation of serum amylase and lipase, can devleop into shock, renal fialure, acute respiratory fialure and sepsis, dehydration; Grey-Turner sign: bruising of the flank, Cullen's sign: periumbilical bruising, elevated serum amylase and lipase

Front 13

Complications of acute pancreatitis

Back 13

pseudocyst formation, pancreatic absces, peritonitis, pancreatic ascities, involvement of adjacent organs, obstructive jaundcie, fetal loss

Front 14

Pathophysiology of multi-organ failure from acute pancreatitis

Back 14

intense release of cytokines and pancreatic enzymes into the blood -> diffuse damage to tissues, much more common with pancreatic necrosis

Front 15

Treatment of acute pancreatitis

Back 15

rehydration and gut rest, supportive care, antibiotics (especially imipenem)

Front 16

Indications for early ERCP in acute pancreatitis

Back 16

pregnant or severe pancreatis from gall stone

Front 17

Pathophysiology of chronic pancreatitis

Back 17

repeated bouts of acute pancreatitis -> atrophy and destruction of acini -> fibrosis -> last to be damaged is beta cells of the islet of langerhans, ducts dilate

Front 18

How is acute different from chronic pancreatitis

Back 18

chronic has irreverisible impairment of pancreatic function

Front 19

Causes of chronic pancreatits

Back 19

alcoholism, obstruction, hyperparathyroidism, hyperlipidemia, pancreas divisum, hereditary pancreatitis, mutatoin in CFTR (different polymorphism from cystic fibrosis

Front 20

Mechanism for alcohol induced pancreatitis

Back 20

alcohol increases protein concentratoin in pancreatic juice -> forms concretions in the ducts -> ducts obstructed ; oxidative stress, direct toxic affect on acinar cells

Front 21

Clinical presentation of chronic pancreatitis

Back 21

may have repeated attacks with jaundice, may have vague attacks of indigestion, may be relatively silent until late stage DM develops

Front 22

Complications of chronic pancreatitis

Back 22

pancreatic maldigestion, pancreatic diabetes, pleural or pericardial effusion, pancreatic ascites, portal hypertension, ischemic necrosis of bone (from hemoconcentration), addiction to narcotics (from chronic hard to manage pain) retinopathy, carcinoma

Front 23

Pancreatic pseudocyst

Back 23

walling off of areas of hemorrhagic fat necrosis by fibrous tissue without an epithelial lining (pseudocyst)

Front 24

use of CT with pancreatitis

Back 24

important for diagnosis and for prognosis of pt, detects severe pancreatitis, lack of enhancement with contrast shows necrosis of the pancreas

Front 25

Lab values for gallstone pancreatitis

Back 25

ALT > 150

Front 26

Some causes of pancreatitis that should be diagnsoed with ERCP

Back 26

microlithiasis, sphincter of oddi dysfunction, pancreas divisum

Front 27

Indications of severe acute pancreatitis

Back 27

hypotensive, hypoxic, GI bleed

Front 28

Ranson Scoring system

Back 28

scores severity of acute pancreatitis: scoring for age >55, WBC >16k, glucose >200, elevated LDH and AST, elevated hematocrit, BUN, calcium, PaOs, fluid sequestration ; if greater than 3 points is likely to be or develop into severe pancreatitis

Front 29

use of hematocrit in acute pancreatitis

Back 29

if Hct is >44 after 24 hrs of hydration predicts necrosis

Front 30

Common age of pancreatic carcinoma

Back 30

60-80

Front 31

Risk factors for pancratic carcinoma

Back 31

strongest is smoking, high fat diet, low physical activity, chronic pancreatitis, diabetes melitis, alchoholism, occupational epxosure to certain hydrocarbons; genetics syndromes: heridatry nonpolyposis colon cancer, hereditary breast and ovarian, peutz-jegher's, ataxia telangiectasia, familial atypcal multiple mole melanoma syndrome

Front 32

common cytogenetics of pancreatic carcinoma

Back 32

Kras mutation at codon 12 (80-90%)

Front 33

Precursor lesions to pancreatic carcinoma

Back 33

pancreatic intraepithelial neoplasias

Front 34

Most common sites of pancratic carcinomas

Back 34

head > dffuse > body > tail

Front 35

clinical presentation of pancreatic carcinomas

Back 35

involvement of head: early obstructive jaundice, may be painless, wieght loss (catch earlier); involvement of tail: insidious onset with weight loss and pain, Trousseau's sign (malignancy leading to coagulation), often present with distant metastasis

Front 36

Most common type of histologic pattern of pancreatic carcinoma

Back 36

ductal adenocarcinoma, grow all around the wall leading to functional obstruction, often see desmoplasia next to atrophic and fibrotic parenchyma; perineural, lymphatic and vascular invasion common and makes resection difficult; invasion in to adjacent structures and frequent metastasis

Front 37

Desmoplasia

Back 37

reactive fibrosis from malignancy, surrounds the malignancy

Front 38

presentatoin of neoplasms of the ampulla of vater and terminal common bile duct

Back 38

present early with jaundice so have better prognosis

Front 39

Prognosis of pancreatic endocrine tumor vs. pancreatic carcinoma

Back 39

worse with pancreatic carcinoma

Front 40

Treatment of pancreatic carcinoma

Back 40

whipple procedure: removed ampulla of the stomach, portion of duodenum and head of the pancreas, only performed if there are no lymph nodes positive for metastasis

Front 41

Some pancreatic endocrine tumors

Back 41

insulinoma, gastrinoma, VIPoma, glucagonoma

Front 42

Presentation of insulinoma

Back 42

whipple triad: attacks of hypoglycemia, anxiety cold sweat and confusion, attacks precipitated by fasting or exercise, relieved by ingesting sugar

Front 43

Presentation of VIPoma

Back 43

werner -morrison syndrome: severe watery diarrhea, hypokalemia, achlorhydria (low HCl in gut)