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115 Cards in this Set

  • Front
  • Back
what structure is the tail of the pancreas said to tickle?
spleen
name the 2 pancreatic ducts. which duct is the main duct?
wirsung duct (main duct), santorini duct
how is blood supplied to the head of the pancreas?
1. celiac trunk --> gastroduodenal --> anterior superior pancreaticoduodenal, posterior superior pancreaticoduodenal. 2. superior mesenteric artery --> anterior inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal. 3. splenic artery --> dorsal pancreatic artery
why must the duodenum be removed if the head of the pancreas is removed?
they share the same blood supply (gastroduodenal artery)
what is the endocrine function of the pancreas? exocrine function?
endocrine is islets of langerhans: alpha cells (glucagon), beta cells (insulin). exocrine is digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase
what maneuver is used to mobilize the duodenum and pancreas and evaluate the entire pancreas?
kocher maneuver: incise the lateral attachments of the duodenum and then lift the pancreas to examine the posterior surface
what is acute pancreatitis?
inflammation of the pancreas
what are the most common etiologies of acute pancreatitis in the US
alcohol abuse (50%), gallstones (30%), idiopathic (10%)
what is the acronym to remember all of the causes of pancreatitis?
I GET SMASHED: idiopathic, gallstones, ethanol, trauma, scorpion bite, mumps (viruses), autoimmune, steroids, hyperlipidemia, ERCP, drugs
what lab tests should be ordered for acute pancreatitis?
CBC, LFT, amylase/lipase, type and cross, ABG, calcium, chemistry, coags, serum lipids
what are the symptoms and signs of acute pancreatitis?
sx: epigastric pain (frequently radiates to back), nausea and vomiting. signs: epigastric tenderness, diffuse abdominal tenderness, decreased bowel sounds (adynamic ileus), fever, dehydration/shock
what is the DDx of acute pancreatitis?
gastritis/PUD, perforated viscus, acute cholecystitis, SBO, mesenteric ischemia/infarction, ruptured AAA, biliary colic, inferior MI/pneumonia
what are associated diagnostic findings of acute pancreatitis? what is the most common sign of pancreatitis on AXR?
lab - high amylase, high lipase, high WBC. AXR - sentinel loop (most common sign), colon cutoff, possibly gallstones (only 10% visible on x-ray), U/S - phlegmon, cholelithiasis. CT - phlegmon, pancreatic necrosis
what is the tx of acute pancreatitis
NPO, IVF, NGT if vomiting, +/- TPN v. postpyloric tube feeds, H2 blocker/PPI, analgesia (demerol not morphine - less sphincter of oddi spasm), correction of coags/electrolytes, +/- EtOH withdrawal prophylaxis, tincture of time
what are the possible complications of acute pancreatitis>?
pseudocyst, abscess/infection, pancreatic necrosis, splenic/mesenteric/portal vessel rupture or thrombosis, pancreatic ascites/pancreatic pleural effusion, diabetes, ARDS/sepsis/MOR, coagulopathy/DIC, encephalopathy, severe hypocalcemia
what is the prognosis of acute pancreatitis?
based on ranson's criteria
are postpyloric tube feeds safe in acute pancreatitis?
yes
what are ranson's criteria at presentation?
age >55, WBC >16,000, Glc >200, AST >250, LDH >350 (remember GA LAW, A before L and 250 before 350 for AST and LDH values)
what are ranson's criteria during the initial 48 hrs?
(remember C HOBBS) base deficit >4, BUN increase >5 mg/dL, fluid sequestration >6L, serum Ca++ <8, Hct decrease >10%, PO2 (ABG) <60mmHg. note: amylase value is not one of ranson's criteria!
what is the mortality per positive ranson's criteria?
0-2: <5%. 3-4: ~15%. 5-6: ~40%. 7-8: ~100%
what is the etiology of hypocalcemia w/pancreatitis?
fat saponification: fat necrosis binds to calcium
what complication is assoc w/splenic vein thrombosis?
gastric varices (treatment w/splenectomy)
can TPN w/lipids be given to a patient w/pancreatitis?
yes, if the patient does not suffer from hyperlipidemia (triglycerides <300)
what is the least common cause of acute pancreatitis (and possibly the most commonly asked cause on rounds)?
scorpion bite (found on the island of trinidad)
what is chronic pancreatitis?
chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine tissue
what are the subtypes of chronic pancreatitis?
chronic calcific pancreatitis, chronic obstructive pancreatitis (5%)
what are the sx of chronic pancreatitis? signs?
sx: epigastric and/or back pain, weight loss, steatorrhea. signs: type 1 diabetes mellitus (up to 1/3), steatorrhea (up to 1/4), weight loss.
what are the causes of chronic pancreatitis?
alcohol abuse (most common, 70% of cases), idiopathic (15%), hypercalcemia (hyperparathyroidism), hyperlipidemia, familial, trauma, iatrogenic, gallstones
what are the signs of pancreatic exocrine insufficiency? endocrine insufficiency?
exocrine insufficiency: steatorrhea (fat malabsorption from lipase insufficiency - stools float in water), malnutrition. endocrine insufficiency: diabetes (glucose intolerance)
what are the common pain patterns in chronic pancreatitis? what is the DDX?
common pain patterns: unrelenting pain, recurrent pain. DDx: PUD, biliary tract dz, AAA, pancreatic cancer, angina
what % of patients w/chronic pancreatitis have or will develop pancreatic cancer?
~2%
what are the appropriate lab tests for chronic pancreatitis?
amylase/lipase, 72-hr fecal fat analysis, glc tolerance test (IDDM)
why may amylase/lipase be normal in a patient w/chronic pancreatitis?
b/c of extensive pancreatic tissue loss (burned-out pancreas)
what radiographic tests should be performed for chronic pancreatitis?
CT: has greatest sensitivity for gland enlargement/atrophy, calcifications, masses, pseudocysts. KUB: calcification in the pancreas. ERCP: ductal irregularities w/dilation and stenosis (chain of lakes), pseudocysts
what is the medical treatment of chronic pancreatitis?
discontinuation of EtOH use (can reduce attacks though parenchymal damage continues secondary to ductal obstruction and fibrosis), insulin for type I DM, pancreatic enzyme replacement, narcotics for pain
what is the surgical treatment for chronic pancreatitis?
puestow: longitudinal pancreaticojejunostomy (pancreatic duct MUST BE DILATED); duval: distal pancreaticojejunostomy; near-total pancreatectomy
what is the frey procedure?
longitudinal pancreaticojejunostomy w/core resection of the pancreatic head
what is the indication for surgical treatment of chronic pancreatitis?
severe, prolonged/refractory pain
what are the possible complications of chronic pancreatitis?
insulin dependent DM, steatorrhea, malnutrition, biliary obstruction, splenic vein thrombosis, gastric varices, pancreatic pseudocyst/abscess, narcotic addiction, pancreatic ascites/pleural effusion, splenic artery aneurysm
gallstone pancreatitis: what is it?
acute pancreatitis from a gallstone in or passing through the ampulla of vater (the exact mechanism is unknown)
how is the dx of gallstone pancreatitis? what radiologic tests should be performed
acute pancreatitis and cholelithiasis and/or choledocholithiasis and no other cause of pancreatitis (e.g., no hx of EtOH abuse). radiology: U/S to look for gallstones, CT to look at the pancreas (if sx are severe)
what is the tx for gallstone pancreatitis?
conservative measures and early interval cholecystectomy (laparoscopic cholecystectomy or open cholecystectomy) and intraoperative cholangiogram (IOC) (3-5 days after pancreatic inflammation resolves)
why should early interval cholecystectomy be performed on patients w/gallstone pancreatitis?
pancreatitis will recur in ~33% of patients w/in 8 wks (so always perform early interval cholecystectomy and IOC in 3-5 days when pancreatitis resolves)
what is the role of ERCP in gallstone pancreatitis?
1. cholangitis. 2. refractory choledocholithiasis.
what is hemorrhagic pancreatitis?
bleeding into the parenchyma and retroperitoneal structures w/extensive pancreatic necrosis
what are the signs of hemorrhagic pancreatitis?
abdominal pain, shock/ARDS, cullen's sign, grey turner's sign, fox's sign
cullen's sign
bluish discoloration of the periumbilical area from retroperitoneal hemorrhage tracking around to the anterior abdominal wall through fascial planes
grey turner's sign
ecchymosis or discoloration of the flank in patients w/retroperitoneal hemorrhage from dissecting blood from the retroperitoneum
fox's sign
ecchymosis of the inguinal ligament from blood tracking from the retroperitoneum and collecting at the inguinal ligament
what are the significant lab values in hemorrhagic pancreatitis?
increased amylase/lipase, decreased Hct, decreased calcium levels
what radiologic test should be performed in hemorrhagic pancreatitis?
CT scan w/IV contrast
what is a pancreatic abscess?
infected peripancreatic purulent fluid collection
what are the signs/sx of pancreatic abscess? what are the assoc lab findings?
fever, unresolving pancreatitis, epigastric mass. assoc labs: positive Gram stain and culture of bacteria
what radiographic tests should be performed for pancreatic abscess?
abdominal CT w/needle aspiration --> send for Gram stain/culture
which organisms are found in pancreatic abscesses?
gram negative (most common): e coli, pseudomonas, klebsiella. gram positive: staph aureus, candida
tx of pancreatic abscess
antibiotics and percutaneous drain placement or operative debridement and placement of drains
what is pancreatic necrosis?
dead pancreatic tissue, usually following acute pancreatitis
how is the dx of pancreatic necrosis made?
abdominal CT w/IV contrast; dead pancreatic tissue does not take up IV contrast and is not enhanced on CT scan (doesn't light up)
what is the treatment of pancreatic necrosis? (sterile v. suspicious of infection v. toxic and hypotensive)
sterile: medical management. suspicious of infection: CT-guided FNA. toxic, hypotensive: operative debridement
what is a pancreatic pseudocyst? what makes it a pseudo cyst?
encapsulated collection of pancreatic fluid, pseudo b/c wall is formed by inflammatory fibrosis (NOT epithelial cell lining)
what is the incidence of pancreatic pseudocyst? what are the assoc risk factors?
~1 in 10 after alcoholic pancreatitis. risk factors: acute pancreatitis < chronic pancreatitis from EtOH
what is the most common cause of pancreatic pseudocyst in the US?
chronic alcoholic pancreatitis
signs and symptoms of pancreatic pseudocyst
signs: palpable epigastric mass, tender epigastrium, ileus. symptoms: epigastric pain/mass, emesis, mild fever, weight loss (note: should be suspected when a patient w/acute pancreatitis fails to resolve pain)
what lab tests should be performed for pancreatic pseudocyst?
amylase/lipase, bilirubin, CBC
diagnostic findings of pancreatic pseudocyst
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
DDX of a pseudocyst
cystadenocarcinoma, cystadenoma
what are the possible complications of a pancreatic pseudocyst?
infection, bleeding into the cyst, fistula, pancreatic ascites, gastric outlet obstruction, SBO, biliary obstruction
treatment of pseudocyst
drainage of the cyst or observation. note: it takes 6 wks 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.
what % of pseudocysts resolve spontaneously?
~50%
what is the tx for pseudocyst w/bleeding into cyst? for pseudocyst w/infection?
w/bleeding: angiogram and embolization. w/infection: percutaneous external drainage/IV antibiotics
what are 3 treatment options for pancreatic pseudocyst?
1. percutaneous aspiration/drain. 2. operative drainage. 3. transpapillary stent via ERCP (pseudocyst must communicate w/pancreatic duct)
what size pseudocyst should be drained?
most experts say: pseudocysts larger than 5cm have a small chance of resolving and have a higher chance of complications, calcified cyst wall, thick cyst wall
what are the surgical options for the following: pseudocyst adherent to the stomach? pseudocyst adherent to the duodenum? pseudocyst not adherent to the stomach or duodenum? pseudocyst in the tail of the pancreas?
adherent to stomach: cystogastrostomy (drain into the stomach). adherent to duodenum: cystoduodenostomy (drain into the duodenum). not adherent: roux-en-y cystojejunostomy (drain into the roux limb of the jejunum). tail: resection of the pancreatic tail w/the pseudocyst
what is an endoscopic option for drainage of a pseudocyst?
endoscopic cystogastrostomy
what must be done during a surgical drainage procedure for a pancreatic pseudocyst?
biopsy of the cyst wall to rule out a cystic carcinoma (e.g., cystadenocarcinoma)
what is the most common cause of death due to pancreatic pseudocyst?
massive hemorrhage into the pseudocyst
what is pancreatic carcinoma?
adenocarcinoma of the pancreas arising from duct cells
what are the assoc risk factors for pancreatic carcinoma?
smoking 3x risk, diabetes mellitus, heavy EtOH use, chronic pancreatitis, diet high in fried meats, previous gastrectomy
what is the male:female ratio for pancreatic adenocarcinoma? african-american:white ratio? average age?
male: female is 3:2. AA:W is 2:1. average age >60yo
different types of pancreatic carcinoma? what % arise in the pancreatic head?
>80% are duct cell adenocarcinomas, other types include cystadenocarcinoma and acinar cell carcinoma. 66% arise in the pancreatic head (33% arise in body and tail)
why are most pancreatic cancers in the tail nonresectable?
these tumors grow w/o sx until it is too late and they have already spread - head of the pancreas tumors draw attention earlier b/c of biliary obstruction
what are signs/sx of tumor in head of the pancreas?
PAINLESS JAUNDICE from obstruction of common bile duct, wt loss, abdominal pain, back pain, weakness, PRURITUS from bile salts in skin, anorexia, COURVOISIER'S SIGN, acholic stools, dark urine, diabetes
what are signs/sx of tumor in body or tail of pancreas?
wt loss and pain (90%), migratory thrombophlebitis (10%), jaundice (<10%), nausea and vomiting, fatigue
what are the most common symptoms of cancer of the pancreatic HEAD?
wt loss (90%), pain (75%), jaundice (70%)
what is courvoisier's sign? what % of patients w/cancers of the pancreatic HEAD have courvoisier's sign?
palpable, nontender, distended gallbladder. 33% of patients w/pancreatic cancer in head have courvoisier's sign
what is the classic presentation of pancreatic cancer in the head of the pancreas?
painless jaundice
what metastatic lymph nodes described classically for gastric cancer can be found w/metastatic pancreatic cancer?
virchow's node, sister mary joseph's node
what are the assoc lab findings for pancreatic carcinoma?
increased direct bilirubin and alk phos (result of biliary obstruction), increased LFTs, elevated pancreatic tumor markers
which tumor markers are assoc w/pancreatic cancer?
CA-19-9 (carbohydrate antigen 19-9)
what diagnostic studies are performed for pancreatic carcinoma?
abdominal CT, U/S, cholangiography (ERCP to r/o choledocholithiasis and cell brushings), endoscopic U/S w/biopsy
what are the pancreatic cancer stages?
I: tumor limited to pancreas w/no nodes or mets. II: tumor extends into bile duct, peripancreatic tissues or duodenum, no nodes or mets. III: stage II + positive nodes or celiac or SMA involvement. IVA: tumor extends to stomach, colon, spleen or major vessels, w/any nodal status and no distant mets. IVB: distant mets (any nodal status, any tumor size)
what is the treatment of pancreatic carcinoma?
head of the pancreas --> whipple procedure (pancreaticoduodenectomy). body/tail --> distal resection
what factors signify inoperability in pancreatic carcinoma?
vascular encasement (SMA, hepatic artery), liver mets, peritoneal implants, distant lymph node mets (periaortic/celiac nodes), distant mets, malignant ascites
is portal vein or SMV involvement an absolute contraindication for resection in pancreatic carcinoma?
no - can be resected and reconstructed w/vein interposition graft at some centers
should patients w/pancreatic carcinoma undergo preop biliary drainage (e.g., ERCP)
no (exceptions for sx/preop XRT, trials, etc.)
define the whipple procedure (pancreaticoduodenectomy)
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)
what is the complication rate after a whipple procedure? what mortality rate is assoc w/a whipple procedure?
complication: ~25%. mortality <5% at busy centers
what is the pylorus-preserving whipple?
no antrectomy, anastomose duodenum to jejunum
what are the possible post-whipple complications?
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
why must the duodenum be removed if the head of the pancreas is resected?
they share the same blood supply
what is postop adjuvant therapy for pancreatic cancer?
chemotherapy +/- XRT
what is the palliative tx if pancreatic tumor is inoperable and biliary obstruction is present?
PTC or ERCP and placement of stent across obstruction
what is the prognosis of pancreatic cancer 1 yr after dx? survival rate 5 yrs after resection?
prognosis is dismal, 90% of patients die w/in 1 yr of dx. survival rate 5 yrs after resection is 20%.
what is an annular pancreas?
pancreas encircling the duodenum; if obstruction is present, bypass, DO NOT RESECT
what is pancreatic divisum?
failure of the 2 pancreatic ducts to fuse; the normally small duct of santorini acts as the main duct in pancreatic divisum
what is heterotopic pancreatic tissue?>
heterotopic pancreatic tissue usually found in the stomach, intestine, duodenum
what is a puestow procedure?
longitudinal filleting of the pancreas/pancreatic duct w/a side-to-side anastomosis w/the small bowel
what medication decreases output from a pancreatic fistula?
somatostatin (GI inhibitory hormone)
which has a longer 1/2-life: lipase or amylase?
lipase --> amylase may be normal and lipase will remain elevated longer
what is the WDHA sydrome?
pancreatic VIPoma, also known as verner-morrinson syndrome. tumor secretes VIP, which causes Watery diarrhea, hypokalemia, achlorhydria (inhibits gastric acid secretion)
what is the whipple triad of pancreatic insulinoma?
hypoglycemia (Glc <50), symptoms of hypoglycemia (mental status changes/vasomotor instability), relief of sx w/administration of glucose
what is the most common islet cell tumor?
insulinoma
what pancreatic tumor is assoc w/gallstone formation?
somatostatinoma (inhibits gallbladder contraction)
what is the triad found w/pancreatic somatistatinoma tumor?
gallstones, diabetes, steatorrhea
what are the 2 classic findings w/pancreatic glucagonoma tumors?
diabetes, dermatitis/rash (necrotizing migratory erythema)