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Flashcards in pancreas Deck (103):

what is the main pancreatic duct

duct of Wirsung - typically forms a common channel w the common bile duct and enters the duodenum at the ampulla of Vater and sphincter of Oddi


where is the prox and distal pancreatic duct located

prox is in pancreatic tail and distal is near duodenum in head of pancreas


pancreas divisum

majority of the dorsal pancreas empties into duodenum via duct of Santorini and portion of pancreatic head and uncinate process empties via the major papilla


what does the celiac artery trifurcate into

left gastric, splenic, and common hepatic


two pancreatic ducts

wirsung duct and santorini duct


how is blood supplied to head of pancreas

1. celiac trunk-gastroduodenal-ant sup pancreaticoduodenal artery/post sup pancdu artery

2. sup mesenteric artery-ant inf pandu art/post inf pandu artery

3. splenic artery-dorsal pancreatic artery


why must the duodenum be removed if the head of the pancreas is removed

share same blood supply-gastroduodenal artery


endocrine function of pancreas

-control glucose hemeostasis w feedback mechanism based upon glucose levels

-islets of langerhans: alpha cells (glucagon) and beta cells (insulin)

-delta (somatostatin): strong inhibitor of pancreatic exocrine secretion


exocrine function of pancreas

digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase


what is the only enzyme secreted in active form



result from a malfunction in exocrine secretion

acute pancreatitis


what is acute pancreatitis assoc w in terms of elevated levels

pancreatic enzyme levels in blood/urine


acute inflammatory process of the pancreas w variable involvement of other regional tissues or remote organ systems

acute pancreatitis


assoc w minimal organ dysfunction and uneventful recovery; normal enhancement of pancreatic parenchyma on contrast enhanced computed tomography

mild acute pancreatitis


assoc w organ failure and or local complications such as necrosis, abscess or pseudocyst

severe acute pancreatitis


occur early in the course of acute pancreatitis, are located in or near the pancreas and always lack a wall of granulation of fibrous tissue

acute fluid collection


pancreatic necrosis

Diffuse or focal area(s) of nonviable pancreatic parenchyma typically associated with peripancreatic fat necrosis Nonenhanced pancreatic parenchyma >3 cm or involving more than 30% of the area of the pancreas


acute pseudocyst

Collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a result of acute pancreatitis, pancreatic trauma or chronic pancreatitis, occurring at least 4 weeks after the onset of symptoms, is round or ovoid and most often sterile; when pus is present, the lesion is termed a “pancreatic abscess


pancreatic abscess

Circumscribed, intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis or pancreatic trauma

Often 4 weeks or more after onset

Pancreatic abscess and infected pancreatic necrosis differ in clinical expression and extent of associated necrosis


what is acute pancreatitis due to

acinar cell injury which allows activation of pancreatic enzymes outside of the pancreatic ducts and digestive tract which results in destruction of pancreatic and peripancreatic tissue


mc cause of acute pancreatitis

alcohol ingestion and biliary calculi


in pts w pancreatitis related to alcohol consumption, the first episode is usually preceded by

6-8yrs of heavy alcohol ingestion


how does chronic pancreatitis dev from alcohol consumption

pts experience recurring acute attacks which are freq related to continued alcohol consumption; after multiple attacks of acute pancreatitis, the pancreatic ductal system becomes permanently damaged leading to chronic


mc mechanical cause of pancreatitis



pt w noncrampy, epigastric pain alleviated by sitting/standing that radiated to left/right upper quadrant and back along with n/v

acute pancreatitis


pe with fever, tachycardia, upper abd tenderness with guarding +/- abd distention

acute pancreatitis


what two pe signs may indicate severe acute pancreatitis

-grey turns: flank hematoma

-cullens: falciform ligament resulting in periumbilical ecchymosis


lab values assoc w acute pancreatitis

-elev serum amylase/lipase

-amylase rises quickly within the first 12 hours after admission and usually returns to normal after 3-5days


imaging acute pancreatitis

1. CXR to look for sympathetic pleural effusions, atelectasis or hemidiaphragm elevation, exclude free air
2. plain/upright AXR for calcifications, gallstones, ileus, or cutoff sign

3. US for gallstones, duct dilation, pancreatic enlargement, peripancreatic fluid collections

4. CT for fluid, edema, necrosis



mc sign of pancreatitis on axr

sentinel loop


tx acute pancreatitis



-ngt if vomiting

-H2 blocker/PPI

-analgesia (demerol)

-correction of coags/electrolytes

-+/- alcohol withdrawal prophylaxis


ranson's criteria at presentation

1. age >55
2.wbc >16000
3. glc>200
4. ast >250
5.ldh >350

"GA law"


ranson's criteria during initial 48hrs

1. base deficit >4
2. BUN inc >5mg/dL
3. fluid sequestration >6L
4. serum Ca 10%
6. po2 (abg)


cause of hypocalcemia w pancreatitis

fat saponification: fat necrosis binds to calcium


complication assoc w splenic vein thrombosis

gastric varices (tx w splenectomy)


chronic pancreatitis

chronic inflam of pancreas region causing destruction of parenchyma, fibrosis, and calcification resulting in loss of endocrine/exocrine tissue


2 subtypes of chronic pancreatitis

1. chronic calcific pancreatitis
2.chronic obstructive pancreatitis


s/sx chronic pancreatitis

dull epigastric/back pain, wl, steatorrhea, dm1


signs of pancreatic exocrine insuff

steatorrhea and malnutrition


labs chronic pancreatitis


-72hr fecal fat analysis

-g1c tolerance test


amylase/lipase level chronic pancreatitis

normal because of extensive pancreatic tissue loss


imaging chronic pancreatitis



-ercp ductal irreg w dilation and stenosis (chain of lakes), pseudocysts



tx chronic pancreatitis

- discont alcohol

-insulin for dm1

-pancreatic enzyme replacement

-narcotics for pain


surgery for chronic pancreatitis

-puestow: longitudinal pancreaticojejunostomy (pancreatic duct must be dilated);drainage

-duval: distal panjej near total pancreatectomy


frey procedure

long panjej w core resection of pancreatic head


gallstone pancreatitis

acute pancreatitis from gallstone in or passing through the ampulla of vater


imaging gallstone pancreatitis

-us gallstones

-ct for pancreas


tx gallstone pancreatitis

conservative measures and early interval cholecystectomy and intraop cholangioggram 3-5d after pancreatic inflam resolves


role of ercp

1. cholangitis
2. refractory choledochlithiasis


What is the APACHE 2 score of 8 or greater mean

severe acute pancreatitis


CT grading system for acute pancreatitis

a: normal pancreas

b: pancreatic enlargement

c: pancreatic inflammation/peripancreatic fat

d: single peripancreatic fluid collection

e: two or more fluid collections/ retroperitoneal air


mc complications of acute pancreatitis

-peripancreatic fluid collections


-infected pancreatic necrosis


what is diagnostic of infected pancreatic necrosis

ct scan with retroperitoneal air or air within the lesser sac


cause of peripancreatic fluid

disruption of pancreatic duct; enzymatic fluid collects around the pancreas and is walled off by surrounding viscera


what do fluid collections that persist become

pseudocysts- collection of peripancreatic fluid contained in cyst like structure without an epithelial lining


s/sx of pseudocyst

epigastric pain, n/v, early satiety from compression of stomach, duodenum, or common bile duct


best imaging study for pseudocyst

ct scan


tx of noncommunicating pseudocyst

aspirated or drained percutaneously


tx of communicating pseudocyst

internal drainage into stomach, duodenum or roux limb

(internal drainage by sewing cyst wall directly to draining organ)


mc cause of chronic pancreatitis

alcohol consumption


mc pancreatic carcinoma

pancreatic adenocarcinoma


principal risk factors of developing pancreatic cancer

inc age and smoking


3 main genetic abnorm leading to pancreatic cancer

1. oncogene activation
2. tumor suppressor gene inactivation
3. over expression of growth factors or their receptors


mc expressed genetic mutation in malignant pancreatic neoplasms

Kirsten rat sarcoma oncogene (K-ras)- ras gene encodes GTP binding protein that is involved in growth signal transduction and when mutated aids in transforming cells


most important gene in hereditary pancreatic cancer



what kind of surgery is for pancreatic head or peiampullary lesions

pancreaticoduodenectomy (whipple)


what kind of surgery is for pancreatic body and tail lesions

distal pancreatectomy that usually includes a splenectomy


whipple procedure

-removal of the head of the pancreas, duodenum, and distal common bile duct; performed for carcinoma of the pancreas, duodenum, or distal common bile duct, and for trauma.

Reconstruction includes a choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy


highest rate of anastomoses leakage from whipple is assoc with



prognosis of pancreatic cancer

-unresectable has median survival of approx 6m even w chemo

-resection approx 19m


poor prognostic indicators of pancreatic cancer

-lymph node metastasis

-tumor size >3cm

-perineural invasion


other names for pancreatic endocrine tumors (PETs)

pancreatic islet cell tumors and pancreatic neuroendocrine neoplasms


most common functional PET

insulinomas- majority are benign



dx of insulinoma

-monitored 72hr fast


whipples triad

1. symptoms of hypoglycemia

2. low blood glucose (40-50mg/dL)

3. relief of symptoms following iv glucose

suggests insulinoma


if results of 72hr fast for insulinoma is indeterminate then what test

secretin injection test- won't release insulin in response to secretin and inhibit normal response of beta cells to secretin


gastrinoma triangle

-junction of common bile/cystic ducts

-neck/body of pancreas

-second/third portion of duodenum


abd pain, severe esophagitis, persistent diarrhea

gastric acid hyper secretion



what is diagnostic for a gastrinoma

- gastrin levels >1000pg.mL in pt w gastric pH of 200, basal acid output >15mEq/hr and positive secretin stimulation test >200pg/mL inc in gastrin after injection of secretin


where do glucagonomas arise from

pancreatic alpha cells- located in body or tail


mild glucose intolerance and necrolytic migratory erythema skin rash



dx of glucagonoma

serum glucagon level of 500-1000pg/mL


watery diarrhea, hypokalemia, and hypochlorhydria


triad known as WDHA syndrome/ watery diarrhea syndrome/pancreatic cholera syndrome/endocrine cholera/verner-morrison syndrome


dx of VIPoma

serum VIP level >75-150pg/mL



somatostatin inhibits production of variety of hormones including growth hormone, gastrin, insulin, and glucagon; also inhibits intestinal absorption, gastrointestinal motility, and gallbladder contraction


dx of somatostatinomas

fasting somatostatin level >160pg/mL and pancreatic/duodenal mass


eval of PETs

-CT or MRI

-ASVS if others aren't able to localize the lesion

-somatostatin scintigraphy (Octreoscan)


tx PETs

-complete surgical extirpation of primary and all metastatic ds; controlled preop by somatostatin analogues and PPI

-nonop palliative tx symptom control and ablative modalities


WHO classification for PETs

1. Well-differentiated neuroendocrine tumor

  • Benign: confined to pancreas, 2 mitoses/HPF, >2% KI-67-positlve cells, or angloinvaslve

     ο Functioning: gastrinoma, insulinoma, VIPoma, glucagonoma, somatostatinoma, or ectopic hormonal syndrome

     ο Nonfunctioning

2. Well-differentiated neuroendocrine carcinoma

  • Low grade malignant: invasion of adjacent organs and/or metastases

     ο Functioning: gastrinoma, insulinoma, glucagonoma, VIPoma, somatostatinoma or ectopic hormonal syndrome

     ο Nonfunctioning

3. Poorly differentiated neuroendocrine carcinoma

  • High grade malignant


TNM classification of PETs

T-primary Tumor

TX:Primary tumor cannot be assessed

TO:No evidence of primary tumor

T1:Tumor limited to the pancreas and size 4 cm or invading duodenum or bile duct

T4:Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or superior mesenteric artery);For anyT, add (m) for multiple tumors

N-regional Lymph Nodes

NX:Regional lymph node cannot be assessed

NO:No regional lymph node metastasis

N1:Regional lymph node metastasis

M-distant Metastases

MX:Distant melaslasis cannot be assessed

MO:No distant metastases

M1a: Distant metastasis

Disease Stages

Stage I: T1,NO,MO

Stage IIa:T2,NO,MO


Stage Illa:T4,NO,MO

     lllb: Any T,N1,MO

Stage IV:Any T, Any N,M1


A 20-year-old man comes to the emergency department with severe epigastric pain. He has a history of pancreatitis 8 months ago, but no cause was identified. He has otherwise been healthy. He does not smoke or drink alcohol. He takes no medications. His vital signs are temperature—38°C, blood pressure (BP)—130/80 mm Hg, pulse—110/minute, and respirations—18/minute. He has severe epigastric tenderness with guarding. There Is no scleral icterus. An ultrasound does not show gallstones. The bile ducts are not dilated. Laboratory studies show:

Lipase—20,000 units

Total bilirubin—0.9 mg/dL

Calcium—9/0 mg/dL

Which of the following additional findings Is most likely to support the diagnosis of pancreas divisum?

- separate dorsal and ventral ducts

Pancreatic divisum generally encompasses a variety of anatomic abnormalities whereby the majority of the dorsal pancreas empties Into the duodenum via the duct of Santorini and a portion of the pancreatic head and uncinate empty via the major papilla. The abnormalities can include an absent duct of Wirsung and separate dorsal and ventral ducts that do not fuse as well as a filamentous connection between the dorsal and ventral ducts. In the absence of divisum, that Is, in the normal state, the dorsal and ventral ducts join and the majority of secretions enter the duodenum via the duct of Wirsung through the major papilla. The common bile duct Is separate from the pancreatic duct until they merge at near the ampulla. .


A 50-year-old woman has severe gallstone pancreatitis. She is receiving IV fluid and is receiving nothing by mouth In an effort to slow pancreatic secretion to decrease the amount of active pancreatic enzyme leaking Into the disrupted glandular tissue. Which of the following enzymes Is produced by the pancreas and secreted in its active form?


The pancreas secretes a variety of digestive enzymes Including amylases, lipases, and proteases. The majority of enzymes Including trypsin and chymotrypsln are secreted in their inactive form (trypslnogen and chymotrypsinogen). Amylase Is secreted In Its active form. Cholecystoklnin (CCK) is secreted by the duodenum and leads to the secretion of several pancreatic enzymes, while gastrin is a hormone primarily produced In the antrum.


A 42-year-old man comes to the emergency department with severe abdominal pain. He takes no medications. He drinks a quart of vodka daily and smokes one to two packs of cigarettes dally. Temperature is 38°C, BP is 110/90, pulse Is 20/minute, and respirations are 24/minute. He has severe epigastric tenderness. Which of the following variables Is included In Ranson’s criteria on admission to predict the severity of this patient’s Illness?


Ranson’s criteria is one of the grading systems for the severity of pancreatitis that relies on clinical and laboratory values on admission and during the Initial 48 hours. On admission, the criteria Include age, WBC, serum glucose, serum LDH, and SGOT. Arterial PO2, calcium, and base deficit are three of six criteria measured during the Initial 48 hours. Total bilirubin, although often measured, is not part of the criteria.


A 70-year-old woman is brought to the clinic by her family because of jaundice. She has also had a 20-pound weight loss over the past few months and has recently noticed very dark urine and light-colored stools. She does not have any pain. She Is thin. There is a nontender, globular mass in the right upper quadrant. An ultrasound shows dilated intrahepatic and extrahepatic bile ducts with a dilated pancreatic duct and a mass In the head of the pancreas. Mutations In which of the following Is most likely associated with this patient’s diagnosis?

-k ras

The most commonly expressed genetic mutation in pancreatic cancer occurs in the K-ras oncogene. It Is present in at least 75% of pancreatic carcinomas. Mutations In the p53 tumor suppressor gene are the second most common mutation In pancreatic cancer and the most common genetic event in all human cancers. Mutations in other genes Including p16, the retinoblastoma gene, and in the DNA mismatch repair genes also occur but are less common.


A 66-year-old man presented to the clinic with painless jaundice. Further evaluation with CT imaging and endoscopic ultrasonography (EUS) showed a small resectable tumor In the head of the pancreas and no evidence of metastatic disease. EUS-gulded biopsy confirmed the diagnosis of pancreatic adenocarcinoma. Pancreaticoduodenectomy is planned. Which of the following statements regarding the role of adjuvant or neoadjuvant therapy for this patient Is true?

-adjuvant and neoadjuvant strategies can include radiation/chemo

Unfortunately, even after successful surgical resection, the majority of patients with pancreatic cancer will develop recurrence of their disease—both locally and systemically. Due to the high recurrence rates, efforts aimed at developing adjuvant and neoadjuvant strategies have been pursued. Treatment can consist of either chemotherapy alone or with radiation. Treatment can be given preoperatively (neoadjuvant) or postoperatively (adjuvant). Although there are several theoretical advantages of neoadjuvant strategies with promising results, no randomized comparisons have been done versus adjuvant therapy.


what is the waiting period before a pseudocyst should be drained

6weeks for pseudocyst walls to mature or become firm enough to hold sutures


mc symptoms assoc w cancer of pancreatic head

wl, pain, jaundice


tumor markers assoc w pancreatic cancer



stage 1 cancer

tumor limited to pancreas w no nodes or metastases


stage 2 cancer

tumor extends into bille duct, peripancreatic tissues, or duodenum; no node or metastases


stage 3 cancer

same stage 2 but with positive node, celiac, or sma involvement


stage 4a cancer

tumor extends to stomach, colon, spleen, or major vessels, w any nodal status and no distant metastases


stage 4b cancer

distant metastases