CHAPTER 33- PANCREAS.txt

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CHAPTER 33- PANCREAS.txt
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  1. Name the parts of the pancreas:
    1) head (including uncinate), neck, body, and tail
  2. Uncinate process;
    rests on the aorta, behind SMA
  3. SMA and SMV
    lay behind neck of pancreas
  4. portal vein
    forms behind the neck (SMV and splenic vein)
  5. Blood supply to the pancreas:
    Head: superior (off GDA) and inferior (off SMA) pancreaticoduodenal arteries (anterior and posterior branches for each)

    Body- great, inferior, and caudal pancreatic artery (off splenic artery)

    Tail- splenic, gastroepiploic, and dorsal pancreatic arteries
  6. Whats the venous drainage of the pancreas?
    into the portal system
  7. Lymphatics:
    celiac and SMA nodes
  8. Ductal cells-
    Ductal cells have carbonic anhydrase and secrete HCO3- solution

    Increased flow leads to increased HCO3- and decreased Cl-
  9. Acinar cells
    secrete Cl- and digestive enzymes
  10. Exocrine function of the pancreas-
    • 1) amylase
    • 2) lipase
    • 3) trypsinogen
    • 4) chymotrypsinogen
    • 5) carboxypeptidase
    • 5) HCO3-
  11. What is the only pancreatic enzyme secreted in active form?
    Amylase- hyrolyzes alpha 1-4 linkages of glucose chains
  12. Endocrine function of the pancreas:
    • 1) Alpha cells- glucagon
    • 2) Beta cells- (at center of islets) insulin
    • 3) Delta cells- somatostatin
    • 4) PP or F cells- pancreatic polypeptide
    • 5) Islet cells also produce:
    • 1- vasoactive intestinal peptide (VIP)
    • 2- serotonin
    • 3- neuropeptide Y
    • 3- gastrin releasing peptide (GRP)
  13. Comment on the blood supply to the islet cells:
    Islet cells recieve majority of blood supply related to size
  14. Who gets blood first islet cells or acinar cells?
    after islets, blood goes to acinar cells
  15. Enterokinase
    released by the duodenum, activates trypsinogen to trypsin

    Trypsin activates other pancreatic enzymes including trypsinogen
  16. Hormonal control of pancreatic excretion:
    • Secretin- increased HCO3- mostly
    • CCK- increased enzymes mostly
    • Acetylcholine- increase HCO3- and enzymes
    • Somatostatin and glucagons- decrease endocrine function
    • CCK and secretin- mostly released by cells in the duodenum
  17. Ventral + dorsal pancreatic buds:
    • Ventral pancreatic bud:
    • 1) connected to duct of Wirsung
    • 2) migrates posteriorly, to the right, and clockwise to fuse with the dorsal bud
    • 3) forms uncinate and inferior portion of the head of the pancreas

    Dorsal pancreatic bud: body, tail, and superior aspect of the pancreatic head; has the duct of santorini

    Duct of Santorini- small accessory pancreatic duct that drains directly into duodenum

    Duct of Wirsung- major pancreatic duct that merges with CBD before entering duodenum
  18. Annular pancreas
    • 1) second portion of the duodenum trapped in pancreatic band
    • 2) can see double bubble on abdominal xray
    • 3) Associated with Down syndrome; forms from the ventral pancreatic bud from failure of clockwise rotation
    • 4) Treatment: duodenojejunostomy or duodenoduodenostomy and sphincteroplasty
    • 5) pancreas NOT resected
  19. Pancreas divisium
    • 1) failed fusion of the pancreatic ducts
    • 2) can result in pancreatitis from duct of Santorini (accessory duct) stenosis
    • 3) Most are asymptomatic; some get pancreatitis
    • 4) Diagnosis: ERCP- minor papilla will show long and large duct of Santorini; major papilla will show short duct of Wirsung
    • 5) Treatment- sphincteroplasty and stent placement if symptomatic
    • -may need open sphincteroplasty if that fails
    • - if long-standing, sphincteroplasty, may not work--> then need longitudinal pancreaticojejunostomy
  20. Heterotopic pancreas
    • 1) most commonly found in duodenum
    • 2) usually asymptomatic
    • 3) surgical resection if symptomatic
  21. Acute Pancreatitis
    • 1) stones and EtOH most common causes in US
    • 2) Other causes:
    • 1- ERCP
    • 2- trauma
    • 3- hyperlipidemia
    • 4- hypercalcemia
    • 5- viral infection
    • 6- medications (azathiprine, furosemide, steroids, cimetidine)
    • 7. ascaris lumbridoides and C. sinensis

    • 3) Symptoms:
    • 1- abdominal pain radiating to back
    • 2- nausea/vomiting
    • 3- anorexia
    • 4- jaundice can occur in 40%
    • 5- can also get left pleural effusion and sentinel loop (dilated small bowel near the pancreas as a result of inflammation)

    4) Caused by impaired extrusion of zymogen granules and activation of degradation enzymes--> leads to autodigestion

    5) Mortality rate- 10%; hemorrhagic pancreatitis mortality rate- 50%

    6) pancreatitis without obvious cause- need to worry about malignancy

    • 7) Ranson's Criteria:
    • On Admission:
    • 1) age >55
    • 2) WBC >16
    • 3) glucose >200
    • 4) AST >250
    • 5) LDH >350

    • After 48 hours:
    • 1) Hct decreased by 10%
    • 2) BUN up by 5
    • 3) Calcium < 8
    • 4) PaO2 < 60
    • 5) Base deficit >4
    • 6) fluid sequestration >6L

    8 ranson criteria met--> mortality rate near 100%

    8) Labs: increased amylase, lipase, and WBCs

    • 9) Treatment:
    • 1- NPO, aggressive fluid resuscitation
    • 2- antibiotics for those with stones, if severe, failure to improve or thought to have infection
    • 3- TPN may be necessary during recovery period
    • 4- ERCP may be needed in patients with gallstone pancreatitis and retained stone still in the CBD--> perform sphincterotomy and stone extraction
    • 5- Patients with gallstone pancreatitis should undergo cholecystectomy when recovered from pancreatitis
    • 6- Morphine should probably be avoided in patients with pancreatitis as it can contract the sphincter of Oddi and could worsen attack

    10) Abdominal CT- needed only to check for complications (dead pancreas will not light up)

    11) Ultrasound- needed to check for gallstones and possible CBD dilatation

    • 12) Bleeding:
    • 1- Grey turner sign- flank ecchymosis
    • 2- Cullen's sign- periumbilical ecchymosis
    • 3- Fox's sign- inguinal ecchymosis

    • 13) 15% get necrosis - generally leave sterile necrosis alone
    • - 10% of those patients require surgery for infected necrosis (patient not getting better or positive blood cultures)--> may need to sample this with CT-guided aspiration
    • - CT-guided drainage of pancreatic abscesses is often ineffective

    • 14) Infection- leading cause of death; usually GNRs
    • - need to remove infected material- see gas in pancreas on abdominal CT
    • - May need ultrasound-or CT-guided aspiration to diagnose infection

    15) Surgery only for infected pancreatitis

    • 16)
    • Obesity- most important risk factor for necrotizing pancreatitis
    • ARDS- related to release of phospholipases
    • Coagulopathy- related to release of proteases
    • Pancreatic/fat necrosis- related to release of phospholipases
    • Mildly increased amylase and lipase can be seen with:
    • 1- cholecystitis
    • 2- perforated ulcer
    • 3- sialoadenitis
    • 4- SBO
    • 5- intestinal infarction




  22. Ranson's Criteria:
    • On Admission:
    • 1) age >55
    • 2) WBC >16
    • 3) glucose >200
    • 4) AST >250
    • 5) LDH >350

    • After 48 hours:
    • 1) Hct decreased by 10%
    • 2) BUN up by 5
    • 3) Calcium < 8
    • 4) PaO2 < 60
    • 5) Base deficit >4
    • 6) fluid sequestration >6L

    8 ranson criteria met--> mortality rate near 100%
  23. Pancreatic pseudocysts:
    • 1) most common in patients with chronic pancreatitis
    • 2) symptoms:
    • 1- pain
    • 2- fever
    • 3- weight loss
    • 4- bowel obstruction from compression

    3) Often occurs in the head of the pancreas; small cysts likely to resolve spontaneously (<5cm)

    4) nonepithelialized sac

    5) expectant managment up to 3 months- allow pseudocysts to mature

    6) Only need to treat patients with continued symptoms or pseudocysts that are growing

    7) Maybe need to place these patients on TPN if unable to eat

    8) Usually in head of pancreas

    9) can present with persistent; pain, fever, increased WBCs, palpable mass, jaundice

    • 10) patients with symptomatic or growing pseudocyst need MRCP or ERCP to check for duct involvement.
    • - if duct involved, will need cystogastrostomy (endoscopic or open)
    • - if duct not involved, may get away with percutaneous drainage of pseudocyst

    • 11) complications of pancreatic pseudocyst-
    • 1- SBO
    • 2- infection
    • 3- portal or splenic vein thrombosis

    • 12) Incidental cysts should be resected unless associated with pancreatitis or unless the cyst is purely serous
  24. Pancreatic Fistulas:
    1) most close spontaneously (especially if low output <200cc/day)

    • 2) Treatment:
    • 1- allow drainage
    • 2- TPN
    • 3- Octreotide
    • 4- If failure to resolve with medical management, can try ERCP, sphincterotomy, and pancreatic stent placement
    • 5- If that fails, for distal lesions perform a distal pancreatectomy; for proximal lesions may need whipple.

    3- Amylase will be elevated in the fluid
  25. Chronic Pancreatitis
    1) Corresponds to irreversible parenchymal fibrosis

    2) ETOH most common cause; idiopathic 2nd most common

    3) Pain is the most common problem; anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis

    4) Exocrine tissue gets calcified and fibrotic; islet cells usually preserved

    5) Advanced disease- chain of lakes --> alternating segments of dilation and stenosis in pancreatic duct

    • 6) Can cause malabsorption of fat-soluble vitamins
    • -stents- have temporizing role

    • 7) Diagnosis:
    • Abdominal CT will show shrunken pancreas with calcification
    • Ultrasound- shows pancreatic ducts >4mm, cysts and atrophy
    • ERCP- very sensitive at diagnosing chronic pancreatitis

    8) Treatment: supportive care, including pain control and nutritional support (tube feeds, TPN)

    • 9) Surgical indications-
    • 1- pain that interferes with quality of life
    • 2- nutrition abnormalities
    • 3- addiction to narcotics
    • 4- failure to rule out malignancy
    • 5- biliary obstruction
    • 6- abscess

    • 10) Surgical options:
    • 1- Puestow procedure-pancreaticojejunostomy, for ducts > 8mm (most patients improve) --> open along main pancreatic duct and drain into jejunum.
    • 2- Distal pancreatic resection- for normal duct anatomy, failed puestow procedures, or when only a small portion of the gland is affected
    • 3- Whipple- may be needed in patients with pancreatic head disease
    • 4- Splanchnicectomy or celiac ganglionectomy (ablation) may be used for postop pain control

    • 11) Common bile duct stricture- proximal dilation that can occur with chronic pancreatitis.
    • Treatment- hepaticojejunostomy or choledochojejunostomy for pain, jaundice, cholangitis

    • 12) Splenic Vein Thrombosis-chronic pancreatitis most common cause of splenic vein thrombosis
    • - can get bleeding from gastric varices that form as collaterals
    • -Treatment- splenectomy for bleeding gastric varices
  26. Pancreatic insufficiency
    1) usually the result of long-standing pancreatitis or occurs after total pancreatectomy (over 90% of the function must be lost)

    2) generally refers to exocrine function

    3) Symptoms: 1) malabsorption 2) steatorrhea

    4) Diagnosis: fecal fat testing

    5) Treatment: high carbohydrate, high protein, low fat diet with pancreatic enzyme replacement

    6) steatorrhea- give pancreas (pancreatic enzymes)
  27. Biliary Stenosis (pancreatic etiologies)
    • 1) secondary to pseudocysts, fibrosis
    • 2) Complications- biliary cirrhosis, cholangitis

    • 3) Surgery indicated with:
    • 1- persistant jaundice
    • 2- cirrhosis
    • 3- progressive dilatation of hepatic ducts
    • 4- cholangitis
    • 5- if cannot exclude pancreatic tumor

    4) treatment: hepaticojejunostomy
  28. Jaundice work-up
    • 1) Ultrasound first
    • 1- positive stones, no mass --> ERCP
    • 2- No stones, no mass --> abdominal CT or MRI
    • 3- Positive mass --> abdominal CT or MRI
  29. Pancreatic Adenocarcinoma
    • 1) Male predominance
    • 2) typically occurs in 6th-7th decades of life

    • 3) Symptoms:
    • 1- weight loss (most common symptom)
    • 2-jaundice
    • 3- pain

    4) 20% 5 year survival with resection

    5) Risk factors- tobacco #1

    6) Ca 19-9 : Serum marker for pancreatic Ca

    7) Lymphatic spread first

    • 8) 70% in head
    • 1- 50% invade portal vein, SMV, or retroperitoneum at time of diagnosis (unresectable disease)
    • 2- metastases to peritoneum, omemtum, and liver- indicate unresectable disease
    • 3- metastases to celiac or SMA nodal system (nodal systems outside area of resection)- indicates unresectable disease
    • 4- Most cures in patients with pancreatic head disease

    • 9) 90% ductal adenocarcinoma
    • 1) other tumors of the exocrine pancreas (have more favorable prognosis:
    • 1- papillary cystic adenocarcinoma
    • 2- serous cystadenomas (vast majority benign)
    • 3- mucinous cystadenomas (considered premalignant)

    10) labs: typically show increased conjugated bilirubin and alkaline phosphatase

    11) patients with resectable mass (no signs of metastatic disease) in the pancreas do not need a biopsy because you are taking it out regardless. If the patient appears to have metastatic disease, a biopsy is warranted to direct therapy

    • 12) ERCP good at differentiating dilated ducts secondary to chronic pancreatitis vs cancer
    • - signs of CA on ERCP: duct with irregular narrowing, displacement, destruction

    • 13) Abdominal CT- may show the lesion and double-duct sign for pancreatic head cancers (dilation of both the pancreatic duct and CBD.
    • - may want preop MR angiogram or contrast angiogram if worried about vessel involvement

    14) can consider stents, hepaticojejunostomy, or gastrojejunostomy as palliation for jaundice or obstruction

    15) Chemotherapy: gemcitabine and XRT

    • 16) Complications from Whipple
    • 1- Delayed gastric emptying is #1
    • -Tx: metaclopramide
    • 2- anastomotic breakdown
    • 3- marginal ulceration
    • 4- abscess or infection
    • 5- pancreatitis
    • 6- fistulas

    17) pancreatic duct leak- treatment: drain and possible ERCP and stenting of pancreatic duct

    18) celiac plexus block- for painful unresectable disease

    19) Prognosis related to vascular and nodal invasion and abiliy to get a clear margin

    • 20) Bleeding after a whipple or other pancreatic surgery- go to angio 1st for embolization (the tissue planes are very friable early after surgery and bleeding is hard to control operatively).
  30. Nonfunctional Endocrine tumors
    • 1) represent 1/3 of pancreatic endocrine neoplasms
    • 2) 90% of nonfunctional tumors are malignant
    • 3) Symptoms: pain, weight loss, jaundice
    • 4) Tend to have a more indolent and protracted course compared with pancreatic adenocarcinoma
    • 5) Diagnosis: abdominal CT or MRI
    • 6) Resect these lesions: metastatic disease precludes resection
    • 7) 5FU and streptozocin may be effective
    • 8) Liver metastases most common
    • -50% 5 yr survival rate after resection
  31. Functional endocrine pancreatic tumors
    • 1) represents 2/3 of pancreatic endocrine neoplasms
    • 2) Octreotide is effective for:
    • 1- insulinoma
    • 2- glucagonoma
    • 3- gastrinoma
    • 4- VIPoma

    3) Most common in pancreatic head- gastrinoma, somatostatinoma

    4) All tumors can respond to debulking

    5) Liver spread- 1st for all

    6) 5FU and streptozocin works well in all
  32. Insulinoma
    1) most common islet cell tumor of the pancreas

    • 2) symptoms:
    • Whipple's triad:
    • 1- fasting hypoglycemia (<50)
    • 2- symptoms of hypoglycemia (catecholamine surge-> palpitations, increased HR, and diaphoresis)
    • 3- relief with glucose

    3) 85-90% benign and evenly distributed throughout the pancreas

    • 4) Diagnosis:
    • 1-insulin to glucose ratio >0.4 after fasting
    • 2- increased C peptide and proinsulin --> otherwise suspect munchausen's syndrome

    5) enucleate if <2cm; formal resection if >2cm

    • 6) for metastatic disease
    • - 5FU
    • -streptozocin
    • - octreotide
  33. Gastrinoma (Zolinger Ellison syndrome, ZES)
    1) Most common pancreatic islet cell tumor in MEN I patients

    2) 50% malignant and 50% multiple


    3) 75% spontaneous and 25% MEN I

    • 4) Majority in gastrinoma triangle-
    • -common bile duct
    • -neck of pancreas
    • -third portion of the duodenum

    5) Symptoms: refractory ulcer disease (abodminal pain) and diarrhea (improved with H2 blockers)

    6) Serum gastrin usually >200; 1000s is diagnostic

    7) Secretin stimulation test- ZES patients: increased gastrin (>200); normal patients have decreased gastrin

    8) Suspect ZES with refractory ulcer disease, ulcers occuring with diarrhea, bleeding, obstruction, or perforation

    • 9) Treatment: enucleation if <2cm; formal resection if >2cm
    • 1- malignant disease--> excise suspicious nodes
    • 2- Cant find tumor --> perform duodenostomy and look inside duodenum for tumor (15% of microgastrinomas there)
    • 3- duodenal tumor- resection with primary closure; may need whipple if extensivve; be sure to check pancreas for primary
    • 4- Debulking- can improve symptoms

    10) Somatostatin receptor scintigraphy- single best study for localizing tumor

    11) MRI and CT scan can also be helpful

    • 12) Consider vagotomy and pyloromyotomy for patients with unresectable disease and severe symptoms
  34. Somatostatinoma
    • 1) very rare
    • 2) Symptoms:
    • -diabetes
    • - gallstones
    • - steatorrhea
    • - hypochlorhydria

    • 3) Diagnosis:
    • - fasting somatostatin level

    4) Most malignant, most in head of pancreas

    • 5) perform cholecystectomy with resection
  35. Glucagonoma
    • 1) symptoms:
    • -diabetes
    • -stomatosis
    • -dermatitis (necrolytic migratory erythema)
    • -weight loss

    2) Diagnosis- fasting glucagon level

    3) Most malignant; most in distal pancreas

    4) Zinc, amino acids, or fatty acids may treat skin rash
  36. VIPoma (verner-morrison syndrome)
    • 1) Symptoms- (WDHA)
    • 1- watery diarrhea
    • 2- hypokalemia
    • 3- achlorhydria

    2) hypokalemia from diarrhea

    3) Diagnosis: exclude other causes of diarrhea; increased VIP levels

    4) Most malignant; most in distal pancreas, 10% extrapancreatic (retroperitoneal, thorax)

    5) can measure VIP levels

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