Pancreas ABSITE Questions

*Pancreas

Tropical Pancreatitis Hereditary pattern with mutation in trypsinogen inhibitor SPINK1 gene, associated with pancreatic duct stones QUESTION: young patient who lives in the tropics with abdominal pain and diabetes - diagnosis? management? ANSWER: tropical pancreatitis - pain medication and enzyme supplementation and possible endoscopic decompression Hereditary Pancreatitis QUESTION: What is the etiology of hereditary pancreatitis? - treatment? ANSWER: autosomal dominant trypsin inactivation gene that leads to uncontrolled enzymatic degeneration and greatly increases cancer risk - pancreatectomy Intraductal papillary mucinous neoplasm Presentation - Older Male, PREMALIGNANT QUESTION: Management of IPMNs? ANSWER: Types (as determined radiographically) dictates treatment: 1. Main duct - high CA risk if main duct > 6mm, mucin on endoscopy, mural nodularity - resect all 2. Side branch - usually multifocal, lower malignancy risk 3. Mixed type (both main and side branch) Mucinous Cystic Neoplasm Presentation - Older Woman with peripheral eggshell calcifications on CT scan QUESTION: Management of MCNs? ANSWER: High risk features = size > 3cm, thick wall, peripheral calcifications, mural nodules (RESECT) - Therefore - lesions < 3cm without symptoms can be watched with serial imaging Serous Cystadenoma Presentation - Older Woman with central scar on CT scan QUESTION: Management of serous cystadenomas ANSWER: Malignancy = very RARE - therefore, resection is for symptoms or unknown diagnosis Acute Pancreatitis Alcohol (most common), Biliary tract disease, Hyperlipidemia, Hereditary, Trauma, Ischemia, 10% idiopathic. QUESTION: Is lipase correlated with pancreatitis severity? ANSWER: Surprisingly no Pancreatic divisum QUESTION: Why do patients with divisum have an increased risk of pancreatitis? ANSWER: Minor Duct (Santorini) fails to fuse with Major Duct (Wirsung) and thus pancreas has to drain in minor papilla and sometimes can't handle drainage QUESTION: What is the treatement for recurrent pancreatitis and why doesn't surgery work? ANSWER: Minor duct sphincterotomy, drainage procedures don't work because the main duct is usually not dilated Annular pancreasGI obstruction, chronic pancreatitis, and/or peptic ulcers. QUESTION: What is the etiology of annular pancreas? Treeatment? ANSWER: Failure of normal clockwise rotation of ventral pancreas - duodenojejunostomy - no pancreatic resection Gallstone Pancreatitis5% of symptomatic patients with choleliathiasis can get gallstone pancreatitis 30% recurrence if gallbladder not removed QUESTION: In gallstone pancreatitis, when do you do a lap chole? and who gets an ERCP? ANSWER: wait for lipase to decrease to near normal and near resolution of symptoms and BEFORE DISCHARGE - if concerned for biliary obstruction (hyperbilirubinemia) or prior cholangitis get a pre op ERCP to clear duct Chronic PancreatitisRecurrent bouts of pancreatitis with chronic pain usually due to alcohol QUESTION: What is the surgical management of chronic pancreatitis ANSWER: Peustow (Lateral pancreatico-jejunostomy) if diffusely dilated duct > 8mm, Pancreatectomy for pain with normal duct Pancreatic PseudocystDue to pancreatitis (20%) and trauma QUESTION: Chronic pancreatitis patient with large epigastric fullness - Diagnosis? Management? ANSWER: Pseudocyst - allow to mature for 3 months, then ERCP and if duct involved cystogastrostomy and if not then perc drain Pancreatic Fistula QUESTION: What is the management of a persistent pancreatic internal fistula ANSWER: Drain pancreatic fluid and keep NPO, then ERCP, then pancreatic resection or drainage procedure depending on location of fistula Insulinoma MOST COMMON functioning neuroendocrine tumor but usually 90% benign Whipple's triad - Hypoglycemic symptoms when fasting; <50 mg/dl blood glucose; Symptoms resolve with glucose QUESTION: Diagnosis of insulinoma? and Treeatment ANSWER: low fasting glucose with elevated C-peptide and localization with CT scan - enucleate if < 2cm, formal resection for > 2cm Gastrinoma QUESTION: What are the important points of diagnosis for Gastrinomas? ANSWER: Secretin stimulation test paradoxically increases gastrin levels (> 120) and octreotide scan is very helpful for localization due the high concentration of somatostatin receptors QUESTION: What is Passaro's Triangle or Gastrinoma Triangle ANSWER: the junction of the cystic and common bile duct superiorly, the junction of the second and third portion of the duodenum laterally, the junction of the neck and body of the pancreas medially VIPoma WDHA syndrome or Verner-Morrison Syndrome - watery diarrhea, hypokalemia, and other achlorhydia or hypochlorydia QUESTION: Why are VIPomas so bad and what is mangement? ANSWER: VIPomas cause massive fluid loss and electrolyte abnormalities and are usually malignant at diagnosis.  Management includes resection but often patients are palliated with octreotide. Glucagonoma Diabetes, stomatitis, dermatitis (necrolytic migratory erythema - usually abdominal wall and perineum) QUESTION: CT scan uses mass in tail of pancreas with diabetes and skin rash to perineum - diagnosis? management? ANSWER: Glucagonoma - octreotide but if refractory to medical management than resection (distal pancreatectomy) Somatostatinoma Diabetes, gallstones, steatorrhea, hypochlorhydria (everything slows) QUESTION: Younger patient with exocrine pancreatic dysfunction and pancreatic head mass - diagnosis? Malignant? Treatment? ANSWER: Somatostatinoma, usually malignant at time of diagnosis, resection Pancreatic NecrosisQUESTION: What is the classic picture on CT scan? Who needs an operation? ANSWER: Soap bubbles.  If septic and infected (CT guided aspirate) then antibiotics and drainage (necrosectomy) Pancreatic LymphomaVery Rare, one time where CT guided biopsy might help with pancreatic mass QUESTION: Management of primary pancreatic lymphoma ANSWER: Chemotherapy, not surgery Pancreatic CarcinomaMost significant risk factor is smoking 90% adenocarcinoma (2/3 on the head of pancreas) Ca-19-9, Ca-50. K-Ras QUESTION: What are is the palliative surgery for obstruction secondary to pancreatic cancer? ANSWER: Cholecystojejunostomy or choledochojejunostomy  and Gastrojejunostomy