Fiser Chapter 33. PANCREAS Flashcards Preview

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Flashcards in Fiser Chapter 33. PANCREAS Deck (101)
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1

Blood supply of pancreas

Superior and inferior pancreaticoduodenal arteries (superior off GDA, inferior off SMA); splenic artery, gastroepiploic and great/inferior/caudal/dorsal pancreatic arteries

2

Pancreatic venous drainage

Portal system. PV is behind neck of pancreas (where SMV and splenic vein meet)

3

Pancreatic lymphatics

Celiac and SMA nodes

4

Pancreatic ductal cells

Secrete HCO3- solution (have carbonic anhydrase)

5

Pancreatic acinar cells

Secrete digestive enzymes

6

Pancreatic exocrine function

Amylase (only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains)
Lipase
Trypsinogen
Chymotrypsinogen
Carboxypeptidase
HCO3-

7

Pancreatic endocrine function

Alpha cells: glucagon

Beta cells (at center of islets): insulin

Delta cells: somatostatin
PP or F cells: pancreatic polypeptide

Islet cells: also produce VIP and serotonin

8

Enterokinase

Released by duodenum, activates trypsinogen to trypsin

Trypsin activates other pancreatic enzymes including trypsinogen

9

Hormonal control of pancreatic excretion

Secretin increases HCO3- mostly (from ductal cells)

CCK increases pancreatic enzymes mostly (from acinar cells)

Acetylcholine increases HCO- and enzymes

Somatostatin and glucagons decrease exocrine function

CCK and secretin: most released by cells in duodenum

10

Ventral and dorsal pancreatic buds

Ventral: duct of Wirsung (major duct that merges with CBD before entering duo), migrates posteriorly to the R and clockwise to fuse with dorsal bud; forms uncinated and inferior portion of head

Ductal: body, tail, and superior aspect of pancreatic head; has duct of Santorini (small accessory duct that drains directly into duo)

11

Double bubble

Duodenal obstruction, can be from annular pancreas causing 2nd portion of duo to be trapped in pancreatic band

Annular pancreas is associated with Down syndrome; forms from ventral pancreatic bud from failure of clockwise rotation

Tx of annular pancreas is duodenojejunostomy or duodenoduodenostomy; possible sphincteroplasty; pancreas NOT resected

12

Pancreatitis from duct of Santorini stenosis

Can be from pancreas divisum (failed fusion of pancreatic ducts)

Most with pancreas divisum are asymptomatic, some get pancreatitis

Dx: ERCP shows minor papilla with long and large duct of Santorini; major papilla with short duct of Wirsung

Tx: ERCP with sphincteroplasty; open sphincteroplasty if fails

13

Most common location of heterotopic pancreas

Duodenum. Usually asymptomatic. Surgical resection if symptomatic

14

MCC acute pancreatitis

Gallstones and EtOH

Other: ERCP, trauma, HLD, hyperCa, viral infection, meds (azathioprine, furosemide, steroids, cimetidine)

15

Gallstone pancreatitis mech

Can obstruct ampulla of Vater, causing impaired extrusion of zymogen granules and activation of degradation enzymes -> pancreatic autodigestion

16

EtOH pancreatitis mech

Auto-activation of enzymes while still in pancreas

17

Abdominal pain radiating to back, nausea, vomiting, anorexia; possibly jaundice, L effusion, ascites, or sentinel loop

Acute pancreatitis

18

Mortality rate of acute pancreatitis

10%

50% if hemorrhagic pancreatitis

19

Pancreatitis without obvious cause

Malignancy?

20

Ranson's criteria (on admit and at 48 hr)

Admit: Age > 55, wbc > 16, glucose < 200, AST < 250, LDH > 350

28hr: Hct decreased by 10%, BUN increased by 5, Ca < 8, PaO2 < 60, base deficit > 4, fluid sequestration > 6 L

If 8 criteria met, mortality near 100%

21

Necrotic pancreas on abdominal CT

will NOT uptake contrst

22

Acute pancreatitis tx

NPO, fluid resuscitation

ERCP if gallstone panc and retained CBD stones, with sphincterotomy and stone extraction

Abx for stones, severe pancreatitis, failure to improve (?)

Avoid morphine

If gallstone panc, chole same admission

23

Flank ecchymosis

Grey-Turner sign (bleeding)

24

Periumbilical ecchymosis

Cullen's sign (bleeding)

25

Inguinal ecchymosis

Fox's sign (bleeding)

26

Pancreatic necrosis

15% get it

If sterile, no abx

If infected (fever, sepsis, positive blood cultures): may need to sample with CT-guided aspiration to get diagnosis; then treatment is surgical debridement

27

Pancreatic abscess tx

Surgical debridement

Perc drainage of panc abscess or necrosis is generally NOT effective

28

Gas in necrotic pancreas

infected necrosis or abscess, need open debridement

29

Leading cause of death with pancreatitis

Infection (usually GNRs)

30

Most important risk factor for necrotizing pancreatitis

Obesity