Pancreas All of the following are true about - PowerPoint Presentation

Slide1

Pancreas

Slide2

All of the following are true about

Tropical

Pancreatitis EXCEPT:

It is common in adolescent

It is associated with protein-caloric malnutrition

It has a familial pattern

Frequently leads to chronic pancreatitis

It is not associated with diabetes

Slide3

All of the following are true about Topical Pancreatitis EXCEPT:

It is common in adolescent

It is associated with protein-caloric malnutrition

It has a familial pattern

Frequently leads to chronic pancreatitis

It is not associated with diabetes

Slide4

Tropical panreas

Genetic mutation of the pancreas

secretory

trypsinogen

inhibiter or SPINK1 gene

Abd

pain & DM

Pancreatic duct stone

Risk of cancer

Ttt

: pain + enzymes

Slide5

Which of the following is the

least

faverable

management option for a chronic large pancreatic cyst:

Endoscopic

transpapillary

drainage using stent

CT-guided pig tail catheter

Open Roux-en Y

cystojejunostomy

Laparascopic

cystogastrostomy

Endoscpic

transgasric

cystogastrostomy

Slide6

Which of the following is the least

faverable

management option for a chronic large pancreatic cyst:

Endoscopic

transpapillary

drainage using stent

CT-guided pig tail catheter

Open Roux-en Y

cystojejunostomy

Laparascopic

cystogastrostomy

Endoscpic

transgasric

cystogastrostomy

Slide7

A 65 year old man present with persistent skin rash over the lower abdomen and perineum with mild left upper quadrant pain. Serum glucose 160 mg/dl. Ct showed a large mass in the tail of pancreas. Most likely

Dx

:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Slide8

A 65 year old man present with persistent skin rash over the lower abdomen and perineum with mild left upper quadrant pain. Serum glucose 160 mg/dl. Ct showed a large mass in the tail of pancreas. Most likely

Dx

:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Necrolytic

Migratory

Erythema

Slide9

45

yo

woman presents with RUQ pain and jaundice. Greasy floating stool. US showed GS and pancreatic head mass. Most likely

Dx

:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Slide10

45

yo

woman presents with RUQ pain and jaundice. Greasy floating stool. US showed GS and pancreatic head mass. Most likely

Dx

:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Proximal Pancreas

Metastatic at

Dx

Dx

>>> elevated serum

somatostatin

Slide11

The most common functional pancreatic endocrine neoplasm:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Slide12

The most common functional pancreatic endocrine neoplasm:

VIPoma

Glucagonoma

Somatostatinoma

Gastrinoma

Insulinoma

Whipple triad

High fasting blood sugar

Low C peptide

Even distribution

90% benign

TTT>>

enucleation

Slide13

Octereotide

scanning is most

usaful

for localization of which of the following:

VIPoma

Glucagonoma

Pancreatic polypeptide-secreting tumor

Gastrinoma

Insulinoma

Slide14

Octereotide

scanning is most

usaful

for localization of which of the following:

VIPoma

Glucagonoma

Pancreatic polypeptide-secreting tumor

Gastrinoma

Insulinoma

Detect smaller than 1 cm

Somatostatinoma

and

VIPoma

are large bulky >> CT

40% of

insulinoma

have no sufficient

somatostatin

receptors

Slide15

A 35

yo

female present with episodic sever watery diarrhea. Stool cultures are negative. O/E a mass is palpable in the

epigastric

and RUQ. CT showed large bulky pancreatic mass with

extention

into the SMV and

adjecnt

organs. Best

pallitive

Mx

:

Octreotide

Streptotazocin

Embolization

Chemotherapy

Radiation therapy

Slide16

A 35

yo

female present with episodic sever watery diarrhea. Stool cultures are negative. O/E a mass is palpable in the

epigastric

and RUQ. CT showed large bulky pancreatic mass with

extention

into the SMV and

adjecnt

organs. Best

pallitive

Mx

:

Octreotide

Streptotazocin

Embolization

Chemotherapy

Radiation therapy

VIPoma

Tail

Metastsis

at

Dx

Slide17

All of the following are true regarding alcohol EXCEPT:

It relaxes the sphincter of

Oddi

It has metabolic toxins to the pancreatic

acinar

cells

It increases pancreatic duct permeability

It transiently decreases pancreatic blood flow

It inappropriately activates

trypsin

Slide18

All of the following are true regarding alcohol EXCEPT:

It relaxes the sphincter of

Oddi

It has metabolic toxins to the pancreatic

acinar

cells

It increases pancreatic duct permeability

It transiently decreases pancreatic blood flow

It inappropriately activates

trypsin

Spasm

Slide19

Which of the following is true regarding

panceatogenic

(type3) diabetes:

Ketoacidosis

is common

The diabetes is easily controlled

Peripheral insulin sensitivity is decrease

Glucagon and pancreatic polypeptide (PP) levels are low

Hyperglycemia is usually sever

Slide20

Which of the following is true regarding

panceatogenic

(type3) diabetes:

Ketoacidosis

is common

The diabetes is easily controlled

Peripheral insulin sensitivity is decrease

Glucagon and pancreatic polypeptide (PP) levels are low

Hyperglycemia is usually sever

Slide21

All of the following are true regarding PP EXCEPT:

Proximal

pancreactomy

is associated with a greater PP deficiency than distal

pancreactomy

Patients with PP producing tumor present with sever hypoglycemia

PP regulates expression of the hepatic insulin receptor gene

PP deficiency

corelates

with

sverity

of chronic pancreatitis

It is secreted by F cells

Slide22

All of the following are true regarding PP EXCEPT:

Proximal

pancreactomy

is associated with a greater PP deficiency than distal

pancreactomy

Patients with PP producing tumor present with sever hypoglycemia

PP regulates expression of the hepatic insulin receptor gene

PP deficiency

corelates

with

sverity

of chronic pancreatitis

It is secreted by F cells

Slide23

Which is true regarding pancreatic

divisum

:

The duct of

Santorini

ends in a blind

bouch

The inferior portion of the pancreas drains through the duct of

Santorini

The majority of the pancreas drains through the duct of

Wirsung

The duct of

Santorini

drains through the major papilla

The duct of

Santorini

and

Wirsung

fail to fuse

Slide24

Which is true regarding pancreatic

divisum

:

The duct of

Santorini

ends in a blind

bouch

The inferior portion of the pancreas drains through the duct of

Santorini

The majority of the pancreas drains through the duct of

Wirsung

The duct of

Santorini

drains through the major papilla

The duct of

Santorini

and

Wirsung

fail to fuse

Slide25

Slide26

Slide27

The preferred definitive treatment of recurrent acute pancreatitis

d.t

. pancreatic

divisim

is:

Lateral

pancreaticojeunostomy

(

Puestow

procedure)

Pancreaticoduodenectomy

(

Wipple

)

Minor papilla

sphincterotomy

Major papilla

sphinctrotomy

and pancreatic

ductal

septotomy

Distal

pancreatictomy

Slide28

The preferred definitive treatment of recurrent acute pancreatitis

d.t

. pancreatic

divisim

is:

Lateral

pancreaticojeunostomy

(

Puestow

procedure)

Pancreaticoduodenectomy

(

Wipple

)

Minor papilla

sphincterotomy

Major papilla

sphinctrotomy

and pancreatic

ductal

septotomy

Distal

pancreatictomy

Slide29

Insulinomas

Usually require selective venous sampling for localization

Are more common in the head of the pancreas

Are usually benign

Are treated with anatomic

pancreactomy

Slide30

Insulinomas

Usually require selective venous sampling for localization

Are more common in the head of the pancreas

Are usually benign

Are treated with anatomic

pancreactomy

90%

spradic

10% MEN 1

Slide31

Which of the following is the most common presenting symptom in patients with

Somatostatinoma

:

Cholelithiasis

Constipation

Hypoglycemia

Hypocalcemia

Slide32

Which of the following is the most common presenting symptom in patients with

Somatostatinoma

:

Cholelithiasis

Constipation

Hypoglycemia

Hypocalcemia

Diabetes

steatorhea

Slide33

What percentage of patients with

gastrinoma

have a MEN1 syndrome:

5%

10%

25%

40%

Slide34

What percentage of patients with

gastrinoma

have a MEN1 syndrome:

5%

10%

25%

40%

Slide35

The majority of

gastrinoma

are found in :

Triangle of

Calot

Passaro’s

triangle

Body of the pancreas

Tail of the pancreas

Slide36

The majority of

gastrinoma

are found in :

Triangle of

Calot

Passaro’s

triangle

Body of the pancreas

Tail of the pancreas

Slide37

70 to 90%

Slide38

For VIP-secreting tumor all are true EXCEPT:

Diarrhea unresponsive to anti-

diarreal

agents

Diarrhea that persists during fasting

Hypokalemia

Sever metabolic alkalosis

Slide39

For VIP-secreting tumor all are true EXCEPT:

Diarrhea unresponsive to anti-

diarreal

agents

Diarrhea that persists during fasting

Hypokalemia

Sever metabolic alkalosis

Slide40

During abdominal exploration after RTA, a deep laceration across the body of the pancreas with disruption of the pancreatic duct was discovered,

Mx

is external drainage and:

Direct repair of the duct

Distal

pancreatictomy

Implantation of the pancreas into the posterior wall of the stomach

Lateral

pancreaticojejunostomy

Slide41

During abdominal exploration after RTA, a deep laceration across the body of the pancreas with disruption of the pancreatic duct was discovered,

Mx

is external drainage and:

Direct repair of the duct

Distal

pancreatectomy

Implantation of the pancreas into the posterior wall of the stomach

Lateral

pancreaticojejunostomy

Slide42

Pancreatograph

is performed in 54 y o m, alcoholic with chronic pancreatitis. The study showed a “chain of lakes” pattern, with areas of

ductal

dilatation joined by areas of

ductal

stenosis

.

Mx

:

Cholecystectomy

with CBD exploration

Cholecystectomy

with

sphincteroplasty

Open the pancreatic duct longitudinally and perform side to side

pancreaticojejunostomy

Resect

the tail of the pancreas and perform a

pancreaticjejunostomy

Slide43

Pancreatograph

is performed in 54 y o m, alcoholic with chronic pancreatitis. The study showed a “chain of lakes” pattern, with areas of

ductal

dilatation joined by areas of

ductal

stenosis

.

Mx

:

Cholecystectomy

with CBD exploration

Cholecystectomy

with

sphincteroplasty

Open the pancreatic duct longitudinally and perform side to side

pancreaticojejunostomy

Resect

the tail of the pancreas and perform a

pancreaticjejunostomy

Slide44

Slide45

Slide46

What is the recommended treatment of an adult with duodenal obstruction caused by annular pancreas:

Endoscopic division

Gastrojejunostomy

Duodenojejunostomy

Surgical division

pancreaticoduodenectomy

Slide47

What is the recommended treatment of an adult with duodenal obstruction caused by annular pancreas:

Endoscopic division

Gastrojejunostomy

Duodenojejunostomy

Surgical division

pancreaticoduodenectomy

Slide48

Which of the following is more

characterestic

of pancreatic

centroacinar

cells than

acinar

cells:

Carbonic

anhydrase

Zymogen

granules

Golgi apparatus

Rough endoplasmic reticulum

Contractile proteins

Slide49

Which of the following is more

characterestic

of pancreatic

centroacinar

cells than

acinar

cells:

Carbonic

anhydrase

Zymogen

granules

Golgi apparatus

Rough endoplasmic reticulum

Contractile proteins

H2O + CO2 >> H + HCO3

Slide50

A 45 y o non-diabetic male with

chroinc

alcoholic pancreatitis and intractable abdominal pain has a 10 mm pancreatic duct. The best option of

Mx

:

Sphincteroplasty

Lateral

pancreaticojejunostomy

Distal

pancreatectomy

Total

pancreatectomy

Continued non-operative therapy

Slide51

A 45 y o non-diabetic male with

chroinc

alcoholic pancreatitis and intractable abdominal pain has a 10 mm pancreatic duct. The best option of

Mx

:

Sphincteroplasty

Lateral

pancreaticojejunostomy

Distal

pancreatectomy

Total

pancreatectomy

Continued non-operative therapy

Slide52

Which of the following is the most important determinant of the need of drainage of pancreatic

pseudocyst

:

Pseudocyst

symptoms

Pseudocyst

size

Pseudocyst

duration

Associated chronic pancreatitis

Slide53

Which of the following is the most important determinant of the need of drainage of pancreatic

pseudocyst

:

Pseudocyst

symptoms

Pseudocyst

size

Pseudocyst

duration

Associated chronic pancreatitis

Slide54

In which one or more of the following situation is resection of pancreatic tumor contraindicated:

Age > 70

Tumor located in the body of the pancreas

Inability to verify malignancy

histologically

before resection

Tumor invading portal vein

Presence of small peritoneal metastasis

Slide55

In which one or more of the following situation is resection of pancreatic tumor contraindicated:

Age > 70

Tumor located in the body of the pancreas

Inability to verify malignancy

histologically

before resection

Tumor invading portal vein

Presence of small peritoneal metastasis

Slide56

Which of the following operations would not be

approperite

for a 3cm

adenoCa

of the head of pancreas:

Whipple with

hemigastrectomy

Whipple with preservation of the stomach and pylorus

Duodenum sparing Whipple

Total

pancreaticodeudonectomy

Slide57

Which of the following operations would not be inappropriate for a 3cm

adenoCa

of the head of pancreas:

Whipple with

hemigastrectomy

Whipple with preservation of the stomach and pylorus

Duodenum sparing Whipple

Total

pancreaticodeudonectomy

Slide58

True about pancreatic trauma:

Often 2ry to blunt abdominal trauma

It is the most common cause of pancreatic

pseudocyst

Hyperamylasemia

is

pathognomonic

Negative peritoneal tap exclude pancreatic injury

Exclusion requires exploration of all central retroperitoneal hematomas

Slide59

True about pancreatic trauma:

Often 2ry to blunt abdominal trauma

It is the most common cause of pancreatic

pseudocyst

Hyperamylasemia

is

pathognomonic

Negative peritoneal tap exclude pancreatic injury

Exclusion requires exploration of all central retroperitoneal hematomas

Slide60

Q 1. Regarding cystic lesions of the pancreas:

(a) Serous cystic

neoplasms

are usually benign.

(b) Serous cystic

neoplasms

usually communicate with the main pancreatic duct.

(c)

Intraductal

papillary

mucinous

tumours

(IPMTs) can be reliably differentiated from

pseudocysts

by demonstration of communication with the main pancreatic duct.

(d) Cystic degeneration of

adenocarcinoma

is a common occurrence.

Slide61

Q 2. Regarding true cystic pancreatic

neoplasms

:

(a) All IPMTs are associated with a dilated main pancreatic duct.

(b) Both main-duct type (MDT-IPMT) and branch-duct type (BDT-IPMT)

intraductal

papillary

mucinous

tumours

never co-exist.

(c)

Mucinous

cystic

neoplasms

are almost always benign.

(d) Solid

pseudopapillary

tumours

are associated with better prognosis than

adenocarcinoma

of the pancreas.

Slide62

Q 3. Regarding IPMTs:

(a) They are more commonly found in the tail of the pancreas.

(b) Ovarian-type stroma is characteristic of these lesions.

(c) They may have a “cluster of grape” like appearance on endoscopic ultrasonography.

(d) A diameter of the main pancreatic duct > 15 mm is suspicious for malignant change in an IPMT

Slide63

Q 4. In a favourable pre-morbid patient, surgery is indicated for:

(a) 1-cm cystic tumour of the pancreas with no mural nodules.

(b) 5-cm cystic tumour with solid mural components.

(c) Suspected MDT-IPMT.

(d) 2-cm simple epithelial cyst of the pancreas.