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SURGERY

Pancreas

QuestionAnswer
common causes of acute pancreatitis Alcohol & gallstones (other: trauma, hypercalcemia/lipidemia, meds, etc.)
common causes of chronic pancreatitis Alcohol abuse (other: idiopathic, familial, trauma, stones, etc.)
sx's of acute pancreatitis Epigastric tenderness radiating to back, diffuse abd pain, N/V, dec bowel sounds, shock/dehydration, +/-fever
sx's of chronic pancreatitis Epigastric +/- pain, weight loss, steatorrhea & DM; pain is unrelenting and recurrent
How to diagnose acute pancreatitis CBC, LFTs, amylase/lipase, type & cross, ABG, Ca++, lytes, coags, lipids; AXR sentinel loop, U/S, CT
How to diagnose chronic pancreatitis Amylase/lipase, 72hr fecal fat analysis, glucose tolerance test; CT, KUB (calcifications), ERCP (ductal irregularities w. dilation & stenosis)
Tx for acute pancreatitis NPO, NGT, IVF, TPN, H2 blocker, analgesia, correct coags/lytes
Tx for chronic pancreatitis Cessation of alcohol; insulin, pancreatic enzyme replacement, narcotics; surgery for refractory pain (Peustow longitudinal pancreaticojejunostomy, Duval distal pancreaticojejunostomy, near-total pancreatectomy)
Complications of acute pancreatitis Pseudocyst, abscess/infxn, necrosis, splenic/mesenteric/portal vessel rupture; ascites, pleural effusion, diabetes, ARDS, sepsis, multiple organ failure, DIC
Complications of chronic pancreatitis Diabetes, steatorrhea, malnutrition, biliary obstruction, splenic v. thrombosis, gastric varices, pseudocyst/abscess, ascites, pleural effusion, splenic artery aneurysm
secretin produced in the S cells of the duodenum in the crypts of Lieberk├╝hn.[1] Its effect is to regulate the pH of the duodenal contents via the control of gastric acid secretion and buffering with bicarbonate.
45 yo man w 2d h/o severe, const epigast pain & RUQ pain. Noncrampy, upper abd pain rad to flank & back, relief on bending fwd. +N/V, +h/o EtOH, 1 sim episode 6 mo ago. Mild scleral ict. abd Dist, rigidity, +rebound, hypoactive BS, guaiac + stool. DDX? 1. Acute cholecystitis, 2. perforated peptic ulcer, 3. mesenteric ischemia, 4. ruptured esophagus, 5. MI, 6. pancreatitis
Initial management of pancreatitis NPO, NGT, IVF
Indications for use of H2 blockers ulcer dz, gastritis
Indications for early surgical intervention in pancreatitis 1. uncertain diagnosis, 2. calculus dz of biliary tract, 3. pancreatic abscess
Complications of acute pancreatitis 1. hypovolemia, 2. renal failure, 3. respiratory failure, 4. hemorrhage, 5. coagulopathy, 6. sepsis, 7. pseudocyst, 8. abscess, 9. necrosis, 10. paralytic ileus
appropriate use of ERCP in pancreatitis preoperative study to determine the config of the pancreatic ductal system
Medical management of chronic pancreatitis 1. low fat diet, 2. pancreatic enzyme replacement, 3. insulin to control DM, 4. abstinence from EtOH, 5. tx narcotics addiction
How good is medical management of chronic pancreatitis? poor response to medical therapy in most pts
Indications for surgery in chronic pancreatitis 1. chronic, persistent pain, 2. correction of associated biliary tract dz (bowel or biliary obstruction), 3. associated pseudocyst
Sequelae of chronic pancreatitis 1. endocrine deficiencies, 2. exocrine deficiencies, 3. malabsorption, 4. vitamin B12 deficiency, 5. persistent abd pain, 6. jaundice
What to do if pt with pancreatitis has associated calculus dz of the biliary tract? cholecystectomy +/- CBD exploration
surgical intervention in chronic pancreatitis produces pain relief in what % of pts? 70-80%
What to do if pt with chronic pancreatitis has chain of lakes pancreatic duct on ERCP? When is resection indicated? drainage with pancreaticojejunostomy to preserve the pancreas. Resection indicated when dict is narrow, previous drainage failed, if there is segmental involvement, or if pt is diabetic.
Differential for acute non-obstructive jaundice 1. acute viral hepatitis, 2. drug-induced liver disease, 3. EtOH hepatitis, 4. Septicemia, 5. congenital hyperbilirubinemia, 6. hemolytic d/o, 7. CHF
Differential for chronic non-obstructive jaundice 1. EtOH cirrhosis, 2. post-hepatic cirrhosis, 3. primary biliary cirrhosis, 4. cryptogenic cirrhosis, 5. chronic active hepatitis, 6. primary hepatocellular CA
Differential for obstructive jaundice Benign (gallstone dz, pancreatitis, b9 duct obstruction), Malignant (bile duct CA, pancreatic CA, secondary CA of the liver)
What is the role of ERCP or Percutaneous Transhepatic Cholangiography in the w/u of a pt with obstructive jaundice? 1. delineation of the proximal extent of disease, 2. internal biliary drainage, and 3. external biliary decompression (PTC)
What is the 5y survival rate for pts with pancreatic CA? Is the rate different for peri-ampullary CA? CA of pancreas - 10 to 20% 5y survival. Periampullary CA - 25-45% 5y survival because it presents earlier with obstructive jaundice
what is the average survival after palliative procedures for unresectable CA of the head of the pancreas? 6 mo
What is the criteria for unresectability of pancreatic tumor? 1. hepatic involvement, 2. peritoneal mets, 3. nodal involvement, 4. SMA/portal vein/vena cava involvement
Created by: christinapham