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SURGERY
Pancreas
| Question | Answer |
|---|---|
| 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 Lieberkühn.[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
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