Pancreas Flashcards

Question

what is the inheritance pattern? what is the genetic mutation? what are the imaging features similar to? What are these patients at risk of?

Answer 1

* hereditary pancreatitis * AD * mutation of the cationic trypsinogen gene * acute attacks begin in childhood * imaging features resemble those of tropical pancreatitis * 50-70 fold increased risk of pancreatic adenocarcinoma * Hereditary pancreatitis in an 18-year-old man with recurrent episodes of idiopathic acute pancreatitis. Axial (a) and coronal (b) unenhanced CT scans reveal multiple focal areas of punctate calcifications throughout the pancreatic parenchyma (arrows in a, arrowheads in b), findings that are nonspecific and suggest chronic calcific pancreatitis. However, the young age of the patient, the absence of any known predisposing factors, and the family history of pancreatitis favor a diagnosis of hereditary pancreatitis. * https://www.researchgate.net/figure/Hereditary-pancreatitis-in-an-18-year-old-man-with-recurrent-episodes-of-idiopathic-acute\_fig3\_26674084 * A Clinical and Radiologic Review of Uncommon Types and Causes of Pancreatitis * https://www.researchgate.net/publication/26674084\_A\_Clinical\_and\_Radiologic\_Review\_of\_Uncommon\_Types\_and\_Causes\_of\_Pancreatitis

Answer 2

* CF is an Autosomal recessive disease * secondary to mutation of a gene encoding chloride channel * GIT manifestations * preceded pulmonary manifestations * exocrine pancreatic insufficiency 90% * CF is the most common cause of pancreatic insufficiency in young patients * Genetics Cystic fibrosis is due to a homozygous defect of the CFTR gene located on chromosome 7q31.2. This gene encodes for a transmembrane protein known as **cystic fibrosis transmembrane regulator (**CFTR) which is responsible for regulating chloride passage across cell membranes. There are at least 6 classes of mutations, the commonest being ∂F508 (66-70%) 6. Epidemiology Cystic fibrosis is the most common genetic disease affecting European population with an incidence of approximately 1:2000-3500 live births https://radiopaedia.org/cases/distal-intestinal-obstruction-syndrome-and-cirrhosis The liver has nodular surface and atrophic, in keeping with cirrhosis. Dilated paraumbilical vein and large number of varices around the distal oesophagus, splenorenal, as well as splenic hilum, features of portal hypertension. Splenomegaly is also seen. The small bowel loops are distended, with small bowel faeces signs seen in the distal ileum, leading to a transition point, from there the distal and terminal ileum are collapsed. No enhancing mass can be seen. No abnormal bowel wall thickening or hyperenhancement seen. The pancreas is atrophic with fatty replacement, in keeping with the known history of cystic fibrosis. Portal vein as well as splenic and SMV appear patent. Minimal ascetic free fluid. Interpretation acute small bowel obstruction, with transition point in the distal ileum (distal intestinal obstruction syndrome) features of cirrhosis and portal hypertension Case Discussion CT of the abdomen of a 25-year-old patient with known cystic fibrosis (CF) presents with distal intestinal obstruction syndrome. The liver is markedly nodular in contour in keeping with advanced cirrhosis and extensive dilated portosystemic collaterals are seen, consistent with portal hypertension. The spleen is also markedly enlarged. Also, note the complete fatty atrophy of the pancreas - a feature of cystic fibrosis. The small bowel is dilated and fluid-filled bowel all the way to the distal ileum.

Answer 3

* Common 70% * etoh * cholelithiasis * less common 30% * post op/ERCP/trauma * hyperlipidemia, hypercalcaemia * Drugs * azathioprine, thiazides, sulfonamides * inflammation * PUD * hyperparathyroidism * Pregnancy * The pancreas is diffusely enlarged mainly in its corporeocaudal region with indistinct margins. It shows a homogeneous increase signal on T2WI with no areas of parenchymal necrosis. Peripancreatic and left anterior pararenal fluid collections are noted (the largest measures 33 x 14 mm). The gallbladder is anechoic with normal size and wall thickness. The Intra-and extrahepatic biliary ducts are not dilated. No CBD stone was seen. Case Discussion Case showing acute pancreatitis with peripancreatic fluid collections, without pancreatic necrosis in a pregnant patient at 25 weeks gestation with a history of systemic lupus erythematosus (SLE). Acute pancreatitis is considered as one of the gastrointestinal manifestations of the systemic lupus erythematosus as in this case.

Answer 4

* an inflamed pancrease appears hypoechoic relative to liver (reversal of normal pattern) because of edema * US is mainly used for the ix of gallstones and / or to follow the size of pseudocysts.

Answer 5

* Mass effect * HOP 65% (5% curable) * Tail and body 35% (incurable) * Only part of the pancreas is enlarged * global enlargement from associated pancreatitis is uncommon (15%) * Compression of duodenum * Some small pancreatic tumours are better resulved by US than by CT b/c of texture changes * Alterations of density * subtly hypodense on NCCT and CECT bc of edema and necrosis * Calcifications are VERY UNCOMMON * c/f cystic and islet cell tumours where they are more common * Ductal obstruction * PD +/- CBD obstruction * double duct sign * tumours in the uncinate may not cause ductal obstruction * extrapancreactic extension * usually retropancreatic with obliteration of fat around the CMA or SMA (one sign of incurability) * Portahepatis extension * Direct invasion of stomach or SB * Vascular involvement * Need to rule out REPLACED RIGHT Hepatic artery prior to Whipples * Criteria for unresectability * SMA encased * PV or proximal SMV obstructed/encased * tumours are still resectable if small branches are encased * Dilation of smaller venous branches \>5mm is an indirect sign of venous encasement * Mets * Liver * LNS * peritoneal/serosal * Lung A large heterogeneous mass arising from the head of the pancreas is present which abuts the superior mesenteric artery over more than 180 degrees and results in narrowing. The upper aspect of the superior mesenteric vein and origin of the main portal vein are also stenosed. A biliary stent is in situ with associated pneumobilia. The main pancreatic duct is markedly dilated and pancreatic parenchyma is atrophic. Numerous enlarged retroperitoneal nodes are present. Case Discussion This case illustrates T4 pancreatic cancer. The vascular criteria for unresectability vary from country to country and surgeon to surgeon, but generally it is accepted that SMA with tumour encasement \>180 degrees circumference (which this case has, with associated narrowing) is unresectable. A coronal would probably be better to demonstrate it. The portal vein at the origin is very narrow... combined with the SMA involvement would make it unresectable. https://radiopaedia.org/cases/pancreatic-cancer-t4-uncinate-process

Answer 6

Annular pancreas * Results from abnormal migration of the ventral pancreas * the pancreas surrounds and obstructs the duodenum * appears as annular constriction of the second portion of the duodenum * ERCP is the imaging study of choice * the Pancreatic duct encircles the duodenum * Increased incidence of pancreatitis and PUD

Answer 7

* Simple superficial contusion with minimal parenchumal hemorrhage * deep laceration or performation without duct injury * Laceration with duct transection (picture 1 and 2) * Neck of pancreas transection. Surgically confirmed neck of pancreas transection. Duodenal tear. Vascular pedicle disrupted. Massive haemoperitoneum. case 1 * The pancreatic body was transected with injury to the main pancreatic duct. Case 2

Answer 8

* Necrotising Pancreatitis * accuracy of CECT for detection of pancreatiti necrosis: * 80-90% * presence and extent of cludi a/w fat necrosis cannot be accurately determined by CT attenuation numbers * Prognosis * 30% necrosis = 8% mortality * 50% necrosis = 24% mortality * \>90% necrosis = 50% mortality * Acute necrotic collections (ANC) can be either parenchymal, peripancreatic or a combination of both. * collections can be sterile or infected.

Answer 9

* A subset of patients with 'Chronic Pancreatitis' have autoimmune pancreatitis * Previously AKA idiopathic * may occur alone or with other immune disoders * most patients have increased IgG and ANA lvs * Histo: * dense lymphoplasmacytic infiltrate with scattered eosinophils * A/w * autoimmune cholangitis * Tx: * steroids

Answer 10

The double duct sign refers to the presence of simultaneous dilatation of the common bile and pancreatic ducts. Being an anatomical sign it can be seen on all modalities that can visualise the region, including: MRI, CT, ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). The two most common causes of the double duct sign are carcinoma of the head of the pancreas and ampullary tumours (e.g. carcinoma of the ampulla of Vater), although occasionally an impacted gallstone in the distal duct, with associated oedema, can also result in obstruction of the pancreatic duct.

Answer 11

* AKA PDAC * Poor prognosis * 1 year mean survival rate 8% * 65% are over 60 years * Clinical findings * jaundice * weight loss * Courvoisier sign * enlarged nontender GB 25% * Distended gall bladder and biliary tree down to the distal end where there is a small (3 cm) pancreatic head mass. Note also pancreatic duct enlargement. Case Discussion Courvoisier sign states that in the presence of an enlarged gallbladder which is non-tender and accompanied by jaundice, the cause is unlikely to be gallstones and suspicious for pancreatic/periampullary malignant mass obstructing distal CBD. Here we have the CT and US correlates. It is usually used to describe the physical examination finding of a painless right-upper quadrant mass in the abdomen in a jaundiced patient.

Answer 12

Signs of malignancy * Size \>3cm * Solid mass * mural nodule * main PD \>10mm * Intraluminal calcified content * diffuse or multifocal involvement * presence of diabetes

Answer 13

* usually occurs as a late consequence of vascular injury * Aeitiology * may result from rupture of pseudoaneurysm * erosion into splenic or pancreaticoduodenal artery * rupture of psudocyst * Haemorrhagic pancreatitis Last revised by Dr Jeremy Jones◉ on 20 Sep 2021 Edit article Citation, DOI and article data Haemorrhagic pancreatitis is characterised by bleeding within or around the pancreas, and is usually considered a late sequela of acute pancreatitis. Pathology Haemorrhage can occur in patients with severe necrotising pancreatitis or as a result of pancreatic pseudoaneurysm rupture when it constitutes a life-threatening emergency. Aetiology According to one study, the usual causes of haemorrhage were 2: bleeding pancreatic pseudoaneurysm or peripancreatic pseudoaneurysm: ~60% diffuse bleeding with pancreatic necrosis: ~20% haemorrhagic pancreatic pseudocysts: ~20% Radiographic features CT Acute haemorrhage typically has high attenuation on unenhanced CT scans. The attenuation value then decreases as the haematoma ages through time 5. MRI Haemorrhagic fluid collections are more evident on MRI than CT due to the following reasons 1: T1: high-signal intensity methaemoglobin T2: low-signal intensity haemosiderin rim Signal abnormalities due to haemorrhage remain visible longer on MRI than on CT. Unenhanced MRI of abdomen demonstrates high T1/ low T2 signal in the body of pancreas, as well as within a large peripancreatic collection. T1FS demonstrates markedly high signal in body/tail of pancreas from haemorrhage, with decreased signal in remaining head and distal tail. T2FS demonstrates oedema in head and tail of pancreas as well as retroperitoneum, with decreased T2 signal corresponding to the haemorrhagic area. Axe and Cor T2 demonstrates oedema in head and tail of pancreas as well as retroperitoneum, with decreased T2 signal corresponding to the haemorrhagic area. Large collection displaces stomach anteriorly.

Answer 14

* Pancreatic fistula 10-20% (gastropancreatic fistula in picture) * Abscess 10-20% * Pancreatitis * Pseudocyst

Answer 15

* Exocrine * Endocrine * Other * Exocrine (6) * Pancreatic ductal adenocarcinoma (PDAC) 95% * Cystic neoplasm 1% * microcystic * macrocystic * Intraductal papillary mucinous tumour (IPMT) 1% * Acinar cell carcinoma * Pleomorphic carcinoma * Epithelial Neoplasm * Endocrine (3) * Insulinoma * Gastrinoma * Nonfunctioning islet cell tumour * Other (3) * Lymphoma * metastases * connective tissue Tumours

Answer 16

* Fulid collection \>4 weeks after necrotizing pancreatitis * collections can be sterile or infected Walled-off pancreatic necrosis Last revised by Dr Jeremy Jones◉ on 20 Sep 2021 Edit article Citation, DOI and article data Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis, although it can occur in chronic pancreatitis or as a result of pancreatic trauma. Differentiation of WOPN from pancreatic pseudocyst is essential because management differs. WOPN may need aggressive treatment to avoid complications. WOPN usually occurs four weeks after the episode of acute pancreatitis. Before this time, it is referred to as an acute necrotic collection (ANC). Terminology The following are the latest terms according to the updated Atlanta classification to describe fluid collections associated with acute pancreatitis 10,11: fluid collections associated with interstitial oedematous pancreatitis (i.e. minimal or no necrosis) acute peripancreatic fluid collections (APFC): in the first 4 weeks: non-encapsulated peripancreatic fluid collections pseudocysts: develop after 4 weeks; encapsulated peripancreatic or remote fluid collections fluid collections associated with necrotising pancreatitis acute necrotic collections (ANCs): in the first 4 weeks; non-encapsulated heterogeneous non-liquefied material walled-off necrosis (WON or WOPN): develop after 4 weeks; encapsulated heterogeneous non-liquefied material Clinical presentation The walled-off collection may cause mass effect (e.g. against the biliary system, causing upstream dilatation). It may also become infected. Pathology WOPN consists of necrosis and subsequent liquefaction of pancreatic and/or peripancreatic tissue. It may be intrapancreatic or parapancreatic. Radiographic features A history of pancreatitis is necessary to exclude a complex cystic neoplasm. One should remember that an obstructing adenocarcinoma can cause pancreatitis, and if this is a concern, follow-up imaging (3-6 months) after the resolution of pancreatitis would be useful to exclude a mass. CT cystic lesion within or around the pancreas with an area of heterogeneous attenuation non-enhancing (necrotic) tissue, surrounded by a wall 3 remember to look for other sequelae of pancreatitis (e.g. pseudoaneurysm) MRI MRI is superior to CT in differentiating WOPN from pseudocyst, given its ability to depict the internal necrotic debris that favours the WOPN. Treatment and prognosis The mortality rate with WOPN is high but less than infected pancreatic necrosis. Management depends on the patient's symptoms and the location of the WOPN. Since 40% of walled-off pancreatic fluid collections (including pseudocysts) resolve spontaneously 4, and ~10% of patients develop complications, conservative treatment may appropriate in some asymptomatic patients 5. Symptomatic patients should have WOPNs drained. Percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography (ERCP) drainage (+/- necrosectomy) have been used to treat the walled-off necrosis. These techniques are replacing surgical drainage 1,2. Because of the necrotic debris, WOPN usually requires a wide-bore drainage catheter as compared to the small calibre catheters that can be used to drain a pseudocyst 3. History and etymology The term "walled-off pancreatic necrosis" was used by Connor et al. in 2005 2.

Answer 17

* Second most common functional neuroendocrine tumour (islet cell tumour) * Solitary 25% * can be multiple or ectopic (stomach/duodenum) * 60% have malignant transformation * 35mm mean tumour size * Hyper vascular 70% * CLINICAL * Zollinger-Ellison Syndrome * Diarrhorea * PUD

Answer 18

* Needle aspiration * may be performed on any fluid collection, necrotic tissue or hemorrhage to determine if infected * psuedocysts \<5cm should be monitored rather than aspirated bc pseudocusts commonly resolve spontaenous * aspiration risks superinfection 10% * Percut drainage * fluid collections are amenable to drainage if there is clinical suspicious of infection. * success rate 70% * pseudocysts \>5cm are good candidates for drainage * Pecutaenous and endoscopically placed catheters are now more routinely being used to drain ANC and walled off necrosis * Surgery is still preferred for infected pancreatic necrosis * If the pt is not stable enough for surgery percut drainage is an option.

Answer 19

Heterotopic Pancreas * Abnormally located pancreatic tissue with its own ductal system and no vascular, neural or anatomic contact with the normal pancreas * Most common heterotopia in the GIT * Usually asymptomatic * Most common locations * duodenum 30% * Stomach 25% * usually submucosal in location * prepyloric region along greater curvature in 90% * Jejunum 15% * less common locations * Meckel * ileum * GB * Fallopian tubes * umbilicus * esophagus * spleen * mediatmediastinumum

Answer 20

* Fatty replacement with or without pancreatic gland atrophy (most common finding) * Calcificaiton 7% * Cyst formation * abnormalities in PD * strictures * beading * dilation * obstruction * Pancreatic cystosis: * rare * entire pancreas replaced with multiple cysts of varying sizes

Answer 21

* Mild * pain * vomiting * tenderness * severe * shock * pulmonary insufficiency * renal failure * GIT hemorrhage * metabolic abnormalities * flank ecchymosis * grey turner sign * periumbiliacl ecchymosisi * cullen sign * the severity of acute pancratitis can be assessed using Ranson or PACHE II critteria

Answer 22

* Classificaiotn * Acute pancreatitis * mild * interstitial edema * Severe * necrosis * fluid collections * Groove pancreatitis * inflammation localized to groove between the duodenum and pancreatic head * Chronic Pancreatitis

Answer 23

* The value of prediciting clinical outcome is in dispute * Grade A: normal pancreas * Grade B: focal or diffuse enlargement of pancres * Grade C: pancreatic abnormalities and peripancreatic inflammation * Grade D: 1 peripancreatic fluid colleciton * Grade E: \> 2 peripancreatic fluid collections / or gas in or adjacent to the pancreas

Answer 24

* Glucagonoma * 4 D syndrome * Diahorra * Diabetes * Depression * Dermatitis * DVT * Glossitis * necrolytic eythema migrans * 80% malignant potential Glucagonomas are pancreatic endocrine tumours that secrete glucagon. Most lesions are malignant. Epidemiology They are very rare with an incidence of ~0.000005% or less than 1 case per 20 million. Equal incidence in middle-aged men and women. Accounts for 1% of all the neuroendocrine tumours and less than 5% of all primary pancreatic malignancies 2. Clinical presentation Most patients present with a necrolytic migratory rash and various other elements of the 4D syndrome which includes: 1. dermatitis / necrotising migratory erythema 2. diabetes mellitus 3. deep vein thrombosis 4. depression Stomatitis, diarrhoea, anaemia, and weight loss may also occur. Plasma level of glucagon is elevated (\>500 pg/mL). Radiographic features Tumour size is variable, but most are large (\>5 cm) and have metastasised at the time of diagnosis. Most are located in the distal pancreas and tend to demostrate significant hypervascularity. Tumours may be solid or contain central low-attenuation areas on CT. The MR features of these lesions have not yet been reported. Treatment and prognosis Standard treatment is surgical resection, depending on its location the approach can be divided into local resection, pancreactic body and tail resection and pancreatoduodenectomy. Approximately 50% of patients survive for at least 5 years post-diagnosis.

Answer 25

* Most common Functional Pancreatic endocrine tumour * single 70% * Multiple 10% * diffuse hyperplasia/extrapancreatic 10% * Malignant transformation 10% * \<2cm (90%) * Hypervascular 70% * Symptoms * hypoglycaemia * Pathology They develop from ductal pluripotent cells into unregulated cells secreting insulin. The beta cells of the islets of Langerhans normally secrete insulin. Approximately 10% of insulinomas are multiple and 10% malignant. * Clinical presentation Typically insulinomas present with Whipple's triad consisting of: fasting hypoglycaemia (\<50 mg/dL) symptoms of hypoglycaemia (due to subsequent catecholamine release) immediate relief of symptoms after the administration of IV glucose As with other endocrine tumours of the pancreas, there is an association with multiple endocrine neoplasia type I (MEN I).

Answer 26

* Pancreatic tissue largely nonexistent * often total fatty replacement is seen * endstage disease: pancreatic insufficiency * Imaging features * US * increased echogenicity (fatty replacement) * small cysts are rarely visulaised although that are very common (1-3mm) * large cysts (\<5mm) have been reported but are uncommon * CT * pancreatic tissue totally missing. May see duct * SB may be dilated with fecal appearing contents * Fibrosing colonopathy. Wall thickening is the predominant proximal colon complications of enzyme replacement tx.

Answer 27

* Secretin is given IV and the pancreatic and CBD sizes are measures before and every minute after administration for 15minutes. Secretin increases the volume and bicarbonate contentof secreated pancreatic juice * Changes in duct diameter in normal volunteers * baseline duct size 1.9mm (1-3mm) * 70-100% increase in duct size is normal. * Return to baseline duct size within 10 minutes * Chronic Pancreatitis * No significant change in PD size * Functional ductal obstruction * PD remains dilated 10 min after administration of secretin.

Answer 28

* Suppression of insulin * Thyroid stimulating hormone * Growth Hormone secretion (hyperglycaemia * 90% malignant transformation * The presentation can be variable. Patients with functional somatostatinoma may present with an "inhibitory syndrome" which is a triad of mild diabetes mellitus, cholelithiasis, and diarrhoea/steatorrhoea. Other lesions can present with obstructive pancreatitis. History and Physical Non-functional tumors are frequently asymptomatic. Later in the course of the disease, they may present with abdominal pain, vomiting, jaundice, and steatorrhea due to the mechanical effects of the tumor on the biliary and pancreatic drainage.[11] Functional tumors present with the inhibitory effects of somatostatin on the neuroendocrine system. Cholelithiasis is present in almost 70%, and diabetes mellitus in 60% of symptomatic cases.[4] Rarely, they manifest as a triad of diabetes mellitus, cholelithiasis, and steatorrhea, referred to as inhibitory syndrome due to the suppression of insulin, cholecystokinin, and pancreatic exocrine enzymes, respectively.[5][6] The physical examination might reveal icterus in the patients presenting with obstructive jaundice, abdominal tenderness in acute cholecystitis, and neurocutaneous markers such as cafe au lait spots, neurofibromas, and axillary freckling in patients with concomitant NF1. Go to: https://www.researchgate.net/figure/Somatostatinoma-in-a-39-year-old-man-with-abdominal-pain-and-cholelithiasis-a-Axial\_fig4\_47755312 Somatostatinoma in a 39-year-old man with abdominal pain and cholelithiasis. (a) Axial contrast-enhanced CT image shows a well-defined mass in the pancreatic tail that demonstrates heterogeneous hyperenhancement. (b) Axial T1-weighted MR image shows the homogeneous mass, which demonstrates low signal intensity relative to the normal high signal intensity of the pancreas. (c) Axial T2-weighted fat-suppressed MR image shows the pancreatic mass, which demonstrates characteristic high signal intensity. (d) Axial contrast-enhanced T1-weighted fat-suppressed MR image obtained in the arterial phase shows the mass, which demonstrates heterogeneous hyperenhancement. Somatostatinomas are a rare type of neuroendocrine tumour. Epidemiology They form up to ~1% of all gastroenteropancreatic endocrine neoplasms. Associations multiple endocrine neoplasia type I 2 von Hippel Lindau syndrome 2 duodenal somatostatinoma: neurofibromatosis type I 1 Clinical presentation The presentation can be variable. Patients with functional somatostatinoma may present with an "inhibitory syndrome" which is a triad of mild diabetes mellitus, cholelithiasis, and diarrhoea/steatorrhoea. Other lesions can present with obstructive pancreatitis. Pathology They typically occur in the pancreas but can also manifest in extrapancreatic organs (e.g. duodenum and ampulla of Vater) and can result in chronic obstructive pancreatitis. Biochemistry They may be functional (i.e patients have high fasting somatostatin levels) or non-functional. Functional somatostatinomas can release excessive amounts of somatostatin 2. Radiographic features As they share the radiographic features of other pancreatic endocrine tumours, please refer to this parenting article for a detailed discussion regarding these features.

Answer 29

* Vasoactive intestinal Peptide * WDHA syndrome * 60% malignant trasformation CT of the abdomen and pelvis without contrast was significant for multiple ill-defined, hypodense liver lesions. There was also a hypodense, cystic lesion in the tail of the pancreas measuring 1.0 cm. On arterial phase imaging, again seen are multiple, non-specific, hypodense liver lesions. The lesion in the tail of the pancreas shows subtle peripheral enhancement. Venous phase imaging again demonstrates the hypodense lesion in the pancreatic tail, now with peripheral enhancement. Case Discussion Initial workup was negative for viral, bacterial, parasitic, inflammatory, osmotic, and malabsorptive aetiologies of diarrhoea. **Patient’s laboratory workup was significant for electrolyte disturbances including hypokalaemia, hyponatraemia (K 2.6, Na 127) and Vasoactive Intestinal Peptide (VIP) of 1930 (normal 0-60).** The patient underwent an ultrasound guided liver biopsy of a liver lesion seen on CT. **Pathology results from patient's liver biopsy showed metastatic neuroendocrine cells in the liver representing a tumour arising from the endocrine pancreas (VIPoma).** **VIPomas are a very rare type of pancreatic endocrine tumours that secrete, and get their name from, vasoactive intestinal peptide (VIP). The clinical syndrome resulting from these tumours is commonly known as WDHA syndrome, as an acronym of the cardinal symptoms of watery diarrhoea, hypokalaemia, and achlorhydria.** Epidemiology VIPomas represent \<2% of pancreatic endocrine tumours 2. There are two epidemiological peaks in the diagnosis of these tumours, one peak in middle-age adults and another peak in children aged between two and four years 1. Clinical presentation Patients present with the classic clinical triad of 1: watery diarrhoea that persists with fasting hypokalaemia achlorhydria or hypochlorhydria https://radiopaedia.org/cases/vipoma

Answer 30

Need to rule out REPLACED RIGHT Hepatic artery prior to Whipples Criteria for unresectability * SMA encased * PV or proximal SMV obstructed/encased * tumours are still resectable if small branches are encased * Dilation of smaller venous branches \>5mm is an indirect sign of venous encasement

Answer 31

* pancreas attached to bladder or jejunum by duodenal interposition * stent may be in place * Complications * rejection 35% * pancreatitis 35% * peripancreatic abscess 35% * perpancreatic hemorrhage 35% * vascular thrombosis 20% * Pancreas transplantation aims to restore physiologic normoglycemia in diabetic patients with glomerulopathy and avoid or delay the onset of diabetic retinopathy and arteriopathy. Simultaneous pancreas-kidney transplant is the most common approach, using a cadaveric pancreas donation in conjunction with either cadaveric or live donor renal transplant. Alternative techniques include pancreas after kidney transplant, in which the pancreas transplant is performed some years after renal transplant. Pancreas transplant alone is utilized rarely in diabetic patients with compensated renal function. Pancreas grafts have vascular and enteric connections that vary in their anatomic approach, and understanding of this is critical for imaging with ultrasonography, computed tomography, or magnetic resonance imaging. Imaging techniques are directed to display the pancreatic transplant arterial and venous vasculature, parenchyma, and intestinal drainage pathway. Critical vascular information includes venous thrombosis (partial or complete), arterial occlusion, or aneurysm. Parenchymal abnormalities are nonspecific and occur in pancreatitis, graft rejection, and subsequent graft ischemia. Peripancreatic fluid collections include hematoma/seroma, pseudocyst, and abscess. The latter two are related to pancreatitis, duct disruption, or leak from the duodenojejunostomy. An understanding of transplant anatomy and complications will lead to appropriate use of imaging techniques to diagnose or exclude important complications.

Answer 32

* groove pancreatitis * Pancreatitis involving the pancareatic groove which is a potential space between head of pancreas, duodenum and the CBD * Two forms * segmental * involves the pancreatic head with development of scar tissue in the groove * Pure form * affects groove only sparing pancreatic head Case Discussion This uncommon form of chronic pancreatitis can mimic pancreatic carcinoma. The potential space between the pancreatic head, the common bile duct and the duodenum is referred to as the pancreaticoduodenal groove. In this case, the overall impression was that of improving paraduodenal pancreatitis. On follow-up CT there was no evidence of a mass, but the pancreatic head remained heterogenous in appearance. https://radiopaedia.org/cases/paraduodenal-pancreatitis

Answer 33

* Delayed gastric emptying * persistent need for an NG tube for longer than 10 days and is seen in 11-29% of pts * Pancreatic Fistula * surgical drain output of amylase rich fluid \>5ml/day or beyond 7-10 days * wound infection * hemorrhage * can occur if replaced right HA is severed * Pancreatitis * Abscess formation * Biliary complications * Biloma

Answer 34

* Most hematogenous mets to the pancreas are from * RCC, * lung cancer, * breast cancer or * melanoma * Mets from RCC are the most common * hypervascular tumours, solitary or multiple * Direct invasion occurs most commonly from the transverse colon or stomach

Answer 35

* progressive, irreversible destruction of pancreatic parenchyma by repeated episodes of mild or subclinical pancreatitis * Causes * etoh * hyperparathyroidism * hyperlipidaemia * hereditary

Answer 36

* CT * fragmentation of the gland * pancreatic hematoma * non-enhancing regions * peripancreatic stranding * exudate * Intraoperative pancreatography * should be performed to evaluate integrity of PD. Injury to the duct requires different surgery * Picture: * pancreatic Avulsion

Answer 37

* Pseudocyst * encapsulated collection of pancraetic fluid which is typically round or oval * The capsule is usually indistinguishable but may occasionally be identified. * caused by micro-perforation of the PD such a communication can be identified by ERCP in 50% of patients * Defined by the presence of fluid collection \> 4 weeks after an episode of interstitial edematous pancreatitis * can either be sterile or infected * The only definitive criteria on imaging for infection is the presence of air * occurs in 40% of pts with Acute pancreatitis and 30% of pts with chronic pancreatitis * Prognosis * 50% resolve spontaneously and are not clinically significant * 20% are stable and * 30% cause complications * dissection into adjacent organs: liver spleen, kidney, stomach * hemorrhage (erosion into vessel, thrombosis, pseudoaneurysm) * Peritonitis: rupture into the peritoneal cavity * Obsteciton of duodenum, bile ducts (jaundice, cholangitis) * infeciton

Answer 38

* Clinical manifestations related to duodenal and bniliary obstrcuition * biliary strictures in 50% * Factors related to development of Groove pancreatitis * PUD * gastric resection * true duodenal wall cysts * pancreatic heterotopia * distrubance in flow of main pancreatic duct

Answer 39

* Type 1: Normal anatomy 85% * Type 2: separate duodenal openings for PD and CBD (5%) * Type 3: Pancreatic divism. Lack of fusion of the dorsal and ventral PD. Occurs in 10% of the population. The main pancreatic drainage is thru the minor papilla. Up to 25% of pts with recurrent idiopathic pancreatitis have divism. * orifice of the duct of. santorini is relatively too small to handle secreations. * ERCP: cannulisation of the major pailla only allows visulasion of the ventral duct.

Answer 40

* Most common in the pancreatic head * 80-90% malignant transformation * 5ys 45% * Usually large \>5cm and cause symptoms via mass effect * jaundice * palpable * Calcification 20% * hypervascular at angiography * Liver mets enhance brightly on CT * less aggressive than adenocarcinoma * BEtter response to chemo

Answer 41

Tropical Pancreatitis * Large pancreatic calculi within dilated PD * up to 5cm in size * may extend into side branches * incontrast, calcuili in alcoholic related chronic pancreatitis are small and speckled * parenchymal atrophy * 15-25 fold increased risk of pancreatic adenocarcinoma

Pancreas Flashcards

(66 cards)