Santorini: is Small duct (From Dorsal pancreatic bud)
Wirsung: is Major duct. (From Ventral pancreatic bud)
- Ventral pancreatic bud failure of clockwise rotation
- Second portion of duodenum (duodenal atresia)
- Asociated with Dow syndrome
- Double bubble on XRay.
- Tx obstruction w/duodenojejunostomy and sphincteroplasty
- Do not resect pancreas.
- Failure of fusion of the pancreatic ducts
- Could result on pancreatitis from duct of Santorini stenosis
- 5% of population (most are asymptomatic), prone to pancreatitis.
- Dx: ERPC: Minor papilla with large duct of Satorini; Major papilla with short duct of Wirsung.
- Santorini is then major duct
- Tx: sphincteroplasty and stent placement if symptomatic
Acute Pancreatitis: MCC in US = stones & ETOH
Ranson’s Prognostic Criteria for Acute Pancreatitis
- On admission: (GA-LAW)
@ 48hrs: ( C-HOBBS)
- Hct fall >10%
- Base deficit >4
- Sequestration of fluid > 6000cc
# of criteria
- 0-2 mortality 2%
- 3-4 mortality 15%
- 5-6 mortality 40%
- 7-8 mortality 100%
- MC in patients with chronic pancreatitis
- MC in head of the pancreas
- Small cysts (<5cm) resolve spontaneously
- Non epithelialized sac
- Expectant management if asymptomatic and not enlarging up until ~12 weeks after episode of acute pancreatitis.
- 85% of pseudocysts resolve on their own.
- Internal drainage by cyst-gastrostomy, cyst-duodenostomy, or cyst-jejunostomy
- Complications of untreated pseudocyst:
- Bleed, infection, rupture, obstruction of CBD or duodenum, SBO, portal or splenic vein thrombosis
- Recurrence 10%: much higher with external drainage.
- Overall 90% dead in one year
- 20% 5 years survival with resection
- CA 19-9 (serum marker) is generally high in pancreatic CA.
- Lymphatic spread first
- 70% in the pancreatic head
- 90% ductal adenocarcinoma
- 90% have mutated K-Ras.
- Celiac plexus block is effective pain relief for non-resectable CA (50% EtOH on both sides of aorta near celiac)
- Chemo: gemcitabine & XRT
- Delayed gastric emptying Tx: metoclopramide
- Anastomotic breakdown
- Marginal Ulceration
- Abscess or infection
- Bleeding (go to angio first for embolization) no sx.
Nonfunctional endocrine tumors:
- Represent 1/3 of pancreatic endocrine neoplasms
- 90% are malignant
Functional endocrine tumors:
- #1 islet cell tumor overall.
- 90% benign
- Dx: Insulin to glucose ratio > 0.4
- Increased C peptide (as with parathyroid hormone, C terminal of hormone is inactive).
- Tx = enucleation if <2cm; resect if >2cm
- #1 islet cell tumor in MEN (MEN I)
- 60% malignant
- 50% are multiple
- 90% are in gastrinoma triangle: Cystic/CBD junction, Pancreas neck, 3rd part of duodenum
- Gastrin level > 1000
- Preform secretin stimulation test (normal patients will decrease gastrin)
- Severe ulcer disease, diarrhea (due to lipase destruction by acid, mal-absorption, and increase secretion)
- NGT and H2 blockers help diarrhea
- Steatorrhea, hypochlorydria
- Pancreatitis, diabetes
- Glossitis, stomatitis
- Migratory necrolytic erythema
- Streptozocin and octreotide help
VIP-oma: WDHA syndrome:
- Watery Diarrhea
- Diarrhea does not improve with NGT or H2 blockers