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Santorini: is Small duct (From Dorsal pancreatic bud)

Wirsung: is Major duct. (From Ventral pancreatic bud)


Annular pancreas:

  • 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.


Pancreas divisum:

  • 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)
    • ​Glucose>200
    • Age>55
    • LDH>350
    • AST(SGOT)>250
    • WBC>16


@ 48hrs: ( C-HOBBS)

  • Ca+<8
  • Hct fall >10%
  • O2<60
  • Base deficit >4
  • BUN>8
  • Sequestration of fluid > 6000cc

# of criteria

  • 0-2 mortality 2%
  • 3-4 mortality 15%
  • 5-6 mortality 40%
  • 7-8 mortality 100%

Pancreatic pseudocysts:

  • 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.

Pancreatic CA:

  • 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

Whipple Complications:

  • Delayed gastric emptying Tx: metoclopramide
  • Anastomotic breakdown
  • Marginal Ulceration
  • Abscess or infection
  • Fistulas
  • Pancreatitis
  • 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:

Insulinoma:

  • #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


Gastrinoma:

  • #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

Somatostatinoma:

  • Gallstones
  • Steatorrhea, hypochlorydria
  • Pancreatitis, diabetes

Glucogonoma:

  • Diabetes
  • Glossitis, stomatitis
  • Migratory necrolytic erythema
  • Streptozocin and octreotide help

VIP-oma: WDHA syndrome:

  • Watery Diarrhea
  • Hypokalemia
  • Achlohydria.
  • Diarrhea does not improve with NGT or H2 blockers

Pages in category "Pancreas"

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