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Pancreas

Firas Madbak

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TEST TAKING TIP

Test Taking Tip

  • Neuroendocrine tumors of the pancreas are a favorite. Know the clinical presentation, diagnosis, and medical and surgical treatment particularly in conjunction with multiple endocrine neoplasia (MEN) syndromes.

ANATOMY/PHYSIOLOGY

What is the duct of Wirsung?

  • Major pancreatic duct that forms in the pancreatic head and descends inferiorly and joins the intrapancreatic portion of the common bile duct to form the common pancreaticobiliary channel proximal to the ampulla of Vater.

What is the duct of Santorini?

  • Accessory pancreatic duct that drains the anterior portion of the pancreatic head

FIGURE 16-1.

Arterial supply to the pancreas. Multiple arcades in the head and body of the pancreas provide a rich blood supply. The head of the pancreas cannot be resected without devascularizing the duodenum unless a rim of pancreas containing the pancreaticoduodenal arcade is preserved. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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What is the blood supply to the head of the pancreas?

  • Anterior and posterosuperior pancreaticoduodenal arteries from the gastroduodenal artery that form collaterals with branches of the superior mesenteric artery (SMA) (inferoanterior and posterior pancreaticoduodenal arteries)

What is the venous drainage?

  • It parallels the arterial supply; drains into the portal system via the superior mesenteric and splenic veins.

Which enzyme is responsible for pancreatic necrosis in presence of bile?

  • Phospholipase A

What defines a high-output pancreatic fistula?

  • Output in excess of 200 mL/d

BENIGN PANCREATIC DISEASES

What are the etiologies of acute pancreatitis?

  • Gallstones and alcohol account for >90% of cases. Other causes include hyperlipidemia, hypercalcemia, trauma, pancreatic duct obstruction, ischemia, drugs, familial, and idiopathic.

What are some common medications implicated as possible etiologies of pancreatitis?

  • Azathioprine, furosemide, thiazides, sulfonamide, tetracycline, steroids, estrogens, ethacrynic acid, and H2 blockers

What metabolic conditions could cause pancreatitis?

  • Hyperlipidemia (types I, IV, and V have been implicated); hypercalcemia, which is most commonly found with hyperparathyroidism that could lead to intraductal precipitation of calcium

How is acute pancreatitis diagnosed?

  • The diagnosis of pancreatitis requires 2 of the following 3 features: abdominal pain characteristic of acute pancreatitis, a serum amylase or lipase level at least 3 times the upper limit of normal, and characteristic findings of acute pancreatitis on computed tomography (CT).

Which enzyme is implicated in etiology of pancreatitis?

  • Trypsin

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