Pancreas
Acute and chronic pancreatitis and their local complications, pancreatic adenocarcinoma/Whipple, cystic neoplasms (IPMN), neuroendocrine tumors, and pancreatic trauma.
High-Yield Points
- Acute pancreatitis — gallstones and alcohol are the top causes (gallstones #1 in acute, alcohol #1 in chronic). Dx with lipase; contrast CT grades severity. Management = aggressive isotonic fluids + early enteral nutrition (enteral preferred); no prophylactic antibiotics without infected necrosis.
- Gallstone pancreatitis — mild → same-admission cholecystectomy after resolution; ERCP only for cholangitis/persistent obstruction (stone passes spontaneously in ~80%).
- Severity/complications — Ranson, BISAP; Grey Turner (flank) + Cullen (periumbilical) ecchymoses = hemorrhagic/necrotizing pancreatitis. Infected (walled-off) necrosis → step-up approach (drain → minimally invasive debridement); sterile necrosis is NOT drained.
- Pancreatic pseudocyst — fluid collection persisting >4 weeks, high amylase, non-epithelialized. Observe (most resolve); internal drainage (cystgastrostomy) if symptomatic or fails conservative therapy (>6 cm / >6 weeks); external drainage only if infected + unstable (fistula risk).
- Chronic pancreatitis — alcohol #1; CT shows atrophy + calcifications; chronic pain is the main surgical indication, treat with pancrelipase + pain control. Dilated duct (>6–7 mm) → lateral pancreaticojejunostomy (Puestow). Splenic vein thrombosis → isolated gastric varices (sinistral portal HTN) → splenectomy.
- Pancreatic adenocarcinoma — smoking is the strongest risk factor; painless jaundice + Courvoisier sign + head mass + ↑CA 19-9; KRAS in >95%. Resectable head mass → Whipple (no preop biopsy needed if it's coming out regardless) + adjuvant chemo; borderline → neoadjuvant; unresectable → palliative biliary/duodenal stents + celiac plexus neurolysis.
- Whipple complications — delayed gastric emptying is most common (benign, prokinetics); GDA stump bleed (sentinel bleed) → angiography + embolization (not early reoperation).
- IPMN — main-duct/mixed (~50% malignancy) → resect; side-branch <3 cm, no nodule/symptoms → surveillance. IPMN cyst fluid is high CEA AND high amylase.
- Pancreatic trauma — main pancreatic duct integrity drives management: grade I–II (no duct) → nonoperative/closed-suction drain; duct injury left of the SMV → distal pancreatectomy; head/right of SMV → complex repair/Whipple. Shock on admission = strongest mortality predictor.
Key Tables / Differentials
| Functional PNET | Hormone/syndrome | Clue | Location |
|---|---|---|---|
| Insulinoma | Insulin → Whipple triad | ↑insulin AND C-peptide | Anywhere (90% benign) |
| Gastrinoma (ZES) | Gastrin | Refractory/distal ulcers + diarrhea; secretin ↑gastrin | Passaro triangle; MEN1 |
| Glucagonoma | Glucagon | Necrolytic migratory erythema, diabetes | Tail |
| VIPoma | VIP | WDHA (watery diarrhea, hypokalemia, achlorhydria) | Distal |
| Somatostatinoma | Somatostatin | Diabetes + gallstones + steatorrhea | Head |
| Cystic lesion | Cyst-fluid | Note |
|---|---|---|
| Serous cystadenoma | Low CEA, low amylase | Benign; central scar/calcification |
| Mucinous cystadenoma | High CEA, low amylase | Premalignant → resect (tail, women) |
| IPMN | High CEA + high amylase | Main-duct → resect; side-branch → surveil |
| Pseudocyst | High amylase, low CEA | Post-pancreatitis; observe first |
Board Pearls
- Whipple triad (hypoglycemia symptoms + glucose <50 + relief with glucose) → insulinoma; C-peptide distinguishes from exogenous insulin (low in factitious).
- Courvoisier sign (palpable nontender gallbladder + painless jaundice) → pancreatic head/periampullary cancer.
- Secretin stimulation test → gastrin rises in ZES (falls in normals).
- Most accurate cyst marker for a mucinous lesion = cyst-fluid CEA.
Classic Vignette Triggers
- "Epigastric pain to the back, ↑lipase, alcohol" → acute pancreatitis → fluids + enteral feeding.
- "Sentinel GI bleed days after a Whipple" → GDA stump pseudoaneurysm → angioembolization.
- "Necrolytic migratory erythema + new diabetes + tail mass" → glucagonoma.
- "Watery diarrhea, hypokalemia, achlorhydria" → VIPoma (WDHA).
- "Refractory ulcers beyond the bulb + diarrhea + high gastrin" → gastrinoma (rule out MEN1).