c fluid • definable wall,

Table 1. Pancreatic Islet Cells collection • solid material

Cell Type Hormone Action Pseudocyst >4 weeks • Endoscopic/
Alpha* Glucagon  gluconeogenesis, • Well defined wall • Surgical drainage
glycogenolysis • No necrosis, • Cystoenterostomy
Beta* Insulin  glycogenesis, solid
protein synthesis material We connect the cyst
Delta Somatostatin Inhibits GI secretions, to the stomach or
GI endocrine peptides intestine, as to drain
PP Pancreatic Inhibits pancreatic the pancreas.
Polypeptide exocrine secretion Acute • Contains • Conservative/
*Two main hormones that we should be familiar with Necrotic fluid/solid • Percutaneous/
Table 2. Amylase vs Lipase Collection • No wall • Surgical drainage
Amylase Lipase Walled off • >4 weeks • Surgical
Onset (peak) 6-12 hrs 4-8 hrs (24 hrs) Necrosis • Encapsulated, debridement
Return to 3-5 days 8-14 days • solid/liquid
Normal
Sensitivity 67-83% Table 7. Types of PNEN
Specificity 85-98% 82-100% INSULINOMA
(most common functional pancreatic endocrine neoplasm)
Epidemiology S/Sx Diagnosis Treatment
Solitary Fasting ↑ serum Surgical
hypoglycemia insulin during resection
6% are hypoglycemi
associated Whipple’s Triad: a (72 hr fast)
with MEN1 (1) fasting
hypoglycemia
Indolent, (2) serum
majority glucose level
benign <50 mg/dL
(3) relief of
6% malignant symptoms with
Figure 9. Ranson’s Score. Knowing this well help you administration of
prognosticate the patient and at the same time it allows you 18-60 y/o glucose
to be really aggressive in your management if you see that the
score of the Ranson’s Criteria is high. M=F
GLUCAGONOMA
Table 3. % Mortality based on Ranson’s Score From alpha Weight loss Plasma Surgery
Score Mortality cells (80% of px): glucagon >
<3 0 – 3% most common 500 pg/mL Metastasecto
3–5 11 – 15% Solitary, my
>6 40% majority in the Necrolytic CT
distal migratory MRI Octreotide
pancreas erythema (70% EUS (analog of
NOTE: Doc said to just read on the following criteria in the
of px) Somatostatin Somatostatin
interest of time. What we need to know by heart is the
5th decade receptor w/c controls
RANSON’S CRITERIA.
Glossitis scintigraphy glucagon
20% MEN 1 Angular cheilitis secretion)
APACHE II (ACUTE PHYSIOLOGY AND CHRONIC
associated Stomatitis
EVALUATION II) SCORE
Blepharitis
APACHE score > 8 indicates severe disease
50-80% Hair loss
Table 4. Variables considered in APACHE scoring
metastatic at Nail dystrophy
Rectal Temp K
diagnosis
MAP Creatinine
Glucose
Heart Rate Hct intolerance, mild
Respiratory Rate WBC (75-95%)
Aa Gradient or PO2 GCS
pH or HCO3 Age Diarrhea (due
Na Chronic Disease to gastrin, VIP,
calcitonin and
BISAP/ BEDSIDE INDEX OF SEVERITY IN ACUTE serotonin
PANCREATITIS cosecretion)
• BISAP Score include the following:
o BUN > 25mg/dL (8.9 mmol/L) Venous
o GCS < 15 thrombosis
o SIRS Neuropsychiatr
o Age >60 y/o ic symptoms
o Pleural effusion Dilated
cardiomyopath
Table 4. % Mortality based on BISHAP Points y
Points Mortality
0-2 <2 % VIPoma
3–5 > 15% (Vasoactive intestinal peptide-secreting tumor/Verner Morrison
Syndrome/Pancreatic cholera syndrome/WDHA Syndrome)
ATLANTA CLASSIFICATION 1 in 10 M/yr Secretory Serum VIP > Surgery
diarrhea – 75pg/mL
Table 5. Severity of Acute Pancreatitis based on Atlanta Double peak: persists w/ Metastasectomy
Classification (1) 30-50 y/o fasting and the CT controls
Mild No organ failure/complications (2) 2-4 y/o ff: MRI symptoms
Moderately Transient organ failure (<48hrs) (1) tea-colored
severe Complications w/o persistent organ 75% tail, stool, odorless Somatostatin Octreotide
failure solitary (2) Mild to no Receptor
Severe Persistent organ failure abdominal Scintigraphy
60-80% pain
metastatic at DOTA-PET
Table 6. Pancreatic Inflammatory Fluid Collections diagnosis Scan
Acute Within 4 weeks • Most will resolve
peripancreati • No necrosis, 5% MEN 1
association
 GASTRINOMA (Zollinger Eliison Syndrome)
20-50 y/o Abdominal Intractable Enucleation Table 9. Zones of Adrenal Cortex & their Physiologic functions
pain ulcers Resection Glomerular Mineralocorticoids: • Involved in RAS
25% associated Diarrhea (Glomerulosa Aldosterone axis
with MEN 1 GERD Multiple Highly selective ) • Aldosterone is
Weight loss ulcers in vagotomy: may produced by the
50% solitary, GI bleeding atypical reduce PPI cortex in
50% multiple 1-10%: locations requirement response to
second production of
60-80% hormone Severe Metastasectomy Angiotension II
malignant syndrome esophagitis : if primary • Aldosterone then
(VIPoma, tumor is causes an
Most are in Glucagonom *Serum controlled increased in BP,
duodenum a, ACTH) gastrin > Na retention,
1000 pg/mL Chemotherapy metabolic
70-90% found in (Stop PP1 & other ablative alkalosis and K
Passaro’s before techniques if wasting
triangle (see measuring) inoperable Fascicular Glucocorticoids: • Involved in
Figure 13) (Fasciculata) Cortisol, hydrocortisone Hyothalamic-
Secretin Debulking NOT Reticular Cortisol & androgens pituitary-
stimulation helpful (Reticularis) (dehydroisoandrosteron adrenal axis &
test in e& has negative
equivocal dehydroepiandrosterone feedback
cases ) → exert physiologic • Androgens: hair
activity after conversion and libido
Imaging of to testosterone and production
choice: dehydrosterone • Cortisol: for
Octreotide metabolic
Scintigraph regulation
y (protein
catabolism,
EUS, CT insulin
SOMATOSTANIMOMA resistance),
From delta cell Abdominal Fasting Surgery immunomodulati
pain plasma on,
50-75% somatostatin Octreotide if cardiovascular
malignant Most common: >30 pg/mL unresectable regulation
weight loss (raised BP) and
70-90% CT CNS actions
metastatic Classic triad: MRI (increased
(1) gallstone Octreotide appetite,
55% in the (2) diabetes scan impaired
pancreas, (3) DOTA-PET memory)
usually head of steatorrhea
pancreas,
ACTION OF GLUCOCORTICOIDS
pancreatodu-
odenal groove
(60% at the Table 10. Action of Glucocorticoids (NOTE THIS TABLE)
ampulla/peri- Increased Decreased
ampullary area) • Glycogen synthesis (liver) • Glucose utilization by
• Gluconeogenesis peripheral tissue
• Protein synthesis (liver) • Protein synthesis in muscles
• Protein destruction in
Table 8. IPMN & other cystic neoplasms (Note this table muscles
according to Dr. Mendoza) • Lipolysis
Epidemiology Features Malignan Treatment • Anti-inflammatory
t • Immunomodulation
Potential • Cardiovascular regulation
IPMN (increased BP)
5th-7th decade Multiple cysts Branch Resection
M=F (grape like) duct: except if
mucin filled benign “benign
duct with looking” in
papillary Main high risk
projections duct: patient
malignant
Serous cystadenoma
Elderly female Microcystic, 99% Conservative
honeycomb, benign , surgery if
with central malignant or
stellate scar or symptomatic
oligocystic
Mucinous Cystadenoma (MCN)
Perimenopausa Thick walled, Benign Resection
l women septated, with
mucin filled, malignant
no ductal potential
communicatio or
n malignant

Mostly body
and tail

Ovarian
stroma
Solid pseudopapillary tumor
Young female Solid and Low/ Resection
cystic borderline
Figure 15. Functions of Glucocorticoids

CATECHOLAMINES

Figure 18. Algorithm to review if adrenal hyperplasia is

suspected (STUDY!)

Table 11. Causes of Cushing’s Syndrome

.
Figure 16. Synthesis of Catecholamines
Table 12. Features of Cushing’s Syndrome (Schwartz)
System Manifestation
Weight gain—central obesity, buffalo
General hump, supraclavicular fat pads
Hirsutism, plethora, purple striae, acne,
Integumentary
ecchymosis
Cardiovascular Hypertension
Musculoskeletal Generalized weakness, osteopenia
Neuropsychiatric Emotional lability, psychosis, depression
Diabetes or glucose intolerance,
Metabolic
hyperlipidemia
Renal Polyuria, renal stones
Impotence, decreased libido, menstrual
Gonadal
irregularities

Figure 17. Metabolism of Catecholamine Hormones

Figure 23. Diagnosis of Cushing’s syndrome. DST:
dexamethasone suppression test. ACTH: adrenocorticotropic
hormone.
 APPENDIX
APPENDIX 1. Summary of Pancreatic Diseases and their Management
Disease Etiology S/sx Diagnostic Procedures Treatment
Acute • Gallstone, Ethanol, • Severe abdominal • CBC • Fluid Resuscitation
Pancreatitis Trauma&tumors, pain • CRP • Analgesics-
steroids, mumps&viral • Nausea and vomiting • AST meperidine
infections, • May/may not be toxic • CT scan-imaging of • NPO?
autoimmune, looking choice • Antibiotics- in infected
hypertiglycediemia, • Abdominal tenderness • MRI/MRCP- if with necrosis- Imipenem
hypercalcemia, ERCP, • Abdominal distention contraindication to • Somatostatin?
drugs, smoking, • +/- jaundice contrast CT
idiopathic • Cullen’s sign • US- not very helpful
• Gallstones and • Grey Turner’s sign
Ethanol are the most
common causes
Chronic • Alcohol – 70% • Abdominal pain – • Normal amylase and • Cessation of alcohol
Pancreatitis • Idiopathic – 20% most consistent lipase • Analgesics
• Autoimmune finding • Fecal elastase • Pancreatic enymes
• Hereditary – mutation • Weight loss, anorexia • 72 hr fecal fat • Celiac plexus block
of SPINK 1 – before • DM determination • Endoscopic stenting
20 y/o • Steatorrhea, bloating, • Xray • Stoneremoval
• Cystic fibrosis flatulence, diarrhea • CT sphincterotomy
• Tropical pancreatitis – • Vitamin deficiency – • MRI • Surgery
India, Indonesia, Africa bone disease, • ERCP • Pancreatectomy
• Ductal Obstruction impaired night vision • Secretin test • Islet Cell
• Smoking • Jaundice Transplantation
• SLE, • May be asymptomatic
hypertriglyceridemia,
hyperparathyroidism
• Chronic pancreatitis
and alcohol intake

Ductal • Risk Factors: • Pain • CT Scan • Pancreaticoduodenect

Adenocarci- o Age • Jaundice (*painless • MRI omy (Whipple’s
noma o Smoking jaundice!) Procedure)
o DM • Incidental Finding • Distal Pancreatectomy
o Chronic • Weight Loss
pancreatitis • Diabetes – esp. new
onset
• Upper GI obstruction

Transcriber’s Notes: For Pancreatic Neuroendocrine Neoplasm/PNENs (go back to Table 7); For Cystic Neoplasms (go back to Table
8)
APPENDIX 2. Summary of Adrenal Gland Diseases and their Management
Disease Etiology Signs and Symptoms Diagnostic Procedures Treatment
Hyperaldosteronism • Primary • Long standing • Serum Potassium – • Adrenolectomy –
o Autonomous hypertension (HPN hypokalemia (<3.2 unilateral adrenal
aldosterone • Muscle weakness mmol/L or <3.0 mmol/L tumor usually 0.5-2cm
secretion → • Fatigue while on diuretic despite • Medical management
suppression of • Polydipsia K+ replacement)
RAAS • Polyuria • Elevated plasma
• Secondary • Nocturia aldosterone
• Stimulation of the • Headaches • Suppressed plasma renin
RAA system from activity
renal artery • Aldosterone: renin ration
stenosis or low 1:25-30
flow states (ex. • Fail to suppress
CHF) aldosterone level with Na
loading
• CT Scan/MRI
Chronic • Primary • Weakness • Serum electrolytes – • Mostly medical
Adrenocortical o Autoimmune • Malaise hyperkalemia, • Etiologic:Appropriate
Insufficiency processes (50- • Weight loss hyponatremia treatment of
60%) • Anorexia • Low levels of plasma complicating
o Tuberculosis • Depression glucocorticoids and infections (e.g.
o Neoplasm, • Hyperpigmentation of mineralocorticoids, or tuberculosis)
metastatic the skin urinary 17-OHCS or 17- • Pathogenic:
carcinoma • Hypotension or KGS o Diet (enough
o Inflammatory postural hypotension • Plasma ACTH proteins, vitamins,
necrosis • Tachycardia o Primary - increased salt and water)
o Amyloidosis; o Secondary – o Glucocorticoids –
• Weight loss
Hemochromato decreased Cortisol,
• Anorexia, nausea,
sis
vomiting, abdominal • ECG - decreased voltage Prednisone 5-
o Bilateral and prolonged P-R and Hydrocortisone
pain, diarrhea
adrenal Q-T intervals o Mineralocorticoids
• Decreased cold
hemorrhage or • EEG - slowing of the α – ▪ DOCSA 5 mg
infarction, intra- tolerance, with
rhythm orally
adrenal hypometabolism may
hemorrhage be noted
• Secondary: • Sexual disorders
Hypothalamic or • Neurologic and
pituitary disease psychiatric disorders
• Glucocorticoid • Hypoglycemia
therapy - most
common
Adrenal Crisis • Stress, infection • Profound asthenia - • Substitution therapy
(especially with • Severe pains in the • Rehydration
septicemia) abdomen, lower back • Treatment of
• Trauma, surgery, or legs complications
prolonged fasting • Nausea, vomiting (hyperpyrexia,
• Salt loss due to diarrhea psychotic reactions,
excessive • Peripheral vascular high fever)
sweating during collapse
hot weather • Renal shutdown with
• Sudden azotemia
withdrawal of • Severe hyperthermia
adrenocortical due to infection
hormone therapy
Pheochromocytoma MEN2A and Hypertension – most 24-hour urine samples for Adrenalectomy - TOC
MEN2B; autosomal common catecholamines and their
dominant mutations Classic Triad metabolites
in RET proto- o Headache CT for localization
oncogene o Palpitation
o Diaphoresis

Cushing’s Syndrome Pituitary Adenoma Hypertension Dexamethasonesuppression Surgery:

(70%) Obesity test o The transfrontal
Majority is ACTH Skin – thick purple striae Cortisol and ACTH exploration,
dependent Round facies, buffalo o Transsphenoidal
Varied hump hypophysectomy
Osteoporosis o Adrenalectomy
Pituitary irradiation
Pharmacologic therapy
Adrenocortical CA Over expression of 50% nonfunctioning CT SCAN or MRI Open En Bloc Surgical
IGF II (90%) -Enlarging abdominal Remember: Size >6cm: Resection
P53 mutations mass, rarely abdominal suspect malignancy!
or back pain