Board Pearls

By Board Pearls

The most complete gastroenterology board-review podcast on the web, and it is entirely free. This is the GI series from Board Pearls: board review built around clinical reasoning, not recall. Every ep... more

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How many episodes does Board Pearls have?

The podcast currently has 153 episodes available.

Board Pearls episodes:

July 16, 2026Chapter 28, Ep 4 of 7: When Standard ERCP Fails
Episode four picks up the moment standard ERCP fails, and it runs on a single habit: name the anatomic barrier and let it choose the technique. When you cannot cannulate the papilla, a dilated duct becomes an EUS target, and the finishing options rank by how much natural drainage they keep, rendezvous over choledochoduodenostomy over hepaticogastrostomy. When surgery has hidden the papilla, the question is how to restore the duodenoscope's en face view through the particular barrier, so EDGE tunnels into the bypassed stomach, balloon enteroscopy reaches a hepaticojejunostomy, and a reversed cautious approach handles Billroth two. Device design and technique are consequences of the anatomy, not lists to memorize.

Topics covered
EUS-guided biliary drainage and the dilated-duct target
EUS-guided rendezvous
Choledochoduodenostomy with a LAMS
Hepaticogastrostomy and anti-migration stents
Roux-en-Y gastric bypass and the EDGE procedure
Balloon enteroscopy for hepaticojejunostomy
Billroth two and the reversed sphincterotomy
En face access as the organizing principle

Key decisions
Reserve EUS-guided biliary drainage for obstruction with upstream dilation, because a dilated duct is the only target you can puncture; a normal-caliber duct offers nothing to aim at.
Choose EUS-guided rendezvous first whenever the papilla is reachable, since advancing a wire across the papilla for a duodenoscope preserves natural drainage and leaves no permanent fistula.
Use choledochoduodenostomy with a lumen-apposing metal stent when the papilla is unreachable but the extrahepatic duct sits within a centimeter of the duodenal bulb with no intervening vessels on Doppler.
Fall back to hepaticogastrostomy with a partially covered stent (covered tract segment, uncovered intraductal segment) only when neither the papilla nor the extrahepatic duct is available and a dilated left intrahepatic duct remains.
Prefer the EDGE procedure over balloon enteroscopy in Roux-en-Y gastric bypass, then remove the LAMS and close the fistula at the end of biliary therapy to prevent weight regain.
Reach a Roux-en-Y hepaticojejunostomy anastomosis with balloon-assisted enteroscopy, using percutaneous transhepatic cholangiography or EUS-guided hepaticogastrostomy as fallbacks.
In Billroth two anatomy prefer a forward-viewing endoscope up the afferent limb given the five to eight percent perforation risk, and cut the sphincterotomy in the reversed direction, ideally a needle-knife over a placed stent.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: ERCP and EUS Procedures
Read this episode: boardpearls.com/gi/episodes/ercp-and-eus-procedures-ep4
Questions or feedback: [email protected].
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17min
July 16, 2026Chapter 28, Ep 3 of 7: The Obstructed and Indeterminate Biliary Tree
Episode three centers on the stricture you cannot name: painless jaundice, a tight narrowing, and imaging that says cancer without proving it. Tissue acquisition is the whole game, and every step up the diagnostic cascade works by getting closer to the tumor, from a shallow brush that misses submucosal cholangiocarcinoma to intraductal biopsy and FISH to cholangioscopy to an EUS needle in the mass itself. The transplant candidate inverts that hierarchy, because a needle in the hilar primary can seed the peritoneum and disqualify the cure. Then durable drainage follows anatomy: covered metal distally to block ingrowth, uncovered metal at the hilum to preserve side branches, and always enough viable liver drained to clear the bilirubin.

Topics covered
Brush cytology and why it misses cholangiocarcinoma
Intraductal biopsy, FISH, and cholangioscopy
EUS fine needle biopsy of a pancreatic head mass
Transplant candidate and needle-tract seeding
Endoscopic ampullectomy versus Whipple
Distal covered metal stents
Hilar uncovered metal stents and side branches
Draining fifty percent of viable liver

Key decisions
Do not trust a negative brush cytology in a malignant-looking stricture; stack intraductal forceps biopsy and FISH for polysomy, then cholangioscopy with targeted biopsy, because each step samples deeper than superficial shed cells.
For a pancreatic head mass needing tissue before neoadjuvant chemotherapy, use EUS-guided fine needle biopsy of the mass itself, favoring a biopsy needle over aspiration when you need core architecture and immunohistochemistry.
In a transplant candidate never needle the hilar primary by EUS or percutaneous route; stay inside the duct with brush and intraductal biopsy, and biopsy suspicious regional nodes only as a transplant-eligibility test.
Resect an ampullary adenoma en bloc for lesions up to two to three centimeters after EUS excludes intraductal extension, accepting a ten to fifteen percent pancreatitis rate to spare the patient a Whipple.
Place a prophylactic five French pancreatic duct stent after ampullectomy, skip the submucosal lift, and survey the resection bed at three and six months with a side-viewing duodenoscope in FAP.
Use a fully covered self-expanding metal stent for distal malignant obstruction to block tumor ingrowth and allow removal at the Whipple, reserving plastic stents for a life expectancy under three months.
At the hilum use an uncovered metal stent so side-branch bile flows through the mesh, map viable territories with MRCP, and drain at least fifty percent of viable liver while avoiding atrophic segments.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: ERCP and EUS Procedures
Read this episode: boardpearls.com/gi/episodes/ercp-and-eus-procedures-ep3
Questions or feedback: [email protected].
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17min
July 16, 2026Chapter 28, Ep 2 of 7: Patient Selection and Complications
Episode two is about the decision that comes before cannulation and the restraint it takes to decline the procedure when objective evidence for benefit is absent. A landmark sham-controlled trial retired type three sphincter of Oddi dysfunction as a sphincterotomy indication, so pain with normal labs and a normal duct becomes a functional pain disorder, not an ERCP. Pregnancy raises the threshold highest because a second patient absorbs all the risk and none of the benefit. The back half turns on two failure mechanisms, the cut that bleeds and the elevator that harbors biofilm, and each names the patient to protect and the device choice that protects them.

Topics covered
Sphincter of Oddi dysfunction types and the landmark trial
Post-cholecystectomy duct dilation as physiologic compensation
ERCP in pregnancy and radiation minimization
Sedation and positioning in pregnancy
Post-sphincterotomy bleeding risk factors
Balloon dilation versus sphincterotomy in coagulopathy
Perforation and the Stapfer classification
Duodenoscope biofilm and single-use scopes

Key decisions
Do not offer sphincterotomy for type three sphincter of Oddi dysfunction (pain with normal enzymes and a non-dilated duct); a sham did at least as well, so manage it as a functional pain disorder with neuromodulators and behavioral therapy.
Treat type one dysfunction (pain, elevated enzymes, dilated duct) with biliary sphincterotomy without manometry, and treat type two as shared decision-making with mandatory indomethacin, lactated Ringer, and a pancreatic duct stent since manometry is the highest-PEP procedure.
Read a ten to twelve millimeter duct in a post-cholecystectomy patient with normal enzymes as physiologic compensation, not sphincter dysfunction, so it alone does not justify ERCP.
In pregnancy avoid diagnostic ERCP entirely: use non-contrast MRCP or EUS, shield the uterus, run pulsed fluoroscopy at four to eight pulses per second aiming under one minute, prefer the second trimester, and keep fetal dose under the fifty milligray threshold.
Prefer propofol for sedation in pregnancy, accept moderate-dose fentanyl, avoid midazolam especially in the first trimester, and position the patient left-lateral to avoid aortocaval compression.
In cirrhosis or coagulopathy choose endoscopic papillary balloon dilation over full sphincterotomy for stone extraction, trading the cut for a stretch to avoid a bleeding bed the mucosa cannot control.
Prevent duodenoscope-transmitted infection with disposable elevator caps or single-use duodenoscopes rather than double high-level disinfection or ethylene oxide, which add no benefit because they cannot reach the elevator interior.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: ERCP and EUS Procedures
Read this episode: boardpearls.com/gi/episodes/ercp-and-eus-procedures-ep2
Questions or feedback: [email protected].
...more
13min
July 16, 2026Chapter 28, Ep 1 of 7: Safe Cannulation and PEP Prophylaxis
Episode one of the ERCP and EUS Procedures chapter starts from the single fact that reorganizes everything: ERCP is a therapy, not a test, so you earn the right to do it only when a non-invasive study cannot answer the question. From there the whole episode is risk management. Wire-guided cannulation replaces the hydraulic contrast push that floods the pancreatic duct, difficult-cannulation maneuvers each solve one anatomic problem, and the prophylaxis stack is held by mechanism because the mechanisms tell you who needs which. The organizing thread: find the duct by guidance, then stack indomethacin, a pancreatic duct stent, and lactated Ringer on the patient whose risk factors say the pancreas will react.

Topics covered
ERCP as therapy, not a diagnostic test
Post-ERCP pancreatitis risk and mechanism
Wire-guided versus contrast-first cannulation
Difficult-cannulation escalation and EUS rendezvous
Rectal indomethacin prophylaxis
Prophylactic pancreatic duct stent
Aggressive lactated Ringer hydration
High-risk patient profile and protective chronic pancreatitis

Key decisions
Reserve ERCP for therapeutic intent (stone extraction, stricture stenting, cholangitis decompression, leak repair); if you only need to image the ducts, order MRCP or EUS, which carry no pancreatitis risk.
Use wire-guided cannulation rather than contrast-first, because threading a soft hydrophilic guidewire avoids the hydraulic acinarization injury that flooding the pancreatic duct with contrast produces.
Give rectal indomethacin one hundred milligrams before every native-papilla ERCP, timed pre-procedure so the drug is therapeutic at the moment of cannulation.
In high-risk patients keep the prophylactic pancreatic duct stent on top of indomethacin, not instead of it, since indomethacin alone was not non-inferior to indomethacin plus a stent.
Run lactated Ringer at three milliliters per kilogram per hour during the procedure, a twenty milliliter per kilogram bolus immediately after, then three milliliters per kilogram per hour for eight hours, chosen over saline because lactate buffers acidosis.
Concentrate the full stack on high-risk patients (suspected sphincter of Oddi dysfunction, prior PEP, female sex, normal bilirubin, difficult cannulation, acinarization), remembering a normal bilirubin raises risk and burnt-out chronic pancreatitis runs it backwards.
Do not use octreotide, gabexate, or intravenous secretin; they sound plausible but do not reduce post-ERCP pancreatitis.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: ERCP and EUS Procedures
Read this episode: boardpearls.com/gi/episodes/ercp-and-eus-procedures-ep1
Questions or feedback: [email protected].
...more
11min
July 16, 2026Chapter 27, Ep 4 of 4: Cysts, Leaks, Strictures, and Sphincter Dysfunction
Episode four turns to the duct that is structurally abnormal from birth or made abnormal by an operation, where the recurring move is to read the anatomy and let it dictate whether an endoscopic fix can work at all. Choledochal cysts drive cholangiocarcinoma through decades of epithelial exposure to refluxed enzymes, and the Todani type dictates the operation, with complete excision the rule and the choledochocele the low-risk exception. Bile leak and stricture are the iatrogenic version, where the Strasberg level decides whether endoscopic stenting can bridge the injury at all, so a cystic-stump leak seals with a stent while a complete transection needs hepaticojejunostomy. Sphincter of Oddi dysfunction divides into a true stenosis that sphincterotomy cures, a functional pain that a procedure only harms, and a heterogeneous middle where empiric sphincterotomy beats a manometry-driven workup.

Topics covered
Choledochal cysts and the Todani classification
Cholangiocarcinoma risk and cyst anatomy
Cyst excision and hepaticojejunostomy
Pancreaticobiliary maljunction
Caroli disease and syndrome
Bile leaks and the Strasberg classification
Type E transection and reconstruction
Post-cholecystectomy strictures
Sphincter of Oddi dysfunction reclassified

Key decisions
Todani type one, two, and four choledochal cysts need complete cyst excision, cholecystectomy, and a Roux-en-Y hepaticojejunostomy, because a Whipple leaves proximal cyst epithelium and its cancer risk in place.
The choledochocele is the exception, where the intraduodenal location and very low malignancy risk make endoscopic sphincterotomy or limited excision sufficient.
Whenever pancreaticobiliary maljunction is found, prophylactic cholecystectomy is part of the operation cyst or no cyst, because in maljunction without cysts gallbladder cancer develops in about a third of patients.
After cyst excision, current guidance recommends lifelong MRCP every three to five years to surveil retained at-risk epithelium that can still progress to cholangiocarcinoma.
Strasberg type A cystic-stump leaks seal in most cases with endoscopic sphincterotomy plus a transpapillary stent within four to six weeks, and type C and D injuries with luminal continuity can also be stented.
Strasberg type E complete transection has no continuity for a stent to reach and requires surgical Roux-en-Y hepaticojejunostomy, with the Bismuth level predicting complexity.
The former SOD type one is true mechanical stenosis treated with empiric biliary sphincterotomy without manometry, the former type three is functional pain that should not undergo ERCP, and suspected sphincter dysfunction demands aggressive prophylaxis with rectal indomethacin, lactated Ringer's, and a pancreatic duct stent.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Biliary Tract Disease
Read this episode: boardpearls.com/gi/episodes/biliary-tract-disease-ep4
Questions or feedback: [email protected].
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13min
July 16, 2026Chapter 27, Ep 3 of 4: Duct Stones and Acute Cholangitis
Episode three takes the stone into the bile duct, and the whole problem sits on a probability question, because ERCP carries its own complication profile, headlined by post-ERCP pancreatitis. You earn the right to do an ERCP by raising the pretest probability of a retrievable stone high enough to justify the procedural risk, so high-probability patients go straight to ERCP while intermediate patients confirm the stone first with MRCP or endoscopic ultrasound. When the same stone turns septic, cholangitis runs on a hydraulic mechanism: the obstruction raises intraductal pressure and refluxes bacteria into the blood, which is why antibiotics alone cannot fix it and decompression is mandatory. The Tokyo grade scales the timing, and clinical improvement on antibiotics is never mistaken for a relieved obstruction.

Topics covered
Post-ERCP pancreatitis and the probability tiers
High, intermediate, and low probability features
MRCP versus endoscopic ultrasound
Large stones and post-cholecystectomy stones
Cholangitis and the hydraulic mechanism
Charcot triad and Reynolds pentad
Tokyo grading and decompression timing
Empiric antibiotics and rescue drainage

Key decisions
High-probability duct stone requires any one of a stone seen on imaging, ascending cholangitis, or a bilirubin over four with a duct dilated above six millimeters, and any one of those sends the patient straight to ERCP.
Intermediate-probability patients should not go straight to ERCP; confirm or refute the stone first with MRCP, or endoscopic ultrasound when small stones or sludge are suspected.
MRCP misses stones under six millimeters while endoscopic ultrasound catches sludge and microlithiasis, so small-stone disease favors EUS and an anatomic duct survey favors MRCP.
Stones a centimeter or larger exceed what a conventional sphincterotomy can extract, so first-line therapy is sphincterotomy plus large-balloon dilation, with cholangioscopy-directed lithotripsy as the alternative.
In cholangitis, decompression is the central intervention because antibiotics only suppress bacteremia while the closed obstructed duct keeps reseeding.
Tokyo severe cholangitis with any organ dysfunction needs biliary decompression within twenty-four hours, moderate disease needs ERCP within forty-eight hours, and ERCP within forty-eight hours reduces mortality across all three grades.
Empiric antibiotics target enteric gram-negatives and anaerobes with a third-generation cephalosporin plus metronidazole, piperacillin-tazobactam, or a carbapenem in healthcare-associated or immunocompromised patients.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Biliary Tract Disease
Read this episode: boardpearls.com/gi/episodes/biliary-tract-disease-ep3
Questions or feedback: [email protected].
...more
10min
July 16, 2026Chapter 27, Ep 2 of 4: Uncommon Gallbladder Presentations
Episode two covers the less common gallbladder presentations, and the thread running through all of them is the same: chronic inflammatory remodeling around the gallbladder distorts the anatomy enough to change either the operation, the cancer risk, or the diagnostic frame. Stone-driven inflammation at Calot's triangle either compresses the bile duct from outside in Mirizzi, calcifies the wall in porcelain gallbladder, or erodes into bowel in gallstone ileus and Bouveret. The Csendes stage sets the reconstruction, the calcification pattern sets the cancer indication, and the level of stone impaction sets endoscopy versus surgery. Polyps test on a clean size rule with risk-factor modifiers, and functional gallbladder disorder tests on the discipline not to operate, because the failure mode is over-treating a heterogeneous category.

Topics covered
Mirizzi syndrome and the Csendes classification
MRCP staging and open conversion risk
Porcelain gallbladder and calcification pattern
Cholecystenteric fistula and gallstone ileus
Bouveret syndrome and gastric outlet obstruction
Gallbladder polyps and the size threshold
Gallbladder adenocarcinoma biology
Pancreaticobiliary maljunction
Functional gallbladder disorder and over-treatment

Key decisions
In Mirizzi syndrome the Csendes stage dictates the operation: external compression or a small fistula allows cholecystectomy or primary repair over a T-tube, while destruction of two-thirds or more of the duct wall requires hepaticojejunostomy.
MRCP is the study of choice in suspected Mirizzi because it shows the stone, duct compression, and any fistula without instrumenting, and dense inflammation at Calot's triangle mandates open conversion with intraoperative cholangiography.
Mucosal, incomplete, or focal porcelain gallbladder calcification remains an indication for prophylactic cholecystectomy, while complete circumferential transmural calcification can be observed in selected high-risk surgical patients.
Gallstone ileus is managed with enterotomy and stone extraction, and a staged approach that defers fistula takedown lowers perioperative mortality in elderly comorbid patients; Bouveret syndrome is treated first-line with endoscopic lithotripsy because the duodenal stone is within endoscopic reach.
Gallbladder polyps at or above ten millimeters warrant cholecystectomy regardless of other features, and six-to-nine-millimeter polyps warrant surgery if any risk factor is present, with documented growth of two millimeters or more the highest-yield malignancy signal.
Primary sclerosing cholangitis drops the polyp threshold so that any polyp, or one at eight millimeters, warrants cholecystectomy, with annual ultrasound surveillance.
Functional gallbladder disorder demands strict selection: fully met biliary pain criteria, structural disease excluded, functional GI disease optimized first, and explicit counseling that even low-ejection-fraction patients improve only about sixty percent of the time.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Biliary Tract Disease
Read this episode: boardpearls.com/gi/episodes/biliary-tract-disease-ep2
Questions or feedback: [email protected].
...more
16min
July 16, 2026Chapter 27, Ep 1 of 4: Gallstones and Acute Cholecystitis
Episode one of the Biliary Tract Disease chapter starts with the stone, because the phenotype tells you what biochemical environment produced it, and that environment is really the risk-factor list seen from the mechanism side. Cholesterol stones come from supersaturation, dysmotility, or nucleation; black pigment stones from excess unconjugated bilirubin; brown pigment stones form new in the duct under stasis plus bacterial deconjugation. Asymptomatic stones are observed because the math favors it, unless a cancer or surgical-emergency configuration shifts the calculus, and true biliary colic tips a fit patient toward cholecystectomy. When persistent obstruction converts colic into acute cholecystitis, the Tokyo grade dictates how aggressively to operate, with the friable ischemic wall of the acalculous and emphysematous variants pushing drainage back toward the percutaneous route.

Topics covered
Cholesterol stones and the three lithogenic pathways
Gallstone risk factors mapped to mechanism
Black pigment stones and chronic hemolysis
Brown pigment stones and the two-year rule
Observation versus surgery for asymptomatic stones
Prophylactic cholecystectomy indications
Tokyo diagnosis and grading of cholecystitis
Drainage options for the poor surgical candidate
Acalculous and emphysematous variants

Key decisions
Asymptomatic gallstones are observed because progression to symptomatic disease runs only one to four percent per year, which does not exceed the perioperative mortality of elective cholecystectomy.
Prophylactic cholecystectomy is offered for a discrete list of cancer or emergency configurations: patchy porcelain gallbladder, stones three centimeters or larger, coexisting polyps, Native American women with stones, and pancreaticobiliary maljunction with cysts.
In uncomplicated cholecystitis liver chemistries stay normal or under twice normal, so a marked bilirubin or transaminase elevation signals concurrent duct stones or Mirizzi syndrome and should widen the differential.
Tokyo grade one mild disease gets early laparoscopic cholecystectomy within the admission, usually within seven days, while the planes of Calot's triangle still separate.
Tokyo grade three severe disease with organ dysfunction gets ICU resuscitation plus emergent gallbladder drainage first, with cholecystectomy deferred and sometimes never done.
For the poor surgical candidate, endoscopic-ultrasound-guided drainage with a lumen-apposing metal stent is now preferred over percutaneous drainage, but emphysematous cholecystitis is a contraindication because the ischemic friable wall risks catastrophic perforation.
Acalculous and emphysematous variants prioritize rapid percutaneous cholecystostomy with broad-spectrum antibiotics, and gangrene, perforation, or peritonitis forces operation regardless of stability.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Biliary Tract Disease
Read this episode: boardpearls.com/gi/episodes/biliary-tract-disease-ep1
Questions or feedback: [email protected].
...more
18min
July 16, 2026Chapter 26, Ep 5 of 5: Pancreatic Adenocarcinoma and Neuroendocrine Tumors
Episode five closes the chapter with two tumors that share the same pancreas and almost nothing else. Adenocarcinoma is desmoplastic, poorly enhancing, presents late with painless jaundice, and is staged by its relationship to four vessels into the resectability categories that drive surgery-versus-systemic-therapy. The neuroendocrine tumors are islet-derived, hypervascular, and often announce themselves with a hormone syndrome while still small, sorted by functional pattern and grade. The same core biopsy and multiphase CT serve both, but everything downstream diverges, so the work is holding the two algorithms apart. Biology sets the staging language, and the staging language sets the treatment, from neoadjuvant FOLFIRINOX to somatostatin analogs and radionuclide therapy.

Topics covered
Adenocarcinoma biology and late presentation
Risk factors: modifiable, hereditary, conditioning
Diagnostic sequence and core biopsy
The autoimmune pancreatitis mimic trap
Four-vessel resectability staging
Neoadjuvant, adjuvant, and metastatic chemotherapy
Neuroendocrine tumor biology and imaging
Functional syndromes: insulinoma and gastrinoma
VIPoma, glucagonoma, somatostatinoma
Treatment stratified by size and receptor status

Key decisions
A patient over sixty with a painless head mass and obstructive jaundice has adenocarcinoma until proven otherwise, so a mildly elevated IgG4 does not justify empiric prednisone that would cost the curative window.
Resectability is defined by the tumor relationship to the celiac axis, common hepatic artery, superior mesenteric artery, and superior mesenteric and portal veins, with borderline disease showing arterial contact under one hundred eighty degrees or reconstructable venous involvement.
Borderline resectable and many resectable patients receive neoadjuvant modified FOLFIRINOX for four to six months before re-staging, and upfront-surgery patients receive adjuvant modified FOLFIRINOX when fit.
Metastatic disease is treated with modified FOLFIRINOX or gemcitabine plus nab-paclitaxel by performance status, with olaparib maintenance for germline BRCA or PALB2 mutations whose tumors respond to platinum.
In suspected insulinoma, a suppressed C-peptide with high insulin during hypoglycemia indicates factitious insulin use rather than tumor, and endoscopic ultrasound is the dominant localization tool because most insulinomas are somatostatin-receptor negative.
Gastrinoma diagnosis requires a fasting serum gastrin measured off proton pump inhibitor for seven days, with a gastrin above one thousand picograms per milliliter and gastric pH under two diagnostic, and intermediate values prompting a secretin stimulation test.
Non-functional neuroendocrine tumors under one centimeter may be observed while those over two centimeters warrant resection, and unresectable disease is managed with somatostatin analogs, everolimus or sunitinib, and lutetium-DOTATATE radionuclide therapy.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Chronic Pancreatitis, Pancreatic Cysts, and Pancreatic Neoplasms
Read this episode: boardpearls.com/gi/episodes/chronic-pancreatitis-cysts-neoplasms-ep5
Questions or feedback: [email protected].
...more
16min
July 16, 2026Chapter 26, Ep 4 of 5: Pancreatic Cystic Lesions and Surveillance
Episode four takes the incidental cyst through the same endoscopic-ultrasound-and-fluid pathway used for the autoimmune mass, but the cost runs the other way: resecting a cyst that was never going to become cancer commits a patient to major-operation morbidity for nothing. The organizing question is whether the epithelium is mucinous, because only the mucinous lesions carry progressive dysplasia, and the fluid answers it, CEA and glucose for mucin, amylase for duct communication. Demographics and imaging give a pretest guess, then the biochemistry classifies the lesion cleanly. The intraductal mucinous neoplasm is the one left to surveil, where high-risk stigmata mandate resection, worrisome features trigger endoscopic ultrasound, and a size-stratified MRI schedule runs only while it can still change management. Thresholds are the trap throughout.

Topics covered
Mucinous versus non-mucinous as the organizing principle
Demographics and imaging of the five entities
Mucinous cystic neoplasm versus serous cystadenoma
Fluid biochemistry: CEA, glucose, amylase
The four-quadrant classification by CEA and amylase
Clinical pivots by cyst type
High-risk stigmata versus worrisome features
The five- and ten-millimeter thresholds
Size-stratified surveillance and stopping rules

Key decisions
The decision to watch or resect tracks whether the epithelium is mucinous, since intraductal and mucinous cystic neoplasms harbor progressive dysplasia while serous cystadenoma, pseudocyst, and retention cysts have negligible malignant potential.
A cyst fluid CEA above one hundred ninety-two nanograms per milliliter favors mucinous origin, a glucose below fifty is highly sensitive for a mucinous cyst, and an amylase above two hundred fifty units per liter supports duct communication.
A mucinous cystic neoplasm goes to resection in a fit candidate regardless of size, while a confidently diagnosed serous cystadenoma needs no surveillance at all.
Any one of the four high-risk stigmata, obstructive jaundice with a cystic head lesion, an enhancing mural nodule five millimeters or larger, a main pancreatic duct ten millimeters or larger, or suspicious cytology, mandates surgical referral with no confirmatory aspiration needed.
Worrisome features such as a cyst three centimeters or larger, an enhancing nodule under five millimeters, a main duct between five and ten millimeters, or growth of two and a half millimeters or more per year trigger endoscopic ultrasound rather than the operating room.
A new five-millimeter enhancing nodule crosses from worrisome into high-risk regardless of prior stability, so a four-millimeter nodule keeps a patient in surveillance while a five-millimeter nodule is the threshold for resection.
Surveillance continues only while it can change management, stopping when the patient is no longer a surgical candidate or life expectancy is under ten years, with exceptions for younger, familial, or genetically at-risk patients.

This is an AI-generated podcast, and some pronunciations may be imperfect. Thank you for your understanding, and we hope you enjoyed this content.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Chronic Pancreatitis, Pancreatic Cysts, and Pancreatic Neoplasms
Read this episode: boardpearls.com/gi/episodes/chronic-pancreatitis-cysts-neoplasms-ep4
Questions or feedback: [email protected].
...more
12min

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How many episodes does Board Pearls have?

The podcast currently has 153 episodes available.