Transcript Pancreas
Pancreas
Tail
Body
Head
Uncinate process
Neck
Pancreas
Exocrine
Acinar cells
Spontaneous secretion is minimal
Secretin – evokes bicarbonate-rich fluid secretion
Cholecystokinin (pancreozymin) – evokes pancreatic enzymes
secretion
Endocrine
Islet cells
B cells – insulin
A cells – glucagon
D cells – somatostatin
Pancreatic polypeptide cells
Pancreatitis
Acute pancreatitis
Mild
Severe
Chronic pancreatitis
Atlanta Definitions
Acute Pancreatitis
Mild Acute Pancreatitis
Acute inflammatory process of the pancreas, with variable involvement
of other regional tissues or remote organs systems
Pancreatitis associate with minimal organ dysfunction and an uneventful
recovery. The predominant feature is interstitial oedema of the gland
Severe Acute Pancreatitis
It is associate with organ failure and /or local complication such as
necrosis ( with infection) pseudocyst or abscess. Most often this is an
expression of the development of pancreatic necrosis although patients
with oedematous pancreatitis may manifest clinical features of severe
attack
Acute Pancreatitis
Acute pancreatitis
Etiology
Gallstones
ETOH
Iatrogenic
Drugs
Cytomegalovirus, ascariasis, scropion venom, mumps, viral hepatitis
Trauma
Anatomical anomalies
Steroid, furosemide, thiazide diuretics, azathioprine
Infection
ERCP
Pancreatic Divisum
Genetic
Familial pancreatitis
Cystic fibrosis
Alpha-antitrypsin deficiency (risk for ca pancreas)
Pancreatic Divisum
Malunion of the pancreatic ducts from the ventral and
dorsal buds of the pancreas…. Results in complete or
partial separation of the duct systems of Wirsung
(main – dorsal) and Santorini (accessory – ventral)
0.3 – 5.8% endoscopy series
5 - 14% autopsy studies
Prone to pancreatitis due to poor outflow of the
accessory duct system
But majority of the patients with pancreatic divisum don’t
have any association with acute pancreatitsi
Pathogenesis – molecular biology
Premature activation: intracellular zymogens
Nuclear factor (Kappa) B
Activator Protein 1
Cytokines, Chemokines
Pathological Calcium influx
Gap junction disruption – ETOH
Neurally mediated inflammation
Substance P
Acute pancreatitis
Symptoms
Acute Vs Chronic
History / X ray / CT scans / Pancreatic duct assessment (ERCP / MRCP)
Etiology factors
Complications
MOF / ARDS / SIRS → ICU
Infective necrosis → Operation
Pseudocyst
Splenic vein / portal vein thrombosis → varices / cirrhosis
Endocrine insufficiency DM, absorption
Chronic pancreatitis
Ductal strictures
Pancreatic Malignant Neoplasm
Cardio / Respiratory / Renal / Vascular complications
Acute pancreatitis
Rapid progressive onset of pain
Upper abdominal pain - T G R, may mimic any acute
abdominal conditions
AXR - sentinel loop, calcification, gallstones
CXR – right pleural effusion (reactive sympathetic effusion) 20%
Cullen sign (Thomas Stephen Cullen – Prof of Gynaecology. John Hopkins
Uni)
Grey turner sign (George Grey Turner – Prof of Surgery. London)
Amylase
Lipase
Multifactorial Scoring System
To predict the prognosis
Positive predictive value 50%
Ranson’s
Glasgow
Apache II
12 routinely measured physiological and biochemical
parameters, couple with a score for age and preexisting health status
Ranson’s Criteria
Biliary
Age >70
WCC >16
Glucose >12
LDH >400
AST >250
BUN >0.7
HCT↓10%
Ca <2.0
BE <-5
Oxygen < 60mmHg
Fluid >6 liters
Non biliary
Age >55
WCC >16
Glucose >11
LDH >350
AST >250
BUN >1.8
HCT ↓ 10%
Ca <2.0
BE <-4
Oxygen <60mmHg
Fluid >6 liters
Glasgow Score
Age >55
WCC > 15
Urea > 16
PaO2 < 60mmHg
Glucose >10
LDH > 600
AST / ALT > 600
Ca < 2
Albumin < 22
Assessment
Apache II scoring system
>9 severe attack
>6, 95% will have complications
C-reactive protein
36 hours after onset of illness
>210 mgI-1 first 4 days
>120 mgI-1 at end of first week
CT severity index / MRI
MOF
CT abdomen of Necrotising Pancreatitis
MOF
Respiratory
Neurocerebral
Cardiovascular
Haematological
Renal
Hepatobiliary / Gastointestinal
Bernard MOF scoring system: This scoring system does not include hepatic index
Management
Etiology factor
Early ERCP
Supportive
Organs specific
Ventilation / haemofiltration /
inotropes
Early Intensive support
Nutrition – early jejunal feeding / TPN
Octreotide / Somatostatin
Anticytokines therapy / Anti-inflammatory
agents
Gut selective Decontamination – prevent
translocation of bacteria : SIRS
Management of
Complications:
Antibiotic
Surgery – infective necrosis
Radiological guided
drainage – intraperitoneal abscess
/collection
Nutrition
Enteral feeding
Jejunostomy feeding
Nutritional support
Prevent translocation of GI bacteria
TPN
Only if gut not usable
Surgery
Infective necrosis
Clinical / microbiological confirmation
Uncontrolled sepsis
Secondary complications
Indications
Pseudoaneurysm
Intestinal obstruction
Perforation of bowel (ERCP)
Cholecystectomy
Late complications consider surgery when applicable
Pseudocyst
Pancreatic duct stricture / stenosis
Pancreatic ductal stones
Chronic Pancreatitis
Continuing inflammatory disease of the
pancreas characterized by irreversible
morphological change typically causing pain and
/ or permanent loss of pancreatic function
Chronic Pancreatitis - diagnosis
History / Examination
Radiological
Histopathological
Functional deficits
•Malabsorption
•DM
•Sudan staining of stool
72hrs stool collection with diet containing
100g fat per day, if more than 7g per day
excretion is abnormal
•Faecal trypsin / chymotrypsin
•Lundh test – direct duodenal aspiration
•Secretin-pancreozymin test
•Bentiromide test - Enzyme reaction
X Rays
CT- sensitivity 75-90%; specificity 85100% (pancreatic calcification)
degree of calcification does not correlate
with the degree of exocrine insufficiency
MRCP, ERCP
MRI
Histopathological changes:
Parenchymal fibrosis, ductal stricture,
atrophy of acinar and islet cells
•Calcific pancreatitis - alcohol
fibrosis, calcification, and protein plugging
•Obstructive Pancreatitis - stones/Carcinoma
dilatation, acinar atrophy and fibrosis
•Inflammatory Pancreatitis
autoimmune disease (Idopahtic, Sjogren
syndrome & Sclerosing Cholangitis)
Chronic Pancreatitis
Severity
No agreeable assessment method to determine
the severity of chronic pancreatitis
Based on the level of pancreatic dysfunction and
symptoms
Again clinical history and assessment
Radiological assessment for any ductal
disruption
Chronic Pancreatitis
Cambridge Classification
According to ductal anomaly
Level of disease
Main duct
Side branches
Mild
Normal
<3 affected
Moderate
Mildly affected
>3 affected
Severe
Gross disease
Gross disease
Chronic Pancreatitis: etiology
ETOH 70%
Anatomical – pancreatic divisum, ductal stricture
Genetic – cystic fibrosis, antitrypsin deficiency
Hypercalcaemia
•Decrease HCO3 and
increase protein production,
Tropical pancreatitis
increase viscosity lead to
stone formation
Nutritional pancreatitis
•Acinar cell damage
•Repeat attack lead to fat
Idiopathic Chronic Pancreatitis
necrosis, with interlobular
Early onset <35 yo – poor prognosis
Late onset >45 yo
fibrosis
•Liver impairment lead to
failure to detoxify toxic
substance causing direct
damage to the pancreas
Chronic Pancreatitis
Clinical features:
Multiple somatic / psychosocial symptoms
Endocrine / exocrine dysfunction
Burn out syndrome
Usually 15-20 years after onset of illness
Malignancy
Chronic Pancreatitis
Management
Manage symptoms
Endocrine / exocrine function
Pain control – med / thoracoscopic splanchniectomy
Psychosocial support
ETOH
Pancreatic enzyme replacement : PPI
DM control
Malnutrition
Malignancy - investigate if indicated
Chronic Pancreatitis
Other complicatons
Pseudocyst
Splenic vein thrombosis
Hypersplenism / GIB – require splenectomy
Mesenteric / Portal vein thrombosis
Pancreatic ductal deformity / stones
Pancreatic ascites / pleural effusion
Chronic Pancreatitis
Surgery Indications
For focal disease / ductal anomaly
Bypass: pancreaticojejunostomy (Puestow procedure) duct >7mm
Distal Pancreatectomy
Whipple procedure
For pain
If head is > 3cm in size
Bypass surgery – eg Puestow procedure
For suspected malignancy
Distal
Pancreatectomy
Thoracoscopic splanchniectomy
Frey’s operation – Bypass with resection of pancreatic head
Whipple
Laparoscopy
Laparotomy
Chronic Pancreatitis
Management
Conservative
Symptoms
Malnutrition
Endocrine dysfunction
Education
Psychosocial support
ETOH
Depression
Invasive procedure
ERCP
Surgery
Malignancy
Pseudocyst
Collection of pancreatic juice enclosed in a wall of
fibrous or granulation tissue that arises following an
attack of severe pancreatitis.
Acute fluid collection:
Early in the course of acute pancreatitis and is located in or
near the pancreas. The wall is ill defined.
Pancreatic cystic neoplasm:
Cystic lesion lined by epithelium, can be either benign or
malignant in nature
Pseudocyst
4 to 5 weeks after onset of acute pancreatitis
40-60% Spontaneous resolution 6 weeks
> 6 weeks, risk of complication increase
Intervention
Surgical drainage – Open / Laparoscopic
Endoscopic drainage
Pseudocyst
Adequate assessment of pancreatic duct
Stricture / stones / morphology
Communication with cyst
Position of cyst in relation to other organs
Cystojejunostomy
Stomach
Cystogastrostomy
Stenting if communicate with PD
Psuedocyst
Complications
Bleeding
Abscess
Percutaneous Drainage
Suspect Malignancy if atypical history or morphology
Suspect malignancy if
Septum / complex architecture
Solid component
Invasion of surrounding structures / metastatic lesion
Raised tumor marker
Lack of amylase in fluid aspirated from the cyst
Other solid lesions in pancreas
No previous history of pancreatitis / trauma
Carcinoma of pancreas
Pancreatic Carcinoma
Weight loss
Pain
Malnutrition
Jaundice
Anorexia
Pruritus
90%
75%
75%
70%
60%
40%
Courvoisier’s sign
Diabetes mellitus
Ascites
GOO
33%
15%
5%
5%
Gastric outlet obstruction
Carcinoma of Pancreas
Symptom and management depends on the location of the tumor
Head of pancreas usually have better prognosis since their symptoms usually
present earlier then tumor located at the body or tail of pancreas
Usually asymptomatic until late in advance stage
May present earlier with obstructive jaundice, duodenal ulceration etc…
Pancreatic Carcinoma
Etiology uncertain
Cigarette Smoking
Diabetes – long standing
Chronic pancreatitis - Amount of risk ?
Familial predispoistion 5-8%
Coffee / alcohol / organic solvents / petroleum
Pancreatic Neoplasms
Ductal Epithelium
Ductal cell AdenoCa
Giant cell Ca
Adenosquamous Ca
Mucinous Ca
MicroadenoCa
Mucinous CystadenoCa
Acinar cells
Acinar cell Ca
Acinar CystadenoCa
Pancreatoblastoma
Non Epithelial Tissue
Uncertain Histogenesis
Fibrosarcoma
Leiomyosarcoma
Histocytoma
Lymphoma
Papillary cystic neoplasm
NeuroEndocrine tumors
Hypervascular tumor
Gastrinoma
Insulinoma
Vasoactive Intestinal
Polypeptidoma
Glucagonoma
Pancreatic carcinoma
Aim of management
Assess resectability
Curative Mx
Palliative Mx
•Absence of extrapancreatic disease
•Absence of vascular involvement
Clinical & Radiological Staging
(i) Resectable
(ii) Non resectable
(iii) Metastatic disease
Pancreatic carcinoma
Ultrasound abdomen
CT abdomen & thorax
ERCP - 97% will have abnormality
Long irregular stricture
Double duct sign
Brush cytology only 40-50% positive
Endoscopic Ultrasonography
EUS - FNAC
Double duct sign
Negative result does not rule out malignancy
Angiogram
When CT show possible vascular involvement in an otherwise resectable disease
Possible aberrant vascular anomaly
Pancreatic Carcinoma
Type of surgery performed will depends on the location and involvement of the tumor
•Whipple operation
•Pylorus preserving Whipple
•Gastric stasis in early post op period
•Not for bulky tumor – inferior tumor clearance
Distal
pancreatectomy +/- splenectomy
Carcinoma of tail of pancreas invade spleen
Pancreatic carcinoma
Palliative Mx – pain control
ChemoIrradiation
Biliary obstruction
Gastric outlet obstruction
•Endoscopic stenting – plastic / metallic
•Surgical bypass
•Double bypass (gastric + biliary)
•Gastric – gastrojejunostomy
•Biliary –
•Choledochojejunostomy
•Choledochoduodenostomy
Pancreatic carcinoma
High index of clinical suspicion
Little clinical sign, non specific symptoms
Especially differentiating between pseudocyst and cystic
neoplasm
History
Radiological features
Nature / Biochemistry of aspirated content
Amylase, tumor marker, cytology etc…
Tumor marker
CA 19.9 most specific, volume related
CA 125
CEA