Pancreatic Diseases Dr A. Badrek-Amoudi FRCS

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Pancreatic DiseasesDr A. Badrek-Amoudi FRCS
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Anatomy Physiology I
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Anatomy Physiology II
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Anatomy Physiology III

• 1-2 L alkaline, clear, isoosmolar enzyme rich
  fluid
• Na K at plasma levels (165mmol/L)
• 20 enzymes are secreted
• Secretion is regulated by Secretin, CCK, Vagus
  and low Ph
• Proteolytic enzymes (Tryp, Chemotryp, elastase
  etc
• Lipolytic (lipase, colipase, phospholipase..etc)
• amyloytic
• Endocrine function insulin, glucagon,
  somatostatin..etc)

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Acute Pancreatitis
A 54 year old gentleman presented
with acute upper abdominal pain radiating to the
back. He was found to be vitally stable but
severely tender in the centre of the abdomen. On
further investigation his amylase was found to be
2500

• Pancreatic Protective Factors
• Produced in pro-enzymes
• Stored in lysosomes (zymogen)
• Acidic nature low Ca prevent against activation

An inflammation of the pancrease caused by the activation, interstitial liberation and the auto-digestion of the gland by its own enzymes
1. What is the diagnosis? 2. How do we prove it? 3. How bad is it? 4. How do we treat it? 5.What is the prognosis?
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Pancreatitis II

• Oedametous pancreatitis
• Necrotizin Pancreatitis
• Infected Necrosis/ Hemorrhagic necrosis

Autodigestion Activation of neutrophils and macrophages Release of cytokines Endocrine and exocrine function is usually preserved
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Pancreatitis Pathogenesis

1. Obstruction- Secretion
2. Common Channel theory
3. Duodenal reflux
4. Increased permeability of pancreatic duct
5. Enzyme Auto-activation

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PancreatitisAetiology I

1. Gall stone
2. 90 of acute pancreatitis .
3. Life risk of 3-5
4. Age 40s .
5. Fgtm
6. Transient obstruction
7. Alcohol 75 of chronic pancreatitis
8. Spasm of the sphinctor of Oddi
9. Increases the concentration of enzymes
10. Structural damage caused by the precipitation of
    calcium
11. Transient reduction of blood flow
12. Drugs
13. Steroids, AZT
14. Sulphonomids, Tetracyclin
15. Oestrogen

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Pancreatitis Aetiology II

• Trauma Post op 5
• Post ERCP 1-40
• Hyperparathyroidism
• Ca deposition
• Increases the activation of enzymes
• Malnutrition
• Results in paranchymal fibrosis
• Hyperlipidaemia
• May interfere with the levels of amylase

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Pancreatitis Aetiology III

• Pancreatic Dividism
• Duodenal obstruction
• Infection
• Viral Mumps, Coxacki, Herpes
• Ischamia
• Hereditary
• Mutation in Trypsin formation
• Scorapian Venom

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Acute Pancreatitis Clinical Presentation

• Abdominal Pain
• Constant, quick onset, variable in severity
• Epigastric
• Radiating to the back in 50 of patients
• Associated with nausea, vomiting retching
• Relieved by lying on to the L side, legs-up
• Other precipitating factors
• Fever in 70
• Jaundice in 30
• Shock /_ in 10
• Hematemasis malena in 5

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Acute Pancreatitis Clinical Presentation II

• Dyspnoea in 10
• Tender Abdomen Mild to severe
• Peritonitis,could be diffuse
• BS hypoactive
• Abdominal Mass
• Phlegmon
• Pseudocyst,
• Abcess Ascitis
• Cullens
• Gray-turner signs
• Erythametous skin lesions

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Differential diagnosis

• Perforated DU
• Perforated GB
• Emphsymatous cholecystitis
• Mesenteric infarction
• AAA
• Others

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Acute Pancreatitis Investigation

• Diagnostic
• Amylase gt1000 is diagnostic
• High levels do not correlate with the severity of
  pancreatitis
• False Low 1. Rapid clearance by the
  kidney
• 2. Hyperlipidaemia.
• 3. Chronic pancreatitis
• False High Salivary, Ovarian, Liver tumor
• Lipase

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Acute Pancreatitis Investigation II

• High amylase may be caused by
• Perforated DU
• Cholecystitis
• Small bowel obstruction
• Perforated Small bowel
• Ectopic pregnancy

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Acute Pancreatitis Investigation III

• Radiological
• Plain X- rays
• AXR calcification, sentinle loop SB,colonic
  spasm
• CXR pleural effusion differntial
• USS GB stones, pancreatic peripancreatic info
• CT Diagnosis, prognosis, F/U
• Endoscopic USS
• MRCP
• ERCP
• Others
• FBC Hct, WBC, Plat.
• UE, LFT, Ca, glucose.
• ABG

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Acute Pancreatitis Prognostic Indicators

• Biochemical Markers Sensitivity/
  Specificity
• Ransons / Emeris 75
• CRP 70
• Physiological parameters
• Appache II Scoring 80
• Radiological
• Spiral CT 87
• Peritoneal Lavage

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Ransons Criteria0-2 2, 3-415, 5-6 40,
7-8100 Mortality rates

• On admission
• Agegt55
• WBCgt 16
• Glucosegt 200
• LDHgt350
• SGOTgt250

• 1st 48 Hours
• HCT Fallgt 10
• Calt 8
• PO2lt60
• Base deflt4
• Estimate sequestrationgt600 ml

Only applies to the first 24 hours Makes no distinction between derangements due to alcoholic disease
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Acute Pancreatitis Complications I

• Local and regional
• Pseudocysts
• Infection, Hemorrhage, Rupture, obstruction
• Pancreatic Necrosis
• Sterile/ Infected
• Pancreatic Abscess
• Colonic infarction
• Pancreatic Fistula
• Chronic Pancreatitis
• Vascular
• portal vein thrombosis
• Aorto-pancreatic fistula

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Acute Pancreatitis Complications II

• Systemic
• Metabolic
• Hypokalaemia, Hypochloraemia Metabolic
  alkalosis
• Hypocalcaemia
• Hypomagnesemia
• Hypoxemia

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Acute Pancreatitis Complications III

• Respiratory
• Respiratory insufficiency
• Atelactesis
• ARDS
• Renal Failure
• Depressed myocardial contractility
• Multiple organ Failure

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Acute Pancreatitis Treatment

• Conservative
• ( Admit in ICU VS Common Surgical Ward)
• NBM vs Early nutrition
• ? NGT
• Analgesia narcotic
• Adequate fluid replacement ( Initial crystalloid
  then colloid)
• Antibiotics (organisms penetration)
• ??Anticholinergics, somatostatin have no proven
  benifit
• Minimally invasive
• Early ERCP sphinctorotmy for impacted stones
• CT-guided drainage of Psedocusysts

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Treatment II

• The indications for surgical intervention are
• Uncertain diagnosis
• Early cholecystectomy
• CBD stone extraction
• Debridement of necrotic pancreatic tissue
• Pancreatic abcess (Infected Necrosis)
• Complicated Pseudocysts

Surgery is contraindicated in uncomplicated attacks.
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Chronic Pancreatitis

• Recurrent prolonged attacks of pancreatitis
• Associated with endocrine and exocrine
  insufficiency, weight loss and abnormal glucose
  tolerance test
• 75 is caused by alcoholism, 20 stones
• Normal architecture is replaced by dense fibrous
  tissue, dilated pancreatic duct with areas of
  narrowing, Cysts Psuedocysts are common.
• Amylase may remain normal with the acute attack.

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Chronic PancreatitisComplications

1. Narcotic addiction
2. Loco-Regional
3. Pseudocyst, fistula formation.
4. Pseudoaneurysm, vascular thrombosis
5. Bile duct stenosis
6. Diabetes with associated neuropathies
   myopathies
7. Malabsobtion

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Chronic PancreatitisDiagnosis

• Lab
• AXR calcification in 20-50
• CT Image of choice
• ERCP
• shows duct anomalies
• Dilatation
• Strictures
• Stones
• Cysts
• FNAC
• Occasionally difficult to distinguish from
  cancer.
• OGD
• varicies

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Chronic PancreatitisManagement

• Medical
• Manage DM
• Pain control
• Exocrine replacement
• Dietary control

• Surgery
• Drainage
• Pain control
• Pancreatectomy

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Pancreatic Cancer

• Epedemiology
• 5th highest cancer related death
• 13 100000 population
• 5 year mortality poor 5
• 20 survive post surgery
• Median survival 4-6 months
• Genda race?
• 40 are sporadic, 30 related to smoking, 5
  familial, 5 in chronic pancreatitis, 20 dietary
  and fat intake.
• 95 are exocrine in origin
• 75 originate in head neck of the pancrease

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Clinical Manifestation

• Painless obstructive jaundice,
• Weight loss, Anorexia.
• Deep abdominal/ back pain (75)
• Ascending cholangitis, Pancreatitis (14)
• Onset of Diabetes mellitus
• Hepatosplenomegaly, Ascitis
• Migratory thrombophlebitis (Trousseaus)
• Courvoisers sign
• Sister Mary Joseph nodule
• Evidence of pruritis
• Depression

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Diagnostic studies

• USS
• Endo-USS
• CT
• ERCP, MRCP
• Angiography
• FNAC
• Endoscopy
• Laparoscopy
• Tumor markers
• (CEA CA 19-9)

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Treatment

• Palliative
• Pain Depression
• Good analgesia
• Sympathetic neurolysis
• Jaundice
• Stenting via ERCP
• Surgery Dudenal obstruction
• Bypass surgery
• Curative
• (Whipple)

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Prognosis

• In general poor
• Post surgery
• lt 3cm
• Negative resection margins
• No LN

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History A 56 year old patient presented with painless jaundice and weight loss.
What is your differential diagnosis What are the Investigations required
The laboratory results were Bili(D) 8mg/100ml,
Bili(InD) 2.5mg/100ml, ALP 730 iu/L ,
AST 60 iu/L, GGT 200 iu/L, Albumin 4mg/dl,
Amylase 200 u/dl, INR 1.9
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B
A
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1.What are the investigations shown in A
B2. What are the Abnormalities3. How do you
prepare patient for investigation A
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