Pancreatic diseases

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Pancreatic diseases
WU JIAN Department of hepatobiliary Surgery
First Affiliated Hospital Zhejiang University
School of Medicine
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Pancreas Anatomy and Physiology

• Retroperitoneal organ
• 15-20cm in length
• Head, neck, body and tail
• Uncinate process curves behind the superior
  mesenteric vessels

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Neighborhood of the pancreas

• Posterior
• L1-2 vertebral column
• Anterior
• stomach, omentum
• Right
• Duodenum
• Left
• Splenic hilum

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Main duct Wirsung ( 1642) Ampula
Vater (1720) Accessory duct
Santorini( 1734)
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Pancreas blood supply

• HEAD
• Superior pancreatoduodenal A. (from
  gastroduodenal A.)
• Inferior pancreatoduodenal A. (from SMA)
• BODY AND TAIL
• superior pancreatic A.
• pancreatic magna A.
• transverse pancreatic A.
• VEIN
• to splenic vein ,SMV and portal vein

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Lymphatic drainage of pancreas
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• Common
• pathway

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Physiology

• Exocrinepancreatic juice?
• HCO3- and digestive enzyme
• Endocrine
• A cellglycagon
• B cellinsulin
• D cell somatostatin
• G cell gastrin

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• ? Acute Pancreatitis
• Chronic Pancreatitis
• ? Pancreatic cancer
• Periampullary cancer
• Endocrinal tumor

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Acute Pancreatitis

• Common acute abdomen
• Local inflammatory change in pancreas
• Systemic change
• Life-threatening inflammatory disorder of the
  pancreas
• Abrupt onset and unpredictable course
• Variable severity and duration
• Self-limited but remarkable morbidity and
  mortality

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Etiology

• Biliary tract disease
• Abuse of ethanol
• Endoscopic retrograde cholangiopancreatography
• Trauma and operation
• Ischemia of pancreas
• Drugs
• Idiopathic pancreatitis
• Hypercalcemia
• Hyperlipidemia
• Infections and Parasites
• Scorpion sting

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PATHOGENESIS

• Self digestion
• Reflux of bile or duodenal juice
• Trypsinogen was activated
• Trypsin can activate the other zymogens
• Intraparenchymal enzyme activation, tissue
  destruction, and ischaemic necrosis.

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Pathological and clinical type

• Pathological type
• Acute edematic pancreatitis
• Acute hemorrhgic and necrotic pancreatitis
  (AHNP)
• Clinical type
• Mild Acute pancreatitis (MAP)
• Severe Acute pancreatitis (SAP)
• Fulminant Acute pancreatitis (FAP)
• 
  

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Clinical manifestations

• Abdominal pain
• Nausea, vomiting
• Distension
• Tenderness, rebound tenderness, muscular regard
• Fever,jaundice,
• Gray-Turner sign flank ecchymoses
• Cullen sign periumbilical ecchymoses
• MODS

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laboratory test

• Amylase level in serum and in urine
• Lipase assays
• Blood Rt, liver function, FBS, PaCO2 ,serum
  calcium, DIC
• Diagnostic paracentesis

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Image findings

• BUS
• CT
• ERCP
• MRCP
• Abdomen plain film

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Local complication

• Pancreatic necrosis
• Infective pancreatic necrosis
• Sterile pancreatic necrosis
• Pancreatic abscess
• Pancreatic pseudocyst

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Acute pancreatic pseudocyst

• Peripancreatic fluid collections occur in 10-20
  of patients
• Those persisting beyond the phase of acute
  inflammation become pancreatic pseudocysts
• Collection surrounded by fibrous tissue or
  granula tissue
• Diagnosed by PE or image test
• Round or ellipse
• Clear cyst wall

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Severe Acute Pancreatitis

• Severe Acute pancreatitis (SAP)
• Complicated with MODS
• Necrosis, abscess, pseudocyst
• Or both

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Classification system

• General evaluation
• John Ranson score (1974)5 (on admission) 6
  (48hr)
• Imrie score8 (WBC,Ca,sugar,PO2,LF)
• APACHE II score (1985)12ageChronic healthcoma
  
• Atlanta classification system(1992)
• Local evaluation
• Beger criteria (1985)
• Balthazar CT classification system (1990)I, II,
  III GRADE
• MODS evaluation
• Marshall MODS score system(1995)6 systems/organs
  involved

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Clinical manifestation of SAP

• Abdominal sign obvious tenderness, rebound
  tenderness, muscular regard, distension, lose of
  bowl sound
• Mass in abdomen, Grey-Turner, Cullen
• MODS
• Irreversible shock
• CT swelling,uneven density, invade to outside of
  pancreas(Balthazar CTgtII)
• APACHE valuegt8

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MODS

• Cardiac functionquick pulse?shock
• Pulmonary function PaO2lt60mmHg,ARDS
• Liver functionjaundice, elevated ALT
• Renal functionelevated BUN and Creatinine
• Digestive functionGI bleeding
• Endocrinal function glucosegt11.1mmol/L
• Coagulation systemDIC
• Nerve systemunclear consciousness?pancreatic
  brain disease

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Stage of SAP

• Acute response stagewithin 2 weeks
• complicated with shock,ARDS,renal failure
• Systemic infection stage2 weeks to 2 months
• Bacteria or fungus infection
• Post-infection stageafter 2 ? 3 months
• Abscess, fistula,

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TREATMENT
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Non-operative therapy
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Acute Response Stage

• ICU to prevent MODS
• fasting the patient, nasogastric suction
• Minimizing pancreatic secretion
• antacids
• 5-FU
• somatostatin analogues
• antiprotease
• Fluid replacement and Nutritional support
• maintenance of adequate hydration
• TPN,glucose ,lipid, amino acid, protein
• Analgesia
• Antibiotics
• Traditional Chinese Medicine
• Abdominal lavage

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II. Operation
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Indication of Operation

• Biliary obstruction
• Secondary pancreatic infection
• Shock cannot be reversed,
• multiple ogan deteriorate
• Undetermined diagnosis, need to laparotomy

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Principle for treatment of pancreatitis
SAP
MAP
Biliary
Non-biliary
Conservative therapy
No infection
Obstuctive
Non-obstructive
Infection
Urgent operation Or ERCP
Elective operation
Conservative therapy Elective operation
Conservative therapy
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Chronic pancreatitis

• Recurrent upper abdominal pain
• With dysfunction of endocrine and exocrine of
  pancreas

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Clinical manifestition

• Four main symptoms
• Abdominal pain
• Body weight loss
• Diabetes
• Lipid diarrhea

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Therapy of chronic pancreatitis

• Relieve pain
• Drainage of the pancreatic juice
• Prevent acute attack
• Ameliorate the nutrition
• Improve pancreatic function
• Non-operation or operation

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Pancreatic Cyst

• Pancreatic pseudocyst
• Congenital pancreatic cyst
• Retention pancreatic cyst
• Neoplastic pancreatic cyst
• Pancreatic cystadenoma
• Pancreatic cystadenocarcinoma

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Pancreatic pseudocyst

• Indication for operation
• Associated with ongoing pain
• More than 6 cm in diameter which persist for 6
  weeks
• Cyst with haemorrhage and sepsis
• Methods
• Percutaneous drainage
• Operative drainage
• Cystgastrostomy, cystjejunostomy
• Resection of pancreatic body and tail

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Thanks !