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Pancreatic Diseases Dr A. Badrek-Amoudi FRCS. Anatomy & Physiology I. Anatomy & Physiology II. Anatomy & Physiology III. 1-2 L alkaline, clear, isoosmolar enzyme rich fluid Na & K at plasma levels (165mmol/L) 20 enzymes are secreted

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Pancreatic Diseases Dr A. Badrek-Amoudi FRCS


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anatomy physiology iii
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)
pancreatitis ii
Pancreatitis II

Oedametous pancreatitis

Necrotizin Pancreatitis

Infected Necrosis/ Hemorrhagic necrosis

pancreatitis pathogenesis
PancreatitisPathogenesis
  • Obstruction- Secretion
  • Common Channel theory
  • Duodenal reflux
  • Increased permeability of pancreatic duct
  • Enzyme Auto-activation
pancreatitis aetiology i
PancreatitisAetiology I
  • Gall stone
      • 90% of acute pancreatitis .
      • Life risk of 3-5%
      • Age 40’s .
      • F>m
      • Transient obstruction
  • Alcohol 75% of chronic pancreatitis
      • Spasm of the sphinctor of Oddi
      • Increases the concentration of enzymes
      • Structural damage caused by the precipitation of calcium
      • Transient reduction of blood flow
  • Drugs
      • Steroids, AZT
      • Sulphonomids, Tetracyclin
      • Oestrogen
pancreatitis aetiology ii
PancreatitisAetiology 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

pancreatitis aetiology iii
PancreatitisAetiology III
  • Pancreatic Dividism
  • Duodenal obstruction
  • Infection

Viral : Mumps, Coxacki, Herpes

  • Ischamia
  • Hereditary

Mutation in Trypsin formation

  • Scorapian Venom
acute pancreatitis clinical presentation
Acute PancreatitisClinical 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%
acute pancreatitis clinical presentation ii
Acute PancreatitisClinical Presentation II
  • Dyspnoea in 10%
  • Tender Abdomen: Mild to severe
  • Peritonitis,could be diffuse
  • BS: hypoactive
  • Abdominal Mass:
    • Phlegmon
    • Pseudocyst,
    • Abcess Ascitis
  • Cullen’s
  • Gray-turner signs
  • Erythametous skin lesions
differential diagnosis
Differential diagnosis
  • Perforated DU
  • Perforated GB
  • Emphsymatous cholecystitis
  • Mesenteric infarction
  • AAA
  • Others
acute pancreatitis investigation
Acute PancreatitisInvestigation
  • Diagnostic
  • Amylase: >1000 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
acute pancreatitis investigation ii
Acute PancreatitisInvestigation II
  • High amylase may be caused by:
    • Perforated DU
    • Cholecystitis
    • Small bowel obstruction
    • Perforated Small bowel
    • Ectopic pregnancy
acute pancreatitis investigation iii
Acute PancreatitisInvestigation 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.
    • U&E, LFT, Ca, glucose.
    • ABG
acute pancreatitis prognostic indicators
Acute PancreatitisPrognostic Indicators
  • Biochemical Markers: Sensitivity/ Specificity
    • Ranson’s / Emeri’s 75%
    • CRP 70%
  • Physiological parameters
    • Appache II Scoring 80%
  • Radiological
    • Spiral CT 87%
  • Peritoneal Lavage
ranson s criteria 0 2 2 3 4 15 5 6 40 7 8 100 mortality rates
On admission

Age>55

WBC> 16

Glucose> 200

LDH>350

SGOT>250

1st 48 Hours

HCT Fall> 10%

Ca< 8

PO2<60

Base def<4

Estimate sequestration>600 ml

Ranson’s Criteria0-2= 2%, 3-4=15%, 5-6= 40%, 7-8=100% Mortality rates
acute pancreatitis complications i
Acute PancreatitisComplications 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
acute pancreatitis complications ii
Acute PancreatitisComplications II

Systemic

  • Metabolic
    • Hypokalaemia, Hypochloraemia & Metabolic alkalosis
    • Hypocalcaemia
    • Hypomagnesemia
    • Hypoxemia
acute pancreatitis complications iii
Acute PancreatitisComplications III
  • Respiratory
    • Respiratory insufficiency
    • Atelactesis
    • ARDS
  • Renal Failure
  • Depressed myocardial contractility
  • Multiple organ Failure
acute pancreatitis treatment
Acute PancreatitisTreatment
  • 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
treatment ii
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
chronic pancreatitis
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.
chronic pancreatitis complications
Chronic PancreatitisComplications
  • Narcotic addiction
  • Loco-Regional
    • Pseudocyst, fistula formation.
    • Pseudoaneurysm, vascular thrombosis
    • Bile duct stenosis
  • Diabetes with associated neuropathies & myopathies
  • Malabsobtion
chronic pancreatitis diagnosis
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
chronic pancreatitis management
Medical

Manage DM

Pain control

Exocrine replacement

Dietary control

Surgery

Drainage

Pain control

Pancreatectomy

Chronic PancreatitisManagement
pancreatic cancer
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
clinical manifestation
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)
  • Courvoiser’s sign
  • Sister Mary Joseph nodule
  • Evidence of pruritis
  • Depression
diagnostic studies
Diagnostic studies
  • USS
  • Endo-USS
  • CT
  • ERCP, MRCP
  • Angiography
  • FNAC
  • Endoscopy
  • Laparoscopy
  • Tumor markers

(CEA & CA 19-9)

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

In general poor

Post surgery:

  • < 3cm
  • Negative resection margins
  • No LN
slide36

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

slide37

B

A

slide38
1.What are the investigations shown in A & B2. What are the Abnormalities3. How do you prepare patient for investigation A