Disorders of the Pancreas Module 2

1. Disorders of the PancreasModule 2

2. Disorders of the Pancreas Acute Pancreatitis Chronic Pancreatitis Pancreatic Cancer

3. Acute Pancreatitis Acute inflammatory process of the pancreas Degree of inflammation varies from mild edema (edematous pancreatitis) to hemorrhagic necrosis (Necrotizing pancreatizing) Most common middle age Men > women Can be life threatening

4. Acute Pancreatitis�Etiology More common Biliary tract disease Alcoholism Less common Trauma (Post surgical, injury) Viral infections Duodenal conditions Cystic fibrosis Kaposi�s sarcoma Oral contraceptives Medications-steroids, thiazide diuretics, NSAID�s Metabolic disorders Eating disorders Complication of ERCP Idiopathic

5. Acute PancreatitisPathophysiology Believed to be autodigestion of pancreatic cells Injury occurs, enzymes released Trypsinogen normally enters small intestine and activated to trypsin In pancreatitis, trypsin stays in pancreas, can digest pancreas

6. Acute PancreatitisClinical Manifestations Abdominal pain (LUQ or midepigastrum) Pain radiates to back, sudden onset Described as severe, deep piercing pain Aggravated by eating Not relieved by vomiting

7. Acute PancreatitisClinical Manifestations Cardiovascular Hypotension Tachycardia Shock Hypovolemia Respiratory Cyanosis Dyspnea Crackles in lungs Hemovascular/Immune Fever Leukocytosis

8. Acute Pancreatitis-Clinical manifestations GI Bowel sounds decreased/absent Ileus may be present N/V

9. Acute Pancreatitis-Clinical Manifestations Integumentary May have flushing Jaundice Grey Turner spots Eccymosis of the flanks Bluish flank discoloration Cullen�s Sign Bluish discoloration of the periumbilical area

10. Acute Pancreatitis�Complications Pseudocyst Cavity continuous with or surrounding the outside of the pancreas Pseudocyst is filled with necrotic products and liquid secretions (Enzymes) Encapsulation can occur Abdominal pain, N/V, anorexia, fever, leukocytosis occurs May resolve spontaneously or may rupture Treatment-internal drainage with anastamosis

11. Acute Pancreatitis�Complications Pancreatic abscess Large fluid filled cavity within pancreas Abdominal pain, N/V, anorexia, fever, leukocytosis occurs Can infect or perforate adjacent organs Client needs surgical intervention

12. Acute Pancreatitis�Complications Systemic Pulmonary (Pleural effusion, atelectasis) Cardiovascular (Shock) Hypocalcemia indicates severe disease-monitor for tetany (Cvostek�s/Trousseau�s)

13. Acute PancreatitisDiagnostic Studies Serum amylase More commonly used for diagnosis Greater than 200 u/l is diagnostic Elevates earlier Remains elevated for 24-72 hrs Other disorders can elevate amylase Serum Lipase Urine amylase may be elevated Renal-amylase-creatinine clearance test

14. Acute PancreatitisDiagnostic Studies Hyperglycemia Hyperlipidemia Hypocalcemia Endoscopic US CT/MRI ERCP-Diagnostic test for gallstones, pancreatic cysts, abscesses

15. Acute Pancreatitis�Treatment Objectives Pain management Prevent shock Fluid and electrolyte balance Prevention of infection/Complications Remove cause

16. Acute Pancreatitis�Treatment Pain management (Morphine) Hydration Antispasmotic Replace volume (LR) or blood products if needed NPO/TPN NGT Dialysis?? Antibiotics Surgery-ERCP with sphincterectomy

17. Chronic Pancreatitis Abdominal pain (chronic, recurrent) May have constant pain or may diminish as fibrosis develops Heavy knawing feeling Not relieved with food or antacids

18. Chronic PancreatitisClinical manifestations Symptoms of pancreatic insufficiency Malabsorption with weight loss Constipation Mild jaundice with dark urine Steatorrhea Diabetes mellitus Frothy urine and stool

19. Chronic PancreatitisDiagnostic Studies Amylase/Lipase may be slightly elevated or normal Increased serum bilirubin Increased Sed rate Secretin stimulation test Hyperglycemia Stool for fat analysis X-ray-fibrois and calcification

20. Chronic PancreatitisDiagnostic Studies Endoscopic US CT/MRI ERCP

21. Chronic Pancreatitis If exacerbation, treat as for acute pancreatitis Bland, low fat, high carb diet later Control diabetes Pancreatic enzymes (Viokase, Cotazym) Bile salts H2 blockers Proton pump inhibitors Surgery Roux- en Y Choledochojejunostomy Avoid ETOH

22. Pancreatic Cancer Most are adenocarcinoma, occur in head of pancreas Prognosis usually poor Etiology Unknown Risk factors Cigarettes Chemical exposure High fat diet Diabetes Chronic pancreatitis

23. Pancreatic Cancer�Clinical Manifestations Upper abdominal pain (dull, aching to extreme unrelenting (later) Anorexia Rapid weight loss Jaundice

24. Pancreatic Cancer�Diagnostic Studies CT ERCP-gold standard Tumor markers CEA, more specific for colon cancer, less specific for pancreatic cancer

25. Pancreatic Cancer�Treatment Surgery Whipple�s procedure (Radical pancreaticduodenectomy) Total pancreatectomy Radiation-Usually palliative