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Pancreatic Diseases Dr A. Badrek-Amoudi FRCS

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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  1. Pancreatic DiseasesDr A. Badrek-Amoudi FRCS

  2. Anatomy & Physiology I

  3. Anatomy & Physiology II

  4. 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)

  5. Pancreatitis II Oedametous pancreatitis Necrotizin Pancreatitis Infected Necrosis/ Hemorrhagic necrosis

  6. PancreatitisPathogenesis • Obstruction- Secretion • Common Channel theory • Duodenal reflux • Increased permeability of pancreatic duct • Enzyme Auto-activation

  7. 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

  8. 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

  9. PancreatitisAetiology III • Pancreatic Dividism • Duodenal obstruction • Infection Viral : Mumps, Coxacki, Herpes • Ischamia • Hereditary Mutation in Trypsin formation • Scorapian Venom

  10. 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%

  11. 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

  12. Differential diagnosis • Perforated DU • Perforated GB • Emphsymatous cholecystitis • Mesenteric infarction • AAA • Others

  13. 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

  14. Acute PancreatitisInvestigation II • High amylase may be caused by: • Perforated DU • Cholecystitis • Small bowel obstruction • Perforated Small bowel • Ectopic pregnancy

  15. 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

  16. 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

  17. 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

  18. 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

  19. Acute PancreatitisComplications II Systemic • Metabolic • Hypokalaemia, Hypochloraemia & Metabolic alkalosis • Hypocalcaemia • Hypomagnesemia • Hypoxemia

  20. Acute PancreatitisComplications III • Respiratory • Respiratory insufficiency • Atelactesis • ARDS • Renal Failure • Depressed myocardial contractility • Multiple organ Failure

  21. 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

  22. 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

  23. 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.

  24. Chronic PancreatitisComplications • Narcotic addiction • Loco-Regional • Pseudocyst, fistula formation. • Pseudoaneurysm, vascular thrombosis • Bile duct stenosis • Diabetes with associated neuropathies & myopathies • Malabsobtion

  25. 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

  26. Medical Manage DM Pain control Exocrine replacement Dietary control Surgery Drainage Pain control Pancreatectomy Chronic PancreatitisManagement

  27. 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

  28. 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

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

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

  31. Prognosis In general poor Post surgery: • < 3cm • Negative resection margins • No LN

  32. 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

  33. B A

  34. 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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