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Pancreatic diseases

Pancreatic diseases. WU JIAN Department of hepatobiliary Surgery First Affiliated Hospital Zhejiang University School of Medicine. Pancreas: Anatomy and Physiology. Retroperitoneal organ 15-20cm in length Head, neck, body and tail

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Pancreatic diseases

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  1. Pancreatic diseases WU JIAN Department of hepatobiliary Surgery First Affiliated Hospital Zhejiang University School of Medicine

  2. Pancreas: Anatomy and Physiology • Retroperitoneal organ • 15-20cm in length • Head, neck, body and tail • Uncinate process: curves behind the superior mesenteric vessels

  3. Neighborhood of the pancreas • Posterior L1-2 vertebral column • Anterior stomach, omentum • Right Duodenum • Left Splenic hilum

  4. Main duct : Wirsung ( 1642) Ampula: Vater (1720) Accessory duct : Santorini( 1734)

  5. 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

  6. Lymphatic drainage of pancreas

  7. Common pathway

  8. Physiology • Exocrine：pancreatic juice。 • HCO3- and digestive enzyme • Endocrine： • A cell：glycagon • B cell：insulin • D cell ：somatostatin • G cell ：gastrin

  9.  Acute Pancreatitis Chronic Pancreatitis  Pancreatic cancer Periampullary cancer Endocrinal tumor

  10. AcutePancreatitis • 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

  11. 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

  12. 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.

  13. 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)

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

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

  16. Image findings • BUS • CT • ERCP • MRCP • Abdomen plain film

  17. Local complication • Pancreatic necrosis • Infective pancreatic necrosis • Sterile pancreatic necrosis • Pancreatic abscess • Pancreatic pseudocyst

  18. 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

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

  20. Classificationsystem • General evaluation • John Ranson score (1974):5 (on admission) +6 (48hr) • Imrie score:8 (WBC,Ca,sugar,PO2,LF) • APACHE II score (1985):12+age＋Chronic health+coma • 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

  21. 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 CT>II) • APACHE value>8

  22. MODS • Cardiac function：quick pulse、shock • Pulmonary function ：PaO2<60mmHg，ARDS • Liver function：jaundice， elevated ALT • Renal function：elevated BUN and Creatinine • Digestive function：GI bleeding • Endocrinal function ：glucose>11.1mmol/L • Coagulation system：DIC • Nerve system：unclear consciousness、pancreatic brain disease

  23. Stage of SAP • Acute response stage：within 2 weeks • complicated with shock,ARDS,renal failure • Systemic infection stage：2weeks to 2 months • Bacteria or fungus infection • Post-infection stage：after 2  3 months • Abscess, fistula,

  24. TREATMENT

  25. Non-operative therapy

  26. 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

  27. II. Operation

  28. Indication of Operation • Biliary obstruction • Secondary pancreatic infection • Shock cannot be reversed, multiple ogan deteriorate • Undetermined diagnosis, need to laparotomy

  29. 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

  30. Chronic pancreatitis • Recurrent upper abdominal pain • With dysfunction of endocrine and exocrine of pancreas

  31. Clinical manifestition • Four main symptoms • Abdominal pain • Body weight loss • Diabetes • Lipid diarrhea

  32. Therapy of chronic pancreatitis Relieve pain Drainage of the pancreatic juice Prevent acute attack Ameliorate the nutrition Improve pancreatic function Non-operation or operation

  33. Pancreatic Cyst • Pancreatic pseudocyst • Congenital pancreatic cyst • Retention pancreatic cyst • Neoplastic pancreatic cyst • Pancreatic cystadenoma • Pancreatic cystadenocarcinoma

  34. 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

  35. Thanks !

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