The Pancreas

1. The Pancreas Aviad Hoffman, MD Demetrius Pertsemlidis, MD October 20, 2005

2. History Herophilus, a Greek anatomist and surgeon; one of the founders of the ancient school of Medicine in Alexandria, Egypt.

3. Ruphos, an anatomist - surgeon of Ephesus. �pancreas� - "all flesh" Diabetes, named by Aretaeus Asia Minor, (ca A.D. 81-150).

5. 1958 � Frederick Sanger determining the molecular structure of insulin.

6. Anatomy

9. Embryology

11. Normal pancreatic duct

12. Sphincters of the pancreas and bile duct

13. Annular Pancreas

15. Arterial supply of the pancreas

16. Venous drainage of the pancreas

19. Histology of the pancreas 85% exocrine pancreas 2% endocrine pancreas Regulatory feedback system for digestive enzyme and hormone secretion Coordinated function

20. The exocrine pancreas

23. Secretin released from duodenual mucosa in response to acidic chyme passing through the pylorus Major stimulant for HCO3 secretion, buffering gastric acid Provides optimal environment for pancreatic enzymes

25. Cholecystokinin Released from the jejunum in response to luminal digestion products of fat and protein Major stimulant for enzyme secretion

26. Neural regulation of exocrine secretion

27. Regulation of Pancreatic Secretion Neural/Hormonal/Metabolic

29. Pancreatic secretion Pancreatic juice - 800-1200ml/day Bicarbonate - 60-120meq/l, pH 7.6-8.2 Basal rate 0.2-0.3ml/min, max � 5ml/min (secretin) Chloride secretion varies inversely to bicarbonate Chloride/ Bicarbonate sum is constant Na+ and K+ isotonic and constant

31. Pancreatic enzymes

34. Familial pancreatitis Enterokinase Trypsinogen ? Trypsin Deficiency of: pancreatic secretory trypsin inhibitor (PSTI) SPINK

35. Endocrine pancreas

36. Pancreatic neuroendocrine peptide products Hormones Islet Cell Functions Insulin � Decreased gluconeogenesis, glycogenolysis, fatty acid breakdown and ketogenesis �� Increased glycogenesis, protein synthesis Glucagon a Opposite effects of insulin; increased hepatic glycogenolysis and gluconeogenesis Somatostatin d Inhibits gastrointestinal secretion �� Inhibits cell growth Pancreatic PP Inhibits pancreatic exocrine secretion and secretion polypeptide of insulin stimulated by Vagus Facilitates hepatic effect of insulin Amylin (IAPP) � Counterregulates insulin secretion and function Pancreastatin � Decreases insulin and somatostatin release�� Increases glucagon release�� Decreases pancreatic exocrine secretion d -1, EC, G cells Rare IAPP = islet amyloid polypeptide.

37. Regulation of neuroendocrine secretion Neural/Hormonal/Metabolic Neural parasympathetic sympathetic Hormonal insulin/glucagon somatostatin GI hormones Metabolic glucose amino acids fatty acids

42. pancreatitis 300,000 cases/year 10-20% are severe of them up to 30% mortality rate 3 times higher for blacks than whites males more often than females

43. ?

44. The Cullen sign is a bluish discoloration around the umbilicus resulting from hemoperitoneum. Severe necrotizing pancreatitis

45. ?

46. The Grey-Turner sign is a reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes

47. Etiology Biliary tract disease (38%) Alcohol (35%) Post-ERCP (4%) Trauma (1.5%) Hereditary pancreatitis ( <1%) Hypercalcemia ( <1%) Hypertriglyceridemia ( <1%) Tumor ( <1%) Developmental abnormalities ( <1%) Pancreas divisum / Annular pancreas Postoperative ( <1%)

48. Drugs (~1.4%) Diuretics furosemide, hydrochlorothiazide, Immunosupresant azathioprine, 6-mercaptopurine, corticosteroids Antibiotics tetracycline, nitrofurantoin, metronidazole, sulfonamides Anti neoplastic asparaginase, cisplatin, cytosine arabinoside sulindac, valproic acid, didanosine, methyldopa, estrogens, pentamidine, 5- ASA, octreotide, methandienone, phenformin, piroxicam, procainamide, colaspase, chlorthalidone, cimetidine, diphenoxylate, ethacrynic acid.

49. Infection ( <1%)  Viral : mumps, Epstein-Barr,coxsackievirus, echovirus, varicella-zoster, and measles, AIDS (opportunistic infections, neoplasms, drugs) Bacterial : Mycoplasma pneumoniae, Salmonella, Campylobacter, and Mycobacterium tuberculosis. Parasites : ascariasis (resulting from the migration of worms in and out of the duodenal papillae).

50. Tityus trinitatis Toxins

51. Autoimmune Kidney transplant recipients(1.2-6.8%) Idiopathic (10%)

52. Pathophysiology Intraductal hypertention Disruption in the normal separation of lysosomal and pancreatic enzymes

53. Prognostic indicators Glasgow Ranson Balthazar APACHE-II

54. Cystic neoplasms of the pancreas Serous cystadenoma (32-39%) Mucinous cystadenoma (10-45%) Intraductal Papillary Mucinous Neoplasm (11-33%) Solid-cystic neoplasm (<3-4%) Cystic neuroendocrine neoplasm (rare) Ductal adenoca with cystic degeneration (rare) Acinar-cell cystadenocarcinoma (rare)

55. Diagnosis Serous and mucinous neoplasms: Mean age 50 yrs Mostly women Asymptomatic (< 75%) Symptoms: Abdominal pain Mass Jaundice Prior pancreatitis

56. Serous Cystic Neoplasms Most common Minimal malignant potential (< 10 reports) Multiple cysts Polycystic (70%) Oligocystic Honeycomb Central stellate scar/calcification (30%)

57. Mucinous Cystic Neoplasms Majority in body/tail Thick capsule No communication w/ duct

58. IPMN Proximal sites Cystic dilatation of main PD or side branch Mucin-filled ampulla

59. Cystic Pancreatic Lesions

60. Treatment Serous cystic lesions Resection only for symptoms, or ambiguity Enucleation, central pancreatectomy? Mucinous cystic lesions All require resection 2nd malignant potential Operation based on location IPMN Surgery indicated Total pancreatectomy vs. subtotal w/ frozen section margin

61. Results Generally favorable 5 yr survival: mucinous cystadenoma > 95% Mucinous ca 17-33% IPMN > 50%; <30% if invasive Surveillance?