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Diseases of pancreas

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Diseases of pancreas DAI Chao-Liu 2nd clinical college of China Medical University

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Acute pancreatitis Anatomy Head, neck.body, tail, uncinate process, Main pancreatic duct (duct of Wirsung) Dorsal pancreatic duct (duct of Santorini) Pancreatic excretion Exocrine (extra secretion) Endocrine(internal secretion):B,A,D,G cell

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c Causes Gallstones:60%( 35–50% in USA) Alcohol:!4% Drug: Azathioprine .6-Mercaptopurine------ Pancreas divisum(????;???) Microlithiasis Metabolic cause Sphincter of Oddi dysfunction Infectious causes Trauma, ascaris worms,HIV----- Miscellaneous Acute pancreatitis

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Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis, acute necrotizing pancreatitis) Acute pancreatitis

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Pathophysiology Hypersecretion and obstruction Self-enzymatic digestiono Lymphatic obstruction Cytokine,infection Decreased arterial perfusion Edematous hemorrhagic necrotizing Acute pancreatitis

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Clinical finding Abdominal pain Abdominal distention Nausea and vomiting Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension Mild jaundice, Pleural effusion. Shock Acute pancreatitis

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Acute pancreatitis Peritoneal irritation sign (Abdominal tenderness, rebound tenderness and rigidity) Shifting dullness Decreased bowel sounds Cullen’ sign: discoloration of periumbilical area Grey Turner’ sign:discoloration of flanks

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Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis ) 500 400 300 200 100 0 0 1H 24H 48H 5DAY Acute pancreatitis Blood amylase Urine amylase

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Acute pancreatitis Serum calcium Serum glucose Blood gas analysis CRP(C-reactive protein) Imunolipase, trypsinogen ,and immuno elastase. ALT and AST (gallstone pancreatitis )

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Imaging finding X-ray Dilated loop of small bowel (sentinel loop) Abrupt cessation of gas in the distal transverse colon (colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural effusion B-US: pancreatic edema, ascites---- CT: Important Acute pancreatitis

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•CT is the best diagnostic test for the diagnosis of acute pancreatitis. •Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosis ????

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Acute pancreatitis Assessment of severity of acute pancreatitis Ranson's criteria On Admission Within 48 Hours Age > 55 years Hematocrit decrease by >10% WBC > 16,000 mm³ Urea nitrogen increase > 5 mg/dl LDH > 350 IU/L Serum calcium < 8 mg/dl Glucose > 200 mg/dl Arterial PO² < 60 mm Hg AST > 250 IU/L Base deficit > 4 mEq/L Estimated fluid sequestration > 6 L

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Acute pancreatitis Glasgow criteria Within 48 Hours Age > 55 WBC > 15,000 mm³ LDH > 600 IU/L Glucose > 180 mg/dl Albumin < 3.2 g/dl Calcium < 8 mg/dlUrea > 45 mg/dl Arterial PO2 < 60 mm Hg

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Acute pancreatitis APACHE III criteria Temperature • BUN Mean blood pressure • Leukocytes Serum Creatinine • Hematocrit Heart rate • Albumin Respiratory rate • Bilirubin Oxygenation Arterial pH Serum sodium and potassium Serum glucose >?8 Scores ----SAP

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Diagnosis and differential Diagnosis Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatoma Acute pancreatitis Clinical finding Amylase CT Abdominal paracentesis

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Acute pancreatitis Treatment Acute edematous pancreatitis—internal medicine (Emergency surgery is not indicated in mild acute pancreatitis) Acute hemorrhagic necrotizing pancreatitis Supportive care Replacement of fluid and electrolytes Correction of metabolic abnormalities Nutritional support Other measures :nasogastric suction and antibiotics

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Agents to inhibit pancreatic secretion Have not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandostatin stilamin) Glucagon. Protease inhibitors (trasylol) Surgical therapy Inefficiency by internal medicine Complication (pancreatic or/and peripancreatic Infection and abscess) Combined wit biliary diseases(Gallstone ASP) Diagnosis unclear

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Surgical approach Rresection of necrotic tissue and peritoneal lavage severe, progressive necrotizing pancreatitis or pancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis. Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunction outcome is the same as for the endoscopic pancreatic sphincterotomy more invasive requiring laparotomy and duodenotomy

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Acute pancreatitis Endoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, 3) recurrent pancreatitis due to pancreas divisum. The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice

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Chronic pancreatitis Causes Alcohol Pancreas divisum Tropical pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hereditary chronic pancreatitis

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Chronic pancreatitis Classification Obstructive chronic pancreatitis Calcified chronic pancreatitis Inflammatory chronic pancreatitis Pathology pancreatic fibrosis ----

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Chronic pancreatitis Clinical finding and diagnosis Abdominal pain , distention Diarrhage Dyspepsia Malnutrtion Diabetes Narcotic addiction Jaundice

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Biochemical measurements Isoamylase,lipase trypsin,and elastase Quantitative measurement of fecal fat glucose tolerance test Secretin stimulation test Plasma cholecystokinin (CCK)( may be elevated ) Bentiromide (???) test Chronic pancreatitis

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Chronic pancreatitis Imaging finding Plain abdominal film Transabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS)

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Chronic pancreatitis Medical therapy Alcohol and cigarette avoidance Analgesics Enzyme therapy Treatment of malnutrition Surgical therapy Biliary Obstruction, pancreatic pseudocysts, combined with biliary diseases, intractabe pain, Celiac nerve block Therapeutic endoscopy

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Tumors of Pancreas Pancreatic carcinoma Arise from acinar or duct cells Early diagnosis very difficulty , prognosis poor Obstructive jaundice(permanent):main symptom Abdominal pain Diabetes Weakness, emaciation(??) Stools: acholic Gallbladder:Distended Abdominal mass

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Diagnosis of pancreatic carcinoma Laboratory test: AKP ,r-GT,LDH;CEA ,POA, PCCA,CA19-9: C-K-ras--- Imaging finding US,CT( CTA),MRCP ERCP, PTC&PTCD PET(?????????) Biopsy(FNA) and cytology Tumors of Pancreas

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Treatment of pancreatic carcinoma Radical operation Pancreatoduodenectomy ---- tumor in pancreatic head Resection of pancreatic body and tail---tumor in pancreatic body or tail Palliative operation: to relieve jaundice Biotherapy Tumors of Pancreas

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Pancreatic endocrine neoplasm(PEN) Insulinoma Arise from B cell Symptoms: whipple’s triad Spontaneous hypoglycemia accompanied by central nervous system, psychiatric,or vasomotor symptoms Repeated blood sugar levels below 2.8mmol/L(50mg%) Relief of symptoms by oral or intravenous administration of glucose Diagnosis: symptom and IRI/G>0.3,B-us,CT,MRI, Endo-US,Angiography,PTPC,ASVS Treatment:operation(resection) Tumors of Pancreas

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Arise from: Papilla of duodenum Vater ampulla Distal CBD Symptom: obstructive jaundice Diagnosis Treatment :similar to pancreatic carcinoma Carcinoma of periampulla

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Thank you very much

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Treatment; Acute edematous pancreatitis—internal medicine (Emergency surgery is not indicated in mi more Treatment; Acute edematous pancreatitis—internal medicine (Emergency surgery is not indicated in mild acute pancreatitis); Acute hemorrhagic necrotizing …www.cmu.edu.cn/surgery2h/RzInclude/WebEdit/uploadfile/2008518163241526.PPT less

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