Exocrine Pancreas Flashcards
Acute pancreatitis
Cathepsin B = lysosomal enzyme- activates pancreatic enzymes
Lysosome and zymogen colocalise- zymogen contains trypsinogen- cathepsin B inside lysosomes activate zymogen granules i.e trypsinogen- abnormal pancreatic enzyme activation within acinar cells
Acinar cells release proinflammatory cytokines- TNF alpha, IL-1,2,6, IL- 10,1 receptor antagonists recruited- Propagate inflammation locally (acute pancreatitis) and systemically (SIRS, acute lung injury).
Etiology:
Gall stones (m/c/c of acute pancreatitis- obstructive {calcineurin}and reflux {Ca} theory), ethanol, trauma (m/c in children), scorpion bite, mumps, steroid abuse, hypercalcemia (Ca precipitates- calcifications- duct obstruction, hyperPTH), hypertriglyceridemia (familial hyperTG- >2000mg/dl), ERCP (m/c in young female, h/o multiple canullations, therapeutic > diagnostic, SOD dysfunction, h/o ERCP pancreatitis), drug induced (thiazides, furosemide, metronidazole), pancreatic tumors, parasites (Ascaris lumbricoides), anatomic variations (—-)
C/F:
Epigastric pain radiating to the back- relieved on bending forward
Dx:
2/3 of:
Pain abd
Amylase, lipase raised {Amylase<Lipase (>3x upper limit)}
Radio findings
HyperG
TLC increased
LFT abnormal
Macroamylase- falsely negative low amylase levels- also elevated in salpingitis, PUD, mesenteric ischemia.
CECT abdomen and pelvis- 72hrs after onset of pain- portal venous phase 65-70sec after giving contrast- best phase to visualise pancreatic parenchyma
I.v secretin given if pancreatic duct visualisation is difficult- secretin transiently distends the ducts.
EUS>ERCP
Acute pancreatitis- Severity scoring
Ranson’s criteria
At admission:
LDH> 400
AST > 250
G>220
Age>70yrs
WBC >18,000
48 hrs later:
B
BUN > 2
Ca2+<8
Hct >10% decrease
O PaO2<60mm Hg
W
> /= 3- severe pancreatitis
APACHE
CT Severity Index- Balthazar
A.
Normal parenchyma- 0
Enlarged-1
Peripancreatic inflammation-2
Single collection-3
Multiple collections-4
B. Necrosis
<30%- 2
30-50%- 4
>50%- 6
7-10- Severe pancreatitis- Mortality~17%
Revised Atlanta criteria
Mild- No organ failure/ local complications
Moderate- Organ failure- transient- <48hrs+ local complications
Severe- Organ failure>48hrs+ local complications
Local complications- Necrosis/ pseudocyst/ abscess
Organ failure: BP<90 mmHg, PaO2<60mmHg, Creat>2
Systemic complications: Platelet <1L (DIC), fibrinogen, fibrin split products, Ca2+<7.5
Systemic Inflammatory Response Syndrome (SIRS):
HR>90 bpm
Temp> 38.3/ <36
RR> 20
WBC> 12,000/< 4000
Acute Pancreatitis- Treatment
RL
Complications of acute pancreatitis
Pancreatic inflammation:
a. Peripancreatic fluid collection- A/w Acute interstitial oedematous pancreatitis- 4 weeks later the fluid collection becomes a pseudocyst
b. Necrotic collections A/w acute necrotising pancreatitis- 4 weeks later the collection becomes walled off pancreatic collection (WOPN)
Most peripancreatic fluid collections resolve with time as they are absorbed by the peritoneum. They might get infected- E/o gas within fluid on CT is suggestive- if patient does not improve within 10-14 days- CT guided aspiration.
Necrotic collections: If sterile- no intervention reqd.
If patient deteriorates with conservative management/ infected- intervene- Percut drainage f/b min invasive video assisted debridement
Pseudocyst
Lined by collagen and granulation tissue- not epithelium.
Asymptomatic- observe- 70% will regress spontaneously- <4cm, tail, not involving the main pancreatic duct
50% become symptomatic- Pain, nausea, early satiety, weight loss, elevated amylase & lipase.
Endoscopic approach for symptomatic patients- Transgastric/ transduodenal if cyst is <1cm away from the stomach/ duodenum. If communicating with main pancreatic duct- transpapillary approach.
If endoscopic approach fails d/t anatomic/ fail to respond to endoscopic approach-
Surgical approach for symptomatic patients-
1. Cystogastrostomy
2. Cystoduodenostomy
3. Roux en Y cystojejunostomy
12% recur
