L11: Pancreatic Disorders Flashcards
(69 cards)
1
Q
Introduction to Pancreas
A
ο§ Complicated exocrine and endocrine gland
located in the upper abdominal region
ο§ It lies behind the peritoneum of the posterior
abdominal wall
ο§ Divided into head, body, and tail
2
Q
Types of Diseases of Pancreas
A
1- Acute Pancreatitis.
2- Chronic Pancreatitis.
3- Pancreatic Tumors.
3
Q
Def of Acute Pancreatitis
A
Acute inflammation of the pancreas characterized clinically by two of the
following:
- Symptoms: Characterized epigastric pain.
- Laboratory: Elevated serum amylase and lipase level more than 3 times upper limit of normal.
- Radiology: Consistent with pancreatitis, usually using CT or MRI.
4
Q
Common Causes of Acute Pancreatitis
A
5
Q
Rare Causes of Acute Pancreatitis
A
ο Ascaris blocking pancreatic outflow.
ο Ischemia from bypass surgery.
ο Infections other than mumps (EBV, CMV).
ο Pregnancy.
ο Idiopathic
ο Hereditary pancreatitis; AD.
ο Cystic fibrosis
ο Smoking.
6
Q
Pathogenesis of Acute Pancreatitis
A
7
Q
Pathology of Acute Pancreatitis
A
8
Q
Severity of clinical features may not always correlate with pathology
A
β¦.
9
Q
Dx of Acute Pancreatitis
A
- The diagnosis of acute pancreatitis (AP) relies on:
ο Acute abdominal pain
ο Increased serum pancreatic enzymes
ο Imaging procedures. - Etiological diagnosis; A further aspect in diagnosis of
- AP is the identification of the etiological factor.
10
Q
Clinical Dx of Acute Pancreatitis
A
- Acute abdominal pain
- Abdominal enlargement
- Tender rigid abdomen; guarding
- Cullen and Grey-Turnerβs signs; internal hemorrhage.
- Hematemesis and melena
- Patients are agitated; continuously changing their posture.
- Fever: chemical, not due to infection.
- Jaundice: compression or obstruction of bile duct
- Tetany: transient hypocalcemia
- Hypovolemic shock: can lead to renal failure
- ARDS: Acute respiratory distress syndrome
- Coma.
11
Q
Characters of Acute Abdominal Pain in Acute Pancreatitis
A
- Localized to the epigastrium, frequently radiates to the back.
- Usually severe.
- Sudden onset
- Persistent for at least one or two days.
- Often made worse by walking and lying supine and better by sitting and leaning forward.
- Nausea and vomiting.
- History of alcohol intake or biliary colic in the past.
12
Q
Abdominal Enlargment of Acute Pancreatitis
A
- Paralytic ileus.
- Pancreatic ascites.
- Pseudo cyst or abscess.
13
Q
Lab Dx of Acute Pancreatitis
A
14
Q
Assessment of severity of acute pancreatitis
A
15
Q
Rad Dx of Acute Pancreatitis
A
- Plain Radiographs
- Ultrasonography
- Computed tomography (CT)
- MRCP
- Endoscopic ultrasonography (EUS)
- ERCP
16
Q
Plain Radiograoph
Rad Dx of Acute Pancreatitis
A
17
Q
US
Rad Dx of Acute Pancreatitis
A
18
Q
CT
Rad Dx of Acute Pancreatitis
A
19
Q
MRCP
Rad Dx of Acute Pancreatitis
A
Non-invasive
20
Q
EUS
Rad Dx of Acute Pancreatitis
A
- Help to detect small ampullary lesion and microlithiasis
21
Q
ERCP
Rad Dx of Acute Pancreatitis
A
Endoscopic Retrograde Cholangiopancreatography (ERCP).
- In patient suspected to have biliary obstruction.
- Evidence of ascending cholangitis.
22
Q
Classification of Acute Pancreatitis
A
1- Mild acute pancreatitis: is associated with minimal
organ dysfunction and uneventful recovery.
2- Severe acute pancreatitis: is associated with organ failure
23
Q
Complications of Acute Pancreatitis
A
24
Q
DDx of Acute Pancreatitis
A
25
TTT of **Acute Pancreatitis**
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Pain Control in **Acute Pancreatitis**
- with meperidine up to 100/150mg intramuscularly every 3-4 hours as necessary. Better tolerated than morphine, which may induce spasm of the sphincter of Oddi
27
TTT of Complications of **Acute Pancreatitis**
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DDx of hyperamylasemia
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Medical causes of acute abdomen
**VIP**
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Def of **Chronic Pancreatitis**
- Continuous, prolonged, inflammatory and fibrosing process of the pancreas.
- Results in irreversible
ο Morphologic changes.
ο Permanent endocrine and exocrine pancreatic dysfunction.
31
Etiology of **Chronic Pancreatitis**
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Hereditary pancreatitis
- Autosomal Dominant (AD)
- Defect in control mechanism of enzyme proteolytic activity
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Cystic fibrosis
- Autosomal Recessive (AR)
- Cystic fibrosis transmembrane regulator (CFTR) gene
- Disturbed chloride transport across cellular membranes.
34
Autoimmune pancreatitis
- Autoimmune pancreatitis ( IgG4 ) β
- Associated with autoimmune disease (Polyarteritis nodosa, SLE, Sjogren syndrome)
35
CP of **Chronic Pancreatitis**
36
Lab Investigations of **Chronic Pancreatitis**
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Exocrine function test in **Chronic Pancreatitis**
- 72-h fecal fat test.
- Secretin test: gold standard, measures exocrine function but difficult to perform.
**(Measurement of secretory volume after intravenous secretin- stimulation by assessing T2 high signal changes in the duodenum).**
38
Rad Investigations for **Chronic Pancreatitis**
- XR: pancreatic calcifications
- U/S or CT: calcification, dilated pancreatic ducts, pseudocyst
- MRCP or ERCP: pancreatic ducts-narrowing and dilatation
- **EUS most sensitive method**
39
Managment of **Chronic Pancreatitis**
- General management
- Endoscopy
- Surgery
- Steatorrhea TTT
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General Managment
Managment of **Chronic Pancreatitis**
ο Stop alcohol
ο Enzyme replacement
ο Analgesics
ο Celiac ganglion block (trans-abd. or EUS)
41
Endoscopy
Managment of **Chronic Pancreatitis**
Sphincterotomy and/or pancreatic stent using ERCP;
ο If duct dilated.
ο Remove stones from pancreatic duct.
42
Surgery
Managment of **Chronic Pancreatitis**
**Surgery: 2nd option**
- to drain pancreatic duct (pancreatojejunostomy)
- Resect pancreas if duct contracted.
43
Dealing With Steatorrhea
Managment of **Chronic Pancreatitis**
- Pancreatic enzyme replacement
- Restrict fat, increase carbohydrate and protein (may also decrease pain)
44
Complications of **Chronic Pancreatitis**
- Neither endoscopy nor surgery can improve function.
- After 20 years of chronic pancreatitis, there is a 6% cumulative risk of developing pancreatic adenocarcinoma
45
Prognosis of **Pancreatic Cancer**
Aggressive with few symptoms until the cancer is advanced.
46
When do symptoms of **Pancreatic Cancer** appear?
ο Earlier from cancers in the head
ο Later if in the body and tail
47
Pathological types of **Pancreatic Cancer**
- Exocrine pancreatic cancer; It is the most common type (Mostly adenocarcinoma (95%)
- Endocrine pancreatic cancer; Neuroendocrine or islet-cell tumors (uncommon).
48
Endocrine **Pancreatic Cancers**
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PPT Factors for **Pancreatic Cancer**
50
CP of **Pancreatic Cancer**
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CP of **Glucagonomas**
* Hyperglycemia
* Dermatitis
* Stomatitis
* Weight loss and anemia.
52
CP of **Insulinomas**
* Increased Insulin secretion leading to Hypoglycemia.
* Palpitations, Tachycardia, Tremors, Sweating and Irritability
* Headache, Visual disturbances, Confusion, Seizures, or even coma
53
CP of **Somatostatinomas**
Somatostatin Decreases production of;
- Insulin ---> Hyperglycemia
- Pancreatic enzyme --->Diarrhea or steatorrhea
- Cholecystokinin ----> Dilated GB , stones
54
CP of **Gastrinomas (ZES)**
**Peptic ulcer**
ο Multiple
ο Post bulbar (unusual site)
ο Refractory
ο Recurrent
ο Associated with diarrhea
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CP of **VIPomas**
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CP of **Carcinoid tumor**
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Investigations for **Pancreatic Cancer**
- Lab
- Rad
- Bx
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Lab Investigations for **Pancreatic Cancer**
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Rad Investigation for **Pancreatic Cancer**
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Bx in **Pancreatic Cancer**
- **Types of Biopsy:**
* Percutaneous needle biopsy: Under imaging guidance (US or CT)
* Endoscopic ultrasound guided biopsy
* Laparoscopy biopsy.
- **Surgically resectable tumors must not be biopsied**
61
TTT of **Pancreatic Cancer**
- Surgery ----> Localized tumor
- Radiation and Chemotherapy ---> Locally advanced tumors
- Palliative Treatment ---> advanced tumors
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TTT of Localized **Pancreatic Cancer**
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Types of Surgery in **Pancreatic Cancer**
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Surgery in **Pancreatic Cancer** in cases of liver metastasis
- Should be resected when possible.
- Radiofrequency or cryosurgical ablation; In patients with unresectable liver metastasis
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TTT of **Pancreatic Cancer** if locally advanced
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TTT of **Pancreatic Cancer** if Advanced
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**Medical treatment for pancreatic endocrine neoplasms**
68
Somatostain analogue (octereotide)
**Medical treatment for pancreatic endocrine neoplasms**
Can improve symptoms in all the functional pancreatic endocrine neoplasms except Somatostatinomas.
69
Lu 177
**Medical treatment for pancreatic endocrine neoplasms**
**Lutetium Lu 177-dota-tate**
ο Peptide Receptor Radionuclide Therapy (PRRT)
ο Binds to somatostatin receptors.
ο Beta radiation
