L11: Pancreatic Disorders Flashcards
Introduction to Pancreas
Complicated exocrine and endocrine gland
located in the upper abdominal region
It lies behind the peritoneum of the posterior
abdominal wall
Divided into head, body, and tail
Types of Diseases of Pancreas
1- Acute Pancreatitis.
2- Chronic Pancreatitis.
3- Pancreatic Tumors.
Def of Acute Pancreatitis
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.
Common Causes of Acute Pancreatitis
Rare Causes of Acute Pancreatitis
Ascaris blocking pancreatic outflow.
Ischemia from bypass surgery.
Infections other than mumps (EBV, CMV).
Pregnancy.
Idiopathic
Hereditary pancreatitis; AD.
Cystic fibrosis
Smoking.
Pathogenesis of Acute Pancreatitis
Pathology of Acute Pancreatitis
Severity of clinical features may not always correlate with pathology
….
Dx of Acute Pancreatitis
- The diagnosis of acute pancreatitis (AP) relies on:
Acute abdominal pain
Increased serum pancreatic enzymes
Imaging procedures. - Etiological diagnosis; A further aspect in diagnosis of
- AP is the identification of the etiological factor.
Clinical Dx of Acute Pancreatitis
- Acute abdominal pain
- Abdominal enlargement
- Tender rigid abdomen; guarding
- Cullen and Grey-Turner’s 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.
Characters of Acute Abdominal Pain in Acute Pancreatitis
- 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.
Abdominal Enlargment of Acute Pancreatitis
- Paralytic ileus.
- Pancreatic ascites.
- Pseudo cyst or abscess.
Lab Dx of Acute Pancreatitis
Assessment of severity of acute pancreatitis
Rad Dx of Acute Pancreatitis
- Plain Radiographs
- Ultrasonography
- Computed tomography (CT)
- MRCP
- Endoscopic ultrasonography (EUS)
- ERCP
Plain Radiograoph
Rad Dx of Acute Pancreatitis
US
Rad Dx of Acute Pancreatitis
CT
Rad Dx of Acute Pancreatitis
MRCP
Rad Dx of Acute Pancreatitis
Non-invasive
EUS
Rad Dx of Acute Pancreatitis
- Help to detect small ampullary lesion and microlithiasis
ERCP
Rad Dx of Acute Pancreatitis
Endoscopic Retrograde Cholangiopancreatography (ERCP).
- In patient suspected to have biliary obstruction.
- Evidence of ascending cholangitis.
Classification of Acute Pancreatitis
1- Mild acute pancreatitis: is associated with minimal
organ dysfunction and uneventful recovery.
2- Severe acute pancreatitis: is associated with organ failure
Complications of Acute Pancreatitis
DDx of Acute Pancreatitis
TTT of Acute Pancreatitis
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
TTT of Complications of Acute Pancreatitis
DDx of hyperamylasemia
Medical causes of acute abdomen
VIP
Def of Chronic Pancreatitis
- Continuous, prolonged, inflammatory and fibrosing process of the pancreas.
- Results in irreversible
Morphologic changes.
Permanent endocrine and exocrine pancreatic dysfunction.
Etiology of Chronic Pancreatitis
Hereditary pancreatitis
- Autosomal Dominant (AD)
- Defect in control mechanism of enzyme proteolytic activity
Cystic fibrosis
- Autosomal Recessive (AR)
- Cystic fibrosis transmembrane regulator (CFTR) gene
- Disturbed chloride transport across cellular membranes.
Autoimmune pancreatitis
- Autoimmune pancreatitis ( IgG4 ) ↑
- Associated with autoimmune disease (Polyarteritis nodosa, SLE, Sjogren syndrome)
CP of Chronic Pancreatitis
Lab Investigations of Chronic Pancreatitis
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).
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
Managment of Chronic Pancreatitis
- General management
- Endoscopy
- Surgery
- Steatorrhea TTT
General Managment
Managment of Chronic Pancreatitis
Stop alcohol
Enzyme replacement
Analgesics
Celiac ganglion block (trans-abd. or EUS)
Endoscopy
Managment of Chronic Pancreatitis
Sphincterotomy and/or pancreatic stent using ERCP;
If duct dilated.
Remove stones from pancreatic duct.
Surgery
Managment of Chronic Pancreatitis
Surgery: 2nd option
- to drain pancreatic duct (pancreatojejunostomy)
- Resect pancreas if duct contracted.
Dealing With Steatorrhea
Managment of Chronic Pancreatitis
- Pancreatic enzyme replacement
- Restrict fat, increase carbohydrate and protein (may also decrease pain)
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
Prognosis of Pancreatic Cancer
Aggressive with few symptoms until the cancer is advanced.
When do symptoms of Pancreatic Cancer appear?
Earlier from cancers in the head
Later if in the body and tail
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).
Endocrine Pancreatic Cancers
PPT Factors for Pancreatic Cancer
CP of Pancreatic Cancer
CP of Glucagonomas
- Hyperglycemia
- Dermatitis
- Stomatitis
- Weight loss and anemia.
CP of Insulinomas
- Increased Insulin secretion leading to Hypoglycemia.
- Palpitations, Tachycardia, Tremors, Sweating and Irritability
- Headache, Visual disturbances, Confusion, Seizures, or even coma
CP of Somatostatinomas
Somatostatin Decreases production of;
- Insulin —> Hyperglycemia
- Pancreatic enzyme —>Diarrhea or steatorrhea
- Cholecystokinin —-> Dilated GB , stones
CP of Gastrinomas (ZES)
Peptic ulcer
Multiple
Post bulbar (unusual site)
Refractory
Recurrent
Associated with diarrhea
CP of VIPomas
CP of Carcinoid tumor
Investigations for Pancreatic Cancer
- Lab
- Rad
- Bx
Lab Investigations for Pancreatic Cancer
Rad Investigation for Pancreatic Cancer
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
TTT of Pancreatic Cancer
- Surgery —-> Localized tumor
- Radiation and Chemotherapy —> Locally advanced tumors
- Palliative Treatment —> advanced tumors
TTT of Localized Pancreatic Cancer
Types of Surgery in Pancreatic Cancer
Surgery in Pancreatic Cancer in cases of liver metastasis
- Should be resected when possible.
- Radiofrequency or cryosurgical ablation; In patients with unresectable liver metastasis
TTT of Pancreatic Cancer if locally advanced
TTT of Pancreatic Cancer if Advanced
Medical treatment for pancreatic endocrine neoplasms
Somatostain analogue (octereotide)
Medical treatment for pancreatic endocrine neoplasms
Can improve symptoms in all the functional pancreatic endocrine neoplasms except Somatostatinomas.
Lu 177
Medical treatment for pancreatic endocrine neoplasms
Lutetium Lu 177-dota-tate
Peptide Receptor Radionuclide Therapy (PRRT)
Binds to somatostatin receptors.
Beta radiation
