PANREAS 1__ صالح Flashcards
what’re the boundries of the pancreas ?
the tail of the pancreas is close to the spleen and the head near to the dudenum .
the tail of the pancreas is very vascular so any injury lead to heamoltical instability .
what the composition of the pancreas ?
-The main pancreatic duct branches into interlobular and intralobular ducts, ductules and, finally, acini.
80–90% is composed of exocrine acinar tissue, which is organized into lobules
Clusters of endocrine cells, known as islets of Langerhans, are distributed throughout the pancreas. Islets consist of different cell types: 75 per cent are B cells (producing insulin); 20 per cent are A cells (producing glucagon); and the remainder are D cells (producing somatostatin) and a small number of pancreatic polypeptide cells.
The main duct is lined by
The main duct is lined by columnar epithelium, which becomes cuboidal in the ductules. Acinar cells are clumped around a central lumen, which communicates with the duct system.
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what the role of pancreas during the meal?
In response to a meal, the pancreas secretes digestive enzymes in an alkaline (pH 8.4) bicarbonate-rich fluid
what’re the stimulation to release the pancreatic enzyme ?
- INTESTINAL PHASE
Secretin acts in tandem (بالتزامن)with another hormone called cholecystokinin (CCK)that produce by the deudenum Not only does CCK stimulate the pancreas to produce the requisite pancreatic juices, it also stimulates the gallbladder to release bile into the duodenum.
(so the lipid in protein stimulate the secretion )
-CEPHALIC PHASE
Vagal stimulation increases the volume of secretion. During this phase, the proteolytic enzymes ( e.g amylase, lipase, trypsin, elastase and chymotrypsin ) are in an inactive form, the maintenance of which is important in preventing pancreatitis.
what’s the general investigation of the pancreas ?
-Serum levels of proteolytic enzymes
like amylase, lipase, trypsin, elastase and chymotrypsin
directly measuring pancreatic secretion in response to a standardized stimulus.
e.g. ingestion of a test meal, as in the Lundh test, or pharmacological, e.g. intravenous injection of a hormone, such as secretin or CCK
-Imaging
Ultrasound.
C.T scan. ( Computerized tomography)
MRI ( MRCP) ( magnetic resonance cholangiopancreatography)
ERCP. ( endoscopic retrograde cholangiopancreatography)
Endoscopic ultrasound
Cystic fibrosis
is congintal abnormality of the pancreas
Pancreas divisum
Congenital diseases
embryological ventral and dorsal parts of the pancreas fail to fuse. Usually asymptomatic but have a higher incidence of acute , chronic pancreatitis and pancreatic pain
how to diagnosis the pancreas divisum ?
diagnosis can be arrived at by MRCP, EUS or ERCP, augmented by injection of secretin if necessary
what ‘s the treatment of the pancreas divisum ?
-Endoscopic sphincterotomy + stenting of the minor papilla
- sphincteroplasty,
- pancreatojejunostomy or even resection of the pancreatic head
+sphincterotomy is a simple surgery during which the sphincter is cut or stretched
Annular pancreas
failure of complete rotation of the ventral pancreatic bud during development, so that a ring of pancreatic tissue surrounds the second or third part of the duodenum
when we see the annular pancreas ?
seen in association with congenital duodenal stenosis or atresia and is therefore more prevalent in children with Down’s syndrome.
presentation of the annular pancreas ?
. Duodenal obstruction typically causes vomiting in the neonate .
treatment of the annular pancreas ?
duodenoduodenostomy
anastomosis for the purpose of bypassing an obstructed segment of duodenum.
why the blunt trauma is infrequent in pancreas ?
because of the pancreas location retroperitoneally sourround by the viscera
what the source of the blunt of the pancreas ?
it is often concomitant with injuries to other viscera, especially the liver, the spleen and the duodenum.
Occasionally, a forceful blow to the epigastrium may crush the body of the pancreas against the vertebral column.
ضربة قوية
how the pt with blunt presented with ?
- usually presents with epigastric pain minor at first then develop more severe pain due to the sequelae of leakage of pancreatic fluid into the surrounding tissues.
- A rise in serum amylase occurs in most cases.
- A CT scan of the pancreas will delineate the damage
- ERCP and MRCP If there is doubt about duct disruption,
Treatment of blunt injuries
- we should first make sure whether the pancreatic duct has been disrupted
- intravenous fluids and a nil by mouth regimen while these investigations are performed
- no need to rush to a laparotomy if the patient is haemodynamically stable, without peritonitis
- preferable to manage conservatively at first, investigate
- Operation is indicated if there is disruption of the main pancreatic duct; in almost all other cases, the patient will recover with conservative management.
Penetrating injury
- Need urgent surgery. by Haemostasis and closed drainage for minor parenchymal injuries
- distal pancreatectomy should be performed, with or without splenectomy if the gland is transected in the body or tail
- but if the plane of transection is flat and clean anastomose the stump of the distal pancreas to a Roux loop of jejenum as an end-to-side pancreatojejunostomy.
- if there is severe injury to the pancreatic head and duodenum, then a pancreatoduodenectomy may be necessary
- If damage is purely in the head of the pancreas, haemostasis and external drainage is normally effective.
Iatrogenic injury ( VERY IMPORTANT)
its damage happen due to some medical surgery
what’re the causes of the Iatrogenic injury ?
-splenectomy
may cause tail injury resulting in a pancreatic fistula.
- Billroth II gastrectomy
cause Injury to the accessory pancreatic duct (Santorini), which is the main duct in 7 per cent of patients,
-Enucleation of islet cell tumors of the pancreas
can result in fistulae
استئصال
-sphincterotomy
cause Duodenal or ampullary bleeding this need duodenotomy to control the bleeding.
Pancreatic fistula (IMPORTANT) cause
- Trauma
- Acute and chronic pancreatitis
Site of Pancreatic fistula
externally to skin or internally to bowel
the diagnosis of Pancreatic fistula
measurement of the amylase in the fistula content
the treatment of Pancreatic fistula
- correction of metabolic and electrolyte disturbances IVF
- parenteral or nasojejunal nutritional support
- drainage of the fistula into a stoma bag with protection of the skin
- When there is obstruction within the pancreatic duct, stenting the duct endoscopically
- use of octreotide will also suppress pancreatic secretion
+octreotide
mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone.
The pancreas is situated
in the retroperitoneum.
pancreas divided into
- into a head, which occupies 30% of the gland by mass,
- a body and tail, which together constitute 70 %
The head of pancreas lies
within the curve of the duodenum, overlying the body of the second lumbar vertebra and the vena cava.
behind the neck of the pancreas
-The aorta and the superior mesenteric vessels
-Behind the neck of the pancreas, near its upper border,
the superior mesenteric vein joins the splenic vein to form the portal vein
Coming off the side of the pancreatic head pass to Lt
Coming off the side of the pancreatic head and passing to the left and behind the superior mesenteric vein is the uncinate process of the pancreas
The tip of the pancreatic tail
extends up to the splenic hilum.
Weight of pancreas
Weight = 80 grams
Acute pancreatitis
acute condition presenting with
- abdominal pain and usually associated with
- raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation
Acute pancreatitis cause
premature activation of pancreatic enzymes within the pancreas, leading to a process of autodigestion.
the sequele of the Acute pancritis ?
_Anything that injures the acinar cell and impairs the secretion of zymogen granules
or damages the duct epithelium and thus delays enzymatic
_premature activation of pancreatic enzymes
_cellular injury has been initiated
_the inflammatory process can lead to pancreatic oedema
haemorrhage and, eventually, necrosis
_inflammatory mediators are released into the circulation, systemic complications such as
-haemodynamic instability
-bacteraemia (due to translocation of gut flora)
- acute respiratory distress syndrome
- pleural effusions
- gastrointestinal haemorrhage
renal failure
-disseminated intravascular coagulation (DIC)
+Zymogen granules (ZGs) are specialized storage organelles in the exocrine pancreas that allow the sorting, packaging and regulated apical secretion of digestive enzymes. ZG constituents play important roles in pancreatic injury and disease. The molecular mechanisms underlying these processes are still poorly defined.
classification of acute panceritis
Mild is characterised by -interstitial oedema of the gland -minimal organ dysfunction 80% - Mortality 1%
Severe acute pancreatitis is characterised by -pancreatic necrosis, a severe systemic inflammatory response -often multi-organ failure. - mortality varies from 20 to 50 %
About one-third of deaths occur in the early phase of the attack, from multiple organ failure death after the first week of onset are due to septic complications
what’re the causes of the death in acute pancritis ?
1/3 of death in the early phase of the attack, from multiple organ failure
death after the first week of onset are due to septic complications
causes of acute pancritis ?
-Idiopathic
- Gallstones
- Ethanol
- Trauma,Tumer of ampulary of vater
- Steroids
- Mumps, malnutrient
- Autoimmune
- Scorpian venom
- Hyperlipidaemia, hypothermia, hypercalcaemia, hyperthyrodism
- ERCP
- Drugs
I GET SMASHED
and all the congintal pancreas disease
Clinical presentation of acute pancritis
-Pain is dull ,sever, develops quickly, reaching maximum intensity within minutes and persists for hours or even days ,constant and refractory to the usual doses of analgesics
Pain is usually experienced first in the epigastrium but may be localized to either upper quadrant or felt diffusely throughout the abdomen
There is radiation to the back in about 50 per cent of patients,
some patients may gain relief by sitting or leaning forwards
- Nausea, repeated vomiting and retching
- Why ? Hiccough
general exam ----------------------- -the appearance -Tachypnea -tachycardia - hypovolemia and neurogenic shock -The body temperature raised because its systemic
-Mild icterus (technical term for jaundice)
can be caused by biliary obstruction in gallstone pancreatitis
- (Grey Turner’s sign)
- (Cullen’s sign)
- Subcutaneous fat necrosis may produce small, red, tender nodules on the skin of the legs.
- distension due to ileus happen due to paralysis
- mass can develop in the epigastrium due to inflammation
- usually muscle guarding in the upper abdomen, although marked rigidity is unusual
- A pleural effusion is present in 10–20 per cent of patients
- Pulmonary oedema and pneumonitis
- confused encephalopathy
- the signs of metabolic derangement together with hypoxaemia
acute pancreatitis can mimic
most causes of the acute abdomen
acute swinging pyrexia with pancritits suggests
suggests cholangitis
Mild icterus with pancritits
caused by biliary obstruction in gallstone pancreatitis
