Pancreatic diseases


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  • Fig. 15.30 C, Mucus-hypersecreting intraductal carcinoma. There is marked dilatation of a major pancreatic duct accompanied by fibrosis and atrophy of the surrounding parenchyma. This duct contained large amounts of mucin in its lumen. ( A and C courtesy of Dr. David S. Klimstra, Memorial Sloan-Kettering Cancer Center)
  • Fig. 15.24 Microcystic cystadenoma showing typical multilocular appearance.
  • Pancreatic diseases

    1. 1. Diseases of pancreas By Dr / Ahmed Abdel Kahaar Sohag University Hospital EGYPT
    2. 2. Congenital anomalies• Agenesis• Hypoplasia• Pancreas divisum• Annular pancreas• Ectopic pancreas
    3. 3. The Pancreas• Endocrine pancreas: – Diabetes Mellitus (DM) – Islet Cell Tumors• Exocrine pancreas: – Acute pancreatitis – Chronic pancreatitis – Carcinoma of the pancreas
    4. 4. Endocrine Pancreas• 1 million microscopic units – the islets of Langerhans• 4 most important cell types of the islets are: – Β (beta): constitute 70% of the cells and contain insulin – A (alpha): 20% of the cells and elaborate glucagon – D (delta): secrets somatostatin which suppresses the insulin and glucagon secretion – PP (pancreatic polypeptide): unknown physiologic function
    5. 5. 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
    6. 6. Acute pancreatitis c• Causes• Gallstones:60%( 35–50% in USA)• Alcohol:!4%• Drug: Azathioprine .6-Mercaptopurine------• Pancreas divisum( 胰腺分裂 ; 胰分裂 )• Microlithiasis• Metabolic cause• Sphincter of Oddi dysfunction• Infectious causes• Trauma, ascaris worms,HIV-----• Miscellaneous
    7. 7. Acute pancreatitis• Pathology• acute edematous pancreatitis• acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis, acute necrotizing pancreatitis)
    8. 8. Acute pancreatitis• Pathophysiology• Hypersecretion and obstruction Self-enzymatic digestionoLymphatic obstruction Cytokine , infectionDecreased arterial perfusionEdematous hemorrhagic necrotizing
    9. 9. Acute pancreatitis• 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
    10. 10. 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
    11. 11. Acute pancreatitis• Laboratory finding• Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis )• 500• 400 Urine amylase• 300• 200 Blood amylase• 100• 0• 0 1H 24H 48H 5DAY
    12. 12. Acute pancreatitis• Serum calcium• Serum glucose• Blood gas analysis• CRP(C-reactive protein)• Imunolipase, trypsinogen ,and immuno elastase.• ALT and AST (gallstone pancreatitis )
    13. 13. Acute pancreatitis• 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
    14. 14. •CT is the bestdiagnostic test forthe diagnosis ofacute pancreatitis.•Contrast-enhancedCT is excellent fordiagnosis ofpancreatic necrosis
    15. 15. Acute pancreatitis• Assessment of severity of acute pancreatitis Ransons criteriaOn Admission Within 48 HoursAge > 55 years Hematocrit decrease by >10%WBC > 16,000 mm³ Urea nitrogen increase > 5 mg/dlLDH > 350 IU/L Serum calcium < 8 mg/dlGlucose > 200 mg/dl Arterial PO² < 60 mm HgAST > 250 IU/L Base deficit > 4 mEq/L Estimated fluid sequestration > 6 L
    16. 16. 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
    17. 17. 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
    18. 18. Acute pancreatitis• Diagnosis and differential Clinical finding Diagnosis• Acute edematous pancreatitis Amylase and acute hemorrhagic necrotizing pancreatitis CT• Other diseases Abdominal• Acute appendtitis paracentesis• Ileus• Perforated gastroduodenal ulcer• Biliary disease• Ruptured hepatoma
    19. 19. 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
    20. 20. • 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
    21. 21. Surgical approach Rresection of necrotic tissue and peritoneal lavagesevere, progressive necrotizing pancreatitis orpancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis. Surgical sphincteroplasty of the pancreaticsphincter pancreatic sphincter dysfunctionoutcome is the same as for the endoscopic pancreaticsphincterotomymore invasiverequiring laparotomy and duodenotomy
    22. 22. 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
    23. 23. Chronic pancreatitis• Causes• Alcohol• Pancreas divisum• Tropical pancreatitis• Hyperparathyroidism• Trauma• Obstructive pancreatitis• Idiopathic chronic pancreatitis• Cystic fibrosis• Hereditary chronic pancreatitis
    24. 24. Chronic pancreatitis• Classification• Obstructive chronic pancreatitis• Calcified chronic pancreatitis• Inflammatory chronic pancreatitis• Pathology• pancreatic fibrosis ----
    25. 25. Chronic pancreatitis• Clinical finding and diagnosis• Abdominal pain , distention• Diarrhage• Dyspepsia• Malnutrtion• Diabetes• Narcotic addiction• Jaundice
    26. 26. Chronic pancreatitis• 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 ( 苯酪肽 ) test
    27. 27. Chronic pancreatitis• Imaging finding• Plain abdominal film• Transabdominal ultrasound• CT• MRCP• Endoscopic diagnosis procedures(ERC P,EUS)
    28. 28. 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
    29. 29. 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( 消瘦 )• Stools: acholic• Gallbladder:Distended• Abdominal mass
    30. 30. Tumors of Pancreas• 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( 正电子发射断层扫描 )• Biopsy(FNA) and cytology
    31. 31. Tumors of Pancreas• 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
    32. 32. Tumors of Pancreas• 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)
    33. 33. Carcinoma of periampulla• Arise from:• Papilla of duodenum• Vater ampulla• Distal CBD• Symptom: obstructive jaundice• Diagnosis• Treatment :similar to pancreatic carcinoma
    34. 34. Carcinoma of the Pancreas• Carcinoma of the pancreas refers to carcinoma of the exocrine pancreas, almost always arising from ductal epithelial cells (adenocarcinoma).• It is the fourth most common cause of death in the US and accounts for 5% of all cancer death.• Survival rates are 18% at 1 year and only 2% at 5 years.• Incidence rates are higher in smokers (2-3 x) than in nonsmokers; alcohol consumption imposes a modestly increased risk.• 65-80 y/o, M>F, B>W.
    35. 35. Morphology• Distribution: – Head 60% – Body 15% – Tail 5% – Diffuse or widely spread 20%• small and ill defined or large (8-10 cm), with extensive local invasion and regional metastases.• Microscopically, more or less differentiated glandular patterns (adenocarcinoma) arise from ductal epithelium, mucous or non-mucous secreting.
    36. 36. Clinical features• fatigue, anorexia, weight loss, and painless jaundice. Pain may develop later in the course.• local extension or metastases at the time of diagnosis.• With tumors in the head of the pancreas, the ampullary region is invaded, obstructing the outflow of the bile; patients usually die of obstructive jaundice and hepatobilliary dysfunction while the tumor is still relatively small and not widely disseminated.• In marked contrast, carcinoma of the body and tail of the pancreas remain silent for some time and may be quite large and widely disseminated by the time they are discovered.• Migratory thrombophlebitis (Trousseau sign) may occur, particularly with carcinoma of the body and tail.
    37. 37. Diagnosis of pancreatic adenocarcinoma• Tumor markers, including carcinoembryonic antigen (CEA), CA 19-9, and CA 125, are associated with pancreatic cancer but are not accurate enough to rule in or rule out a clinical diagnosis.• CT is the principal diagnostic test, although MRI, endoscopic ultrasonography, and ERCP each have a role.• Cytologic and histologic specimens can be obtained by ERCP. The aim is to determine if curative resection (pancreaticoduodenectomy – Whipple procedure) is possible.
    38. 38. . .
    39. 39. • About half of the patients who are deemed to have operable disease by imaging studies are found to have unresectable tumors at laparatomy.• In most instances, therapy is palliative, with the aim of relieving jaundice, pain, and duodenal obstruction. ERCP with billiary stent placement relieves jaundice in most patients with unresectable tumors.• Survival is related to functional status and is usually 6-12 months.