• The pancreas is a retroperitoneal organ that lies in
an oblique position, sloping upward from the C-loop
of the duodenum to the splenic hilum.
• Weighs about 75 to 100gm
• Length is about 15 to 20cm
• It can be divided into Head, Uncinate process,
neck, body and tail.
• Neck lies over L1 and L2 vertebrae
• The neck of the pancreas lies directly over the
• At the inferior border of the neck, the superior
mesenteric vein joins the splenic vein and then
continues as the portal vein.
• The common bile duct runs in a deep groove on
the posterior aspect of the head.
• The body and tail lie just anterior to the splenic
artery and vein.
• The body overlies the aorta at the origin of the
superior mesenteric artery.
Variations of Portal Vein
• Embryologically pancreas develops from a ventral
bud and a dorsal bud.
• The duct of ventral bud is called as duct of Wirsung,
which is joined by common bile duct.
• The duct of dorsal bud is called as duct of Santorini
and it drains directly into the duodenum.
• With the gut rotation, the two buds and their
respective ducts fuse. The ventral bud becomes the
inferior portion of head and uncinate process while
the dorsal bud becomes the body and tail of
• Most of the pancreas drains through the duct of
Wirsung, the main pancreatic duct, and drains into
duodenum through ampulla of Vater/ major
• In 60% of the people the duct of Santorini persists as
the lesser pancreatic duct and drains into
duodenum through lesser papilla.
• The lesser papilla is usually about 2 cms proximal to
ampulla of Vater.
• In 30% the duct of Santorini ends as blind accessory
duct and does not empty into duodenum.
• In 10% the duct of Wirsung and Santorini fail to fuse,
this results in majority of pancreas draining through
the duct of Santorini and lesser papilla. This is know
as pancreas divisum
• In minority of patients with pancreas divisum the
lesser papilla can be inadequate to handle the flow
of pancreatic juice resulting in outflow obstruction
leading to pancreatitis.
Ampulla Of Vater
Sphincter Of Oddi
• Pancreas secretes approximately 500ml to 800ml of
pancreatic juice per day.
• Exocrine pancreas accounts for 85%
• Endocrine pancreas accounts only for 2%
• only approximately 20% of the normal pancreas is
required to prevent insufficiency.
• The acinar cells secrete amylase, proteases, and
• The centroacinar and intercalated duct cells
secrete the water and electrolytes
glycogenolysis, fatty acid
breakdown, and ketogenesis
Increased glycogenesis, protein
Opposite effects of insulin; increased
hepatic glycogenolysis and
Inhibits GI secretion
Inhibits secretion and action of all GI
Inhibits cell growth
Inhibits pancreatic exocrine
secretion and secretion of insulin
Facilitates hepatic effect of insulin
Counterregulates insulin secretion
Decreases insulin and somatostatin
Increases glucagon release
Decreases pancreatic exocrine
Decreases insulin release and insulin
• Inflammatory disease of pancreas that is associated
with little or no fibrosis of the gland.
• An acute condition presenting with abdominal pain
and is usually associated with raised pancreatic
enzymes levels in the blood or urine as a result of
Acute v/s Chronic
• Acute pancreatitis is reversible pancreatic
parenchymal injury associated with inflammation.
• Chronic pancreatitis is defined as inflammation of
the pancreas with irreversible destruction of
exocrine parenchyma, fibrosis, and, in the late
stages, the destruction of endocrine parenchyma.
• Mild acute pancreatitis: Interstitial oedema of the
gland and minimal organ dysfunction.
• 80% of case fall under Mild category, which has
about 1% mortality.
• Severe acute pancreatitis: pancreatic necrosis,
severe systemic inflammatory response and often
• Mortality rate is as high as 20 to 50%
Biliary tract disease
• Pancreatic duct
o Pancreas divisum
o Ampullary and duodenal lesions
Biliary Tract disease
• Choledocholithiasis is the most common form of
associated biliary abnormality
• Various Theories:
Common channel hypothesis
• Pancreatitis can result with single or little alcohol
• Usually > 2 years of intake, and often history of > 10
• In individuals taking 100 to 150gm/day of
alcohol, 10 to 15% can develop pancreatitis.
• It can become recurrent with continued alcohol
• Theories: secretion with blockage mechanism
• It is a metabolic toxin to pancreatic acinar cells.
• Alcohol also transiently decreases blood flow to
• Should be considered in a non alcoholic patient
with no demonstrable biliary tract disease.
• 1 to 2% of patients with acute pancreatitis have
• It could be the first clinical manifestation of
• Pancreatic biopsy, biliary duct exploration, distal
gastrectomy and splenectomy are associated with
• It is associated post op with billroth II gastrectomy
• ERCP results in pancreatitis in 2 to 10% of cases.
• Mumps, coxsackievirus, and m.pneumoniae are
believed to be capable of inducing pancreatitis by
infecting acinar cells.
• Infection by ascaris lumbricoides, and clonorchis
sinensis are also implicated.
• Cationic trypsinogen/PRSS1: It is a missense
mutation, which results in
premature, intrapancreatic activation of
• It accounts for about two-thirds of cases of
• A failure to express a normal trypsinogen
inhibitor, pancreatic secretory trypsin inhibitor (PSTI)
or SPINK1, is a cause of familial pancreatitis.