Pancreatic disease

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Pancreatic disease

  1. 2. <ul><li>Alcohol abuse </li></ul><ul><li>Biliary tract diseases </li></ul><ul><li>Drugs </li></ul><ul><li>Trauma </li></ul><ul><li>Viral infections </li></ul><ul><li>Metabolic disorders </li></ul><ul><li>Connective tissue diseases </li></ul>
  2. 3. <ul><li>Idiopathic in 30% of acute pancreatitis </li></ul><ul><li>25 – 40% of chronic pancreatitis </li></ul>
  3. 4. <ul><li>Severe constant epigastric pain  back </li></ul><ul><li>Elevated serum Amylase, Lipase levels </li></ul><ul><li>Ascites, pleural effusion </li></ul><ul><li>Hypercalcemia, hypocalcemia </li></ul><ul><li>Hypertriglyceridemia (Serum amylase maybe normal) </li></ul><ul><li>Chronic pancreatitis: Normal enzyme levels </li></ul>
  4. 5. <ul><li>Serum Amylase: rises within 24 hrs; remains elevated 1-3 days; 3x ULN; 85% of patients will have elevated amylase levels </li></ul><ul><li>Amylase also found in salivary glands, liver, small intestines, kidneys and fallopian tubes </li></ul><ul><li>Amylase elevated in CA of lungs, esophagus, breast, and ovary </li></ul><ul><li>Lipase: single best enzyme </li></ul>
  5. 7. <ul><li>Plain radiography: </li></ul><ul><li>1. sentinel loop (localized ileus of jejunum) </li></ul><ul><li>2. air fluid levels </li></ul><ul><li>3. colon cut off sign (distension of transverse colon) </li></ul><ul><li>4. duodenal distension </li></ul><ul><li> 5. mass (pseudocyst) </li></ul>
  6. 8. <ul><li>UGIS: widened C loop </li></ul><ul><li>Ultrasonography: edema, inflammation, calcifications, cysts, mass lesions </li></ul><ul><li>CT Scan </li></ul><ul><li>EUS (Endoscopic Ultrasound) </li></ul><ul><li>MRCP </li></ul><ul><li>ERCP </li></ul>
  7. 9. <ul><li>Interstitial: mild and self-limiting </li></ul><ul><li>Necrotizing: degree of necrosis correlates with the severity of clinical manifestations </li></ul>
  8. 10. <ul><li>Gallstones: 30-60% </li></ul><ul><li>Alcohol: 15-30% </li></ul><ul><li>Others </li></ul>
  9. 13. <ul><li>Initial Phase: Intrapancreatic digestive enzyme activation andacina cell injury </li></ul><ul><li>Second phase: activation, chemoattraction, sequestration of neutrophils  intrapancreatic inflammation </li></ul><ul><li>Third phase: due to the effects on the distant organs of activated proteolytic enzymes and cytokines  proteolysis, edema, insterstitial hemorrhage, vasgular damage, coag necrosis </li></ul>
  10. 14. <ul><li>Cellular necrosis  liberation of bradykinin, histamine and vasoactive substances  vasodilation, increased vascular permeability and edema  lungs (ARDS , SIRS), multiorgan failure </li></ul>
  11. 15. <ul><li>Pain: constant, severe, boring; epigastrium  back, chest, flanks: supine and relieved by trunk flexing and knees drawn up. </li></ul><ul><li>Nausea, vomiting, abdominal distention </li></ul><ul><li>Fever, tachycardia, hypotension </li></ul><ul><li>Hypovolemia; shock </li></ul><ul><li>Cullen’s sign </li></ul><ul><li>Turner’s sign </li></ul>
  12. 16. <ul><li>Amylase: 3x ULN; return to N in 72 hrs; higher in gall stones </li></ul><ul><li>Lipase: elevated for 7-14 days; higher in alcohol-related </li></ul><ul><li>Leukocytosis </li></ul><ul><li>Hyperglycemia </li></ul><ul><li>Hypocalcemia </li></ul><ul><li>Hyperbilirubinemia </li></ul>
  13. 17. <ul><li>Hypertriglyceridemia </li></ul><ul><li>LDH, AST </li></ul><ul><li>Alkaline phosphatase </li></ul><ul><li>Hypoxemia </li></ul>
  14. 21. <ul><li>Self-limited in 85-90% </li></ul><ul><li>Conventional measures: IV fluids, analgesics, colloids, no oral alimentation </li></ul><ul><li>Role of antibiotics – controversial </li></ul><ul><li>Somatostatin, H2 blockers, glucagon, steroids </li></ul><ul><li>Resumption of feeding: decrease/resolution of pain, resolution of organ dysfunction, patient feels hungry </li></ul>
  15. 22. <ul><li>Chronic inflammation, fibrosis, progressive destruction of exocrine, and later endocrine function </li></ul><ul><li>Complications: chronic pain, steatorrhea, DM </li></ul>
  16. 23. <ul><li>Alcohol: as little as <50g/d prolonged consumption </li></ul><ul><li>Idiopathic: 15% genetic defects </li></ul><ul><li>Clinical Features: </li></ul><ul><li>1. pain – related to food intake </li></ul><ul><li>2. maldigestion – diarrhea, steatorrhea, weight loss </li></ul>
  17. 25. <ul><li>Amylase and Lipase not usually elevated </li></ul><ul><li>Secretin test: best sensitivity/specificity; abN when 60% of exocrine function is lost </li></ul><ul><li>Radiography: calcifications </li></ul><ul><li>Ultrasonography </li></ul><ul><li>CT scans </li></ul><ul><li>MRCP </li></ul><ul><li>ERCP </li></ul>
  18. 27. <ul><li>Enzyme therapy to control diarrhea </li></ul><ul><li>Octreotide – somatostatin analogue that inhibits pancreatic secretion; decrease pain in large-duct disease </li></ul><ul><li>Endoscopic treatment: sphincterotomy, stenting, stone extraction, drainage of pseudocyst </li></ul>

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