Acute pancreatitis and Pancreatic Carcinoma

1. PANCREATITIS
AND
PANCREATIC CARCINOMA.
Dr.Bawantha Gamage
Department of Surgery
USJP.

2. OBJECTIVES
 UNDERSTAND THE AETIOLOGY ANDUNDERSTAND THE AETIOLOGY AND
PATHOGENESIS OF CHRONICPATHOGENESIS OF CHRONIC
PANCREATITIS.PANCREATITIS.
 CLINICAL DIAGNOSIS OFCLINICAL DIAGNOSIS OF
PANCREATITISPANCREATITIS
 PRINCIPLES OF MANAGEMENTPRINCIPLES OF MANAGEMENT

3. OBJECTIVES……cntd
 Understand the aetiology and pathology ofUnderstand the aetiology and pathology of
pancreatic and periampulary carcinoma.pancreatic and periampulary carcinoma.
 How to diagnose pancreatic carcinomaHow to diagnose pancreatic carcinoma
 Pre op preperation of a patient withPre op preperation of a patient with
obstructive jaundiceobstructive jaundice
 Principles of treatment of Pancreatic CAPrinciples of treatment of Pancreatic CA

4. Pancreas – anatomy and physiology

6. Relevant surgical anatomy
 Relationship toRelationship to
 duodenum (duodenal obstructions)duodenum (duodenal obstructions)
 common bile duct (obstructive jaundice)common bile duct (obstructive jaundice)
 SMA and Portal vein (cannot be sacrificed)SMA and Portal vein (cannot be sacrificed)
 Lesser sac – fluid collectionsLesser sac – fluid collections
 Duct – accessible, endoscopicallyDuct – accessible, endoscopically
 Retroperitoneal organ (pain relieved by bendingRetroperitoneal organ (pain relieved by bending
forwards), difficult to use USS, images obscuredforwards), difficult to use USS, images obscured
by bowel gasby bowel gas
 Structure – glands (adenocarcinoma)Structure – glands (adenocarcinoma)

7. Chronic Pancreatitis
DefinitionDefinition
Chronic inflammatory disease in which thereChronic inflammatory disease in which there
is irreversible progressive destruction ofis irreversible progressive destruction of
pancreatic tissuepancreatic tissue
Male : female 4:1

8. Aetiology
A)A) AlcoholAlcohol
B)B) HereditaryHereditary
C)C) IdiopathicIdiopathic
D)D) ObstructiveObstructive
E)E) MetabolicMetabolic
F)F) MiscellaneousMiscellaneous
eg : Nutritional, Tropical ,Exposure toeg : Nutritional, Tropical ,Exposure to
chemicals , Radiotherapy , Cyst fibrosischemicals , Radiotherapy , Cyst fibrosis

9. Clinical Features
HistoryHistory
 Recurrent abdominal painRecurrent abdominal pain
 Nausea /VomitingNausea /Vomiting
 Weight LossWeight Loss} Exocrine insufficiency} Exocrine insufficiency
 Steatorhoea } manifest when 90% of theSteatorhoea } manifest when 90% of the
gland is lost.gland is lost.
 Symptoms of DM EndocrineSymptoms of DM Endocrine insufficiencyinsufficiency
ExaminationExamination
 IcterusIcterus
 Abdominal MassAbdominal Mass
 Features of segmental portal HTFeatures of segmental portal HT
 Aetiological StigmataAetiological Stigmata

10. Pathology
 Minimal change in macroscopy & microscopyMinimal change in macroscopy & microscopy
Dense Fibrosis & destruction of the glandDense Fibrosis & destruction of the gland
 Duct systemDuct system Variable stricture formation &Variable stricture formation &
dilatation with epithelialdilatation with epithelial
hyperplasiahyperplasia

11. Investigations
 S.AmylaseS.Amylase Unhelpful in diagnosisUnhelpful in diagnosis
 Plain X-ray abdomenPlain X-ray abdomen
 USS AbdomenUSS Abdomen
 Contrast enhanced CTContrast enhanced CT
 EUSEUS
 MRCPMRCP
 ERCPERCP

13. Complications
A) LocalA) Local
 PseudocystPseudocyst
 AbscessAbscess
 Bile Duct/Duodenal StenosisBile Duct/Duodenal Stenosis
 Pancreatic duct obstructionPancreatic duct obstruction
 CA pancreasCA pancreas
B) SystemicB) Systemic
 Exocrine dysfunctionExocrine dysfunction
 Endocrine dysfunctionEndocrine dysfunction
 Analgesic AbuseAnalgesic Abuse
C) VascularC) Vascular
 PseudoaneurysmsPseudoaneurysms
 Portal/Splenic vein thrombosisPortal/Splenic vein thrombosis
D) DistantD) Distant
 Peptic UlcerationPeptic Ulceration
 Osseous LesionsOsseous Lesions

15. Treatment
 ConservativeConservative

Life style adjustmentLife style adjustment
 Exocrine & Endocrine SupplementationsExocrine & Endocrine Supplementations
 Prevent narcotic abusePrevent narcotic abuse
 InterventionalInterventional
 EndoscopicEndoscopic
 Interventional Radiology to treatInterventional Radiology to treat
complicationscomplications
 SurgerySurgery
Pancreatico duodenectomyPancreatico duodenectomy
Distal PancreatectomyDistal Pancreatectomy
Frey procedureFrey procedure

17. Prognosis
 Mortality is around 50% within 20-25 yearsMortality is around 50% within 20-25 years
of diagnosisof diagnosis
 15-20% die of complications15-20% die of complications
 Good Surgical treatment will ensureGood Surgical treatment will ensure
 Long term freedom from symptoms in 80%Long term freedom from symptoms in 80%
if aetiology is removedif aetiology is removed

18. Pancreatic Cancer
 Cancer with a poor prognosisCancer with a poor prognosis
5 year survival <2%5 year survival <2%
Only 10% will survive one yearOnly 10% will survive one year
after diagnosisafter diagnosis
 Rare in <40 years of ageRare in <40 years of age
 Male > FemalesMale > Females

19. Aeitiology
 Cause is UnknownCause is Unknown
Risk factorsRisk factors
 Chronic pancreatitisChronic pancreatitis
 SmokingSmoking
 Familial (Place for secondary screening)Familial (Place for secondary screening)
 ? High fat diet? High fat diet
 Exposure to pesticidesExposure to pesticides

20. Pathology
 90%90% Duct AdenocarcinomaDuct Adenocarcinoma
– 70% in the head70% in the head
– 30% in the body & tail30% in the body & tail
Periampullary Carcinoma
•What is it ?
•5% of all G.I. Malignancies
3% Pancreas
2% Others

21. Clinical Features
 At presentation only 20% are confined to the pancreas , 40%At presentation only 20% are confined to the pancreas , 40%
locally advanced & 40% will have distant metastasis.locally advanced & 40% will have distant metastasis.
 Symptoms & signs depend on the site of the tumorSymptoms & signs depend on the site of the tumor..
 HistoryHistory
 PainPain
 Weight Loss, Nausia & VomitingWeight Loss, Nausia & Vomiting
 Steotorhoia ectSteotorhoia ect
ExaminationExamination
 IcterusIcterus
 LymphadenopathLymphadenopath
 Migratory thrombophlebitis (10% pancreatic CA)Migratory thrombophlebitis (10% pancreatic CA)
 Courvosier’s SignCourvosier’s Sign
 Enlarged Liver +/- AscitisEnlarged Liver +/- Ascitis
 Pleural effusionPleural effusion

22. Diagnosis
 USS AbdomenUSS Abdomen
 Contrast enhanced CT/MRIContrast enhanced CT/MRI
 EUSEUS
 MRCPMRCP
 ERCPERCP
 Visceral AngiographyVisceral Angiography
 Laparoscopy + Laparoscopic USLaparoscopy + Laparoscopic US
 Tumor MarkersTumor Markers
(Note – 5% of presumed pancreatic CA will turn out to have(Note – 5% of presumed pancreatic CA will turn out to have
Chronic pancreatitis in histology )Chronic pancreatitis in histology )

23. Pre – op preparation
 Why is it important ?Why is it important ?
 How to do it ?How to do it ?

24. Treatment
 SurgicalSurgical
A.) Potentially curativeA.) Potentially curative
Eg:- Pancreatico duodinectomy (Whipple’s surgery)Eg:- Pancreatico duodinectomy (Whipple’s surgery)
Total pancreatectomyTotal pancreatectomy
Distal pancreatectomyDistal pancreatectomy
B.) PalliativeB.) Palliative
Eg:- StentingEg:- Stenting
Bypass surgeryBypass surgery
 ChemoradiationChemoradiation
a.) Neoadjuvent } ?a.) Neoadjuvent } ?
b.) Adjuvent } ?b.) Adjuvent } ?

27. Prognosis of Periampullary CA
 Duodinal > Amupullary > Billiary > PancreasDuodinal > Amupullary > Billiary > Pancreas
Why there is a defference ?Why there is a defference ?
 SizeSize
 L.N. StatusL.N. Status
 Type of tumor(Polypoid& papillary better)Type of tumor(Polypoid& papillary better)
 GradeGrade
 StageStage
 Lymphetic & invasionLymphetic & invasion
 Perinural InvationPerinural Invation

28. Summery
 Commonest pancreatic CA is PDACCommonest pancreatic CA is PDAC
 It starts as PIN type I III Carcinoma in situ PDACIt starts as PIN type I III Carcinoma in situ PDAC
 Increasing age & smoking are the biggest risk factorsIncreasing age & smoking are the biggest risk factors
chronic pancreatitis & familial causes are also identifiedchronic pancreatitis & familial causes are also identified
 Jaundis patient of > 40 years, with abd pain & weight lossJaundis patient of > 40 years, with abd pain & weight loss
warrents investigatios to exclude CA pancreasewarrents investigatios to exclude CA pancrease
 Only 20% has resenctable tumor at presentationOnly 20% has resenctable tumor at presentation

29. THANK YOU.
Please note that the photos are obtained from Grant’s Atlas