Diseases of pancreas, by Prof. Ashok Nayak, BMJH Hospital, Bangalore

1. DISEASES OF PANCREAS
Prof. Ashok Nayak

2. Development
• 1 Day 26 Dorsal pancreatic duct arises from the dorsal side of the
duodenum
• 2 Day 32 Ventral bud arises from the base of the hepatic diverticulum
• 3 Day 37 Contact occurs between the two buds. Fusion by the end of
week 6
• 4 Week 6 Ventral bud the produces the head and uncinate process
• 5 Week 6 Ducts fuse
• 6 Week 6 Ventral duct and distal portion of the dorsal ductform the main
duct (duct of Wirsung)
• 7 Week 6 Proximal dorsal duct forms the duct of Santorini
• 8 Month 3 Acini appear
• 9 Months 3–4 Islets of Langerhans appear and become biologically
active

3. Anatomy

4. Investigations
• Bio-Chemistry
• X-Ray
• U/S Abdomen
• C T Scan
• MRCP
• ERCP
• EUS

5. Ultrasound

6. C T Scan

7. MRCP

8. ERCP

9. EUS

10. X-Ray

11. Congenital Anomalies
■ Aplasia
■ Hypoplasia
■ Hyperplasia
■ Hypertrophy
■ Dysplasia
■ Variations and anomalies of the ductsa Pancreas divisum
Rotational anomalies
■ Annular pancreasa
■ Pancreatic gall bladder
■ Polycystic diseasea
■ Congenital pancreatic cysts, cystic fibrosisa von Hippel–Lindau
syndrome
■ Ectopic pancreatic tissue, accessory pancreasa
■ Vascular anomalies
■ Choledochal cystsa
■ Horseshoe pancreas

12. Injuries to the Pancreas
• Blunt Trauma
• Penetrating Trauma
• Iatrogenic Trauma
oSplenectomy
oBillroth2 gastrectomy
oEndoscopy

13. Injuries to the Pancreas

14. Acute Pancreatitis
Possible causes of acute pancreatitis
■ Gallstones
■ Alcoholism
■ Post ERCP
■ Abdominal trauma
■ Following biliary, upper gastrointestinal or cardiothoracic
surgery
■ Ampullary tumour
■ Drugs (corticosteroids, azathioprine, asparaginase,
valproic acid, thiazides, oestrogens)
■ Hyperparathyroidism

15. Acute Pancreatitis
■ Hypercalcaemia
■ Pancreas divisum
■ Autoimmune pancreatitis
■ Hereditary pancreatitis
■ Viral infections (mumps, coxsackie B)
■ Malnutrition
■ Scorpion bite
■ Idiopathic

16. Symptoms
• Pain radiating into the back.
• Nausea and vomiting.
• Hiccups.

17. Signs
• Tachycardia & Tachypnoea.
• Profound shock
• Mild jaundice
• Grey Turner’s sign
• Cullen’s sign

18. Other Causes of raised serum
amylase
■ Upper gastrointestinal tract perforation
■ Mesenteric infarction
■ Torsion of an intra-abdominal viscus
■ Retroperitoneal haematoma
■ Ectopic pregnancy
■ Macroamylasaemia
■ Renal failure
■ Salivary gland inflammation

19. Investigations in acute pancreatitis should be aimed at
answering three questions:
• Is a diagnosis of acute pancreatitis correct?
• How severe is the attack?
• What is the aetiology?

20. Scoring System

21. Investigation

22. Treatment
• Admission to HDU/ICU
• Analgesia
• Aggressive fluid rehydration
• Oxygenation
• Invasive monitoring of vital signs, central venous
pressure, urine output, blood gases
• Frequent monitoring of haematological and
biochemical parameters (including liver and renal
function, clotting, serum calcium, blood
• glucose)

23. Treatment
• Nasogastric drainage
• Antibiotic prophylaxis can be considered (imipenem,
cefuroxime)
• CT scan essential if organ failure, clinical deterioration or
signs of sepsis develop
• ERCP within 72 hours for severe gallstone pancreatitis or
signs of cholangitis
• Supportive therapy for organ failure if it develops
(inotropes, ventilatory support, haemofiltration, etc.)
• If nutritional support is required, consider enteral
(nasogastric) feeding

24. Complications of acute pancreatitis

25. Pseudocyst

26. Pseudocyst

27. Possible complications of a pancreatic
pseudocyst

28. Chronic Pancreatitis
CT Scan MRI

29. Summary of treatment
Treat the addiction
• Help the patient to stop alcohol consumption and
tobacco smoking
• Involve a dependency counsellor or a psychologist
Alleviate abdominal pain
• Eliminate obstructive factors (duodenum, bile duct,pancreatic
duct)
• Escalate analgesia in a stepwise fashion
• Refer to a pain management specialist
• For intractable pain, consider CT/EUS-guided coeliac axis block

30. Summary of treatment
Nutritional and digestive measures
• •Diet: low in fat and high in protein and carbohydrates
• •Pancreatic enzyme supplementation with meals
• •Correct malabsorption of the fat-soluble vitamins (A, D, E, K) and
vitamin B12
• •Medium-chain triglycerides in patients with severe fat malabsorption
(they are directly absorbed by the small intestine without the need for
digestion)
• •Reducing gastric secretions may help
Treat diabetes mellitus

31. Pancreatico Jejunostomy

32. Carcinoma of the pancreas
Types-
• Exocrine -This cancer originates in the ducts that carry certain
hormones and enzymes away from the pancreas
• Neuroendocrine -The small minority of tumors that arise from
elsewhere in the pancreas are mainly pancreatic neuroendocrine
tumors (PanNETs).Neuroendocrine tumors (NETs) are a diverse
group of benign or malignant tumors that arise from the
body's neuroendocrine cells, which are responsible for integrating
the nervous and endocrine systems.

33. Carcinoma of the pancreas
Signs and symptoms –
• Pain in the upper abdomen or back, often spreading from around the
stomach to the back. The location of the pain can indicate the part of
the pancreas where a tumor is located
• Jaundice, a yellow tint to the whites of the eyes or skin, with or
without pain, and possibly in combination with darkened urine. This
results when a cancer of the head of the pancreas obstructs
the common bile duct as it runs through the pancreas.
• Unexplained weight loss, either from loss of appetite, or loss of
exocrine function resulting in poor digestion

34. Carcinoma of the pancreas

35. Carcinoma of the pancreas

36. Resection of the head of the pancreas

37. Palliation of pancreatic cancer
Relieve jaundice and treat biliary sepsis
■ Surgical biliary bypass
■ Stent placed at ERCP or percutaneous transhepatic cholangiography
Improve gastric emptying
■ Surgical gastroenterostomy
■ Duodenal stent
Pain relief
■ Stepwise escalation of analgesia
■ Coeliac plexus block
■ Transthoracic splanchnicectomy

38. Palliation of pancreatic cancer
Symptom relief and quality of life
■ Encourage normal activities
■ Enzyme replacement for steatorrhoea
■ Treat diabetes
Consider chemotherapy

39. Stents