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Anatomy : The pancreas lies posterior to the stomach and lesser omentum in the retroperitoneum of the upper abdomen. It extends obliquely, rising slightly as it passes from the medial edge of the duodenal C loop to the hilum of the spleen. It lies anterior to the inferior vena cava , aorta, splenic vein, and left adrenal gland. The pancreas is divided into four regions: the head and uncinate process, neck, body, tail.
Head lies within duodenal C loop, and its Uncinate process extends posteriorly and medially to lie behind the portal and superior mesenteric vein and superior mesenteric artery. Neck of the gland extends medially from the head to lie anterior to those vessels. Body extends laterally from the neck toward the spleen , whereas the tail extends into the splenic hilum. Blood supply: celiac trunk and the superior mesenteric artery provide the arterial supply to the pancreas Venous drainage is to the splenic, superior mesenteric, and portal veins
Nausea Vomiting.R.Cholesterol ester hydrolase . Pancreatic duct obstruction Pancreatic duct bleeding Duodenal obstruction Vascular Post-operative Periarteritis nodosa Atheroembolism Infection Mumps Coxsakie B Cytomegalovirus Cryptococcus Symptoms: Pain. often accompanied by vomiting.5 liters of clear. Regional tissues and remote organ systems are sometimes involved.Often starts after alcohol binge or heavy meal. Acute Pancreatitis: Acute inflammation.radiates to the back(50%).Ribonuclease . 2. Elastase .Chymotrypsin. bicarbonate-rich pancreatic juice each day.not coupious.P. plays a critical role in duodenal alkalinization and in food digestion.Physiology: Endocrine Pancreas: Insulin Exocrine pancreas:Trypsin . Dominant symptom in 85%-100%. Etiology: Metabolic Alcohol Hyperlipoproteinemia Hypercalcemia Drugs Genetic Scorpion venom Mechanical Cholelithiasis Postoperative Pancreas divisum Posttraumatic E. Elevated pancreatic enzymes in blood or urine usually occur.Carboxypeptidase B. usually with rapid onset of pain and tenderness.constant. but not invariably.Phospholipase A².Carboxypeptidase A.gastric and duodenal contents (doesn’t relieve discomfort) . colorless.increases in intensity rapidly.Deoxyribonuclease . and systemic inflammatory responses .upper abdominal.Pancreatic α amylase.Colipase. Pancreatic lipase.
epigastric fullness. HyperTG False (+): renal failure. other abdominal or salivary gland process. Grey-turner sign (Left flank ecchymosis) Cullen sign (periumbilical ecchymosis) Fox sign Evaluation: Amylase:Nonspecific !!! Amylase levels > 3x normal very suggestive of pancreatitis May be normal in chronic pancreatitis !!! Enzyme level severity False (-): acute on chronic (EtOH). IL-8 (studies hoping to use these markers to aid in detecting severity of disease) ALT > 3x normal gallstone pancreatitis: (96% specific. but only 48% sensitive) Depending on severity may see: Ca WBC BUN Hct glucose .Signs: Restlessness Rapid pulse Rapid respiratory rate Arterial hypotension Abdomen moderately distended. acidemia lipase : More sensitive & specific than amylase Other inflammatory markers will be elevated: CRP. IL-6.
abscess. and mortality or length of hospitalization APACHE II: conducted 48 hours after admission CT severity Index: • Recent studies show this to be most predictive of adverse outcomes – CT score > 5 associated with 15x mortality rate – Problem is 1 CT study showing this was conducted 72 hours after admission (Ranson/Apache are 24 & 48 hours) Imrie Score Atlanta Classification used to help compare various scores (clinical research trials) . hemorrhage. fluid collections.Imaging: AXR .“sentinel loop” or small bowel ileus US or CT: may show enlarged pancreas with stranding . necrosis or pseudocyst MRI/MRCP(Magnetic Resonance Cholangiopancreatography ): newest “fad” Decreased nephrotoxicity from gadolinium Better visualization of fluid collections MRCP allows visualization of bile ducts for stones – Does not allow stone extraction or stent insertion Endoscopic US :(even newer but used less) Useful in obese patients Morbidity and mortality highest if necrosis present (especially if necroctic area infected) Dual phase CT scan useful for initial eval to look for necrosis necrosis may not be present for 48-72 hours Prognosis: Many different scoring systems: Ranson (most popular in med-school) conducted 24 hours after admission • No association found with score.
0 Increase in BUN > 5 Fluid sequestration > 6L Arterial PO2 < 60 5% mortality risk with <2 signs 15-20% mortality risk with 3-4 signs 40% mortality risk with 5-6 signs 99% mortality risk with >7 signs CT Severity Index: CT Grade A is normal (0 points) B is edematous pancreas (1 point) C is B plus extrapancreatic changes (2 points) D is severe extrapancreatic changes plus one fluid collection (3 points) E is multiple or extensive fluid collections (4 points) Necrosis score None (0 points) < 1/3 (2 points) > 1/3.000 Glucose > 200 LDH > 350 AST > 250 During first 48 hours Hematocrit drop > 10% Serum calcium < 8 Base deficit > 4.Ranson Criteria: Admission Age > 55 WBC > 16. < 1/2 (4 points) > 1/2 (6 points) TOTAL SCORE =CT grade + Necrosis 0-1 = 0% mortality 2-3 = 3% mortality 4-6 = 6% mortality 7-10 = 17% mortality .
hemorrhage or obstruct adjacent structures Asymptomatic. prophylactic antibiotics is not indicated .Therapy: Remove offending agent if possible Supportive !!! #1.NPO(Nil per os:lating for “nothing by mouth” (until pain free): o NG suction for patients with ileus or emesis o TPN (total parenteral nutrition)may be needed #2. not actual improvement of pancreatic inflammation #5. pancreatic necrosis.Don’t forget PPI to prevent stress ulcer Complications: Necrotizing pancreatitis: o Significantly increases morbidity & mortality o Usually found on CT with IV contrast Pseudocysts o Suggested by persistent pain or continued high amylase levels (may be present for 4-6 wks afterward) o Cyst may become infected .Aggressive volume repletion with IVF: o Keep an eye on fluid balance/sequestration and electrolyte disturbances #3. obtain cultures and start broad-spectrum antimicrobials (appropriate for bowel flora) o In the absence of fever or other clinical evidence for infection.Urgent ERCP(endoscopic retrograde Cholangiopancreatography) and biliary sphincterotomy within 72 hours improves outcome of severe gallstone pancreatitis o Reduced biliary sepsis. infected pseudocyst. non-enlarging pseudocysts can be watched and followed with imaging Symptomatic. rapidly enlarging or complicated pseudocysts need to be decompressed Infection: o Many areas for concern: abscess.Narcotic analgesics usually necessary for pain relief…textbooks say Meperidine… o NO conclusive evidence that morphine has deleterious effect on sphincter of Oddi pressure #4. cholangitis. rupture. and aspiration pneumonia -> SEPSIS may occur o If concerned.
a trypsinogen level < 10 is diagnostic for chronic pancreatitis o Manage with low-fat diet and pancreatic enzyme supplements (Pancrease.irreversible parenchymal destruction leading to pancreatic dysfunction Persistent. Renal failure: Severe intravascular volume depletion or acute tubular necrosis may lead to ARF Pulmonary: Atelectasis. pneumonia and ARDS can develop in severe cases Metabolic disturbances: hypocalcemia. hyperglycemia o GI bleeds: Stress gastritis o Fistula formation Prognosis: 85-90% mild. self-limited: Usually resolves in 3-7 days 10-15% severe requiring ICU admission: Mortality may approach 50% in severe cases Chronic pancreatitis: Pathophys .etiology is chronic EtOH abuse (90%) Gallstones Hyperparathyroidism Congenital malformation: o (pancreas divisum) o Idiopathic Evaluation: or normal amylase and lipase Plain AXR / CT may show calcified pancreas Pain management critical: EtOH cessation may improve pain Narcotic dependency is common Complications: Exocrine insufficiency typically manifests as weight loss and steatorrhea o If steatorrhea present. nausea Constipation. pleural effusion. recurrent episodes of severe pain Anorexia. Creon) Endocrine insufficiency may result from islet cell destruction which leads to diabetes . hypomagnesemia. flatulence Steatorrhea Diabetes #1.
Those originating in the body or tail of the pancreas are often larger and more likely to have spread before their presence is known Vascular invasion. lymphatic invasion and perineural growth is highly characteristic. Usually larger than 3 cm in diameter and both nodal and distant metastases are also frequently present. Hereditary Pancreatic Cancer: Hereditary nonpolyposis colon cancer (HNPCC) Familial breast cancer (associated with the BRCA2 mutation) Peutz-Jeghers syndrome Ataxia-telangiectasia Familial atypical multiple mole melanoma (FAMMM) syndrome Hereditary pancreatitis Family history of pancreatic cancer. . have an increased risk of developing pancreatic cancer.Periampullary tumor: Incidence: Pancreas head > AoV > Distal CBD > Duodenum Incidence and Epidemiology: More frequently in men than in women and it is more common among blacks than whites Roughly 80% of cases occur between 60 and 80 years of age Risk factors: o history of hereditary or chronic pancreatitis. especially those with two or more pancreatic cancer-affected first-degree relatives. and occupational exposure to carcinogens o Coffee drinking : no risk factor o DM : manifestation > risk factor Pathology: Ductal adenocarcinoma and its variants Account for 80% to 90% of all pancreatic neoplasms Roughly 70% of ductal cancers arise in the pancreatic head or uncinate process. cigarette smoking.
Risk Factors: Symptoms and Signs: .
: CT or USG guided Transduodenal Bx. tumors • to screen patients with vague symptoms or those in high-risk groups has not been shown to be useful in detecting early disease CA 19-9 can also be elevated in patients with cholangitis and jaundice Extremely high levels usually indicate unresectable and/or metastatic disease Imaging studies: US : solid or cystic tumor CT : usually appears as a hypodense mass with poorly demarcated edges MRI EUS: permits better visualization of nodal structures and allows for determination of the depth of invasion ERCP: particularly helpful in evaluating patients with obstructive jaundice without a detectable mass on CT or MRI PET(Positron emission tomography) o may be of value in diagnosing small pancreatic tumors that escape CT or MRI detection The Role of Biopsy: Percutaneous Bx.Blood Tests: Obstructive juandice : Head lesions Elevated bilirubin and Alkaline phosphatase CEA. : EUS guided Unresectable lesion : o Usually required before chemoradiation therapy of unresectable pancreatic tumors or neoadjuvant treatment of resectable tumors Resectable lesion: o positive biopsy merely confirms the decision for resection and a negative biopsy is inconclusive o most surgeons would not recommend routine preoperative biopsy for confirmation of the diagnosis o 5% to 10% of patients undergoing resection for suspected cancer will be found to have benign lesions . potentially curable. CA 19-9 two most widely used pancreatic cancer serum markers frequently elevated in patients with advanced disease often normal with early.
Staging of Pancreatic Cancer: Stages 1 and 2 cancers amenable to resection 5 year survival rate : 10 ~ 20 % Poor prognostic signs aneuploidy large tumor size (T2) the presence of positive regional nodes (N1) incomplete resection at the pancreatic or retroperitoneal margin Stages 3 and 4 cancers considered to be unresectable mean survival • stage 3 : 8 ~ 12 months • stage 4 : 3 ~ 6 months .
total pancreatectomy along with possible major venous resection can result in increased long-term patient survival ? a prolonged delay in the return of gastrointestinal function and. PPPD(Pylorus preserving pancreaticoduodenectomy o Similar survival rate. and uncinate process of the pancreas account for approximately 70% of pancreatic tumors Pancreaticoduodenectomy(PD) vs. which has a structure that resembles motilin. on occasion. similar morbidity o PPPD is technically easier and faster. neck. with incapacitating and persistent diarrhea Complications of Pancreaticoduodenectomy: Operative mortality : 2% to 4% Intra-abdominal abscesses Anastomotic leaks (pancreatic fistula) o 15% to 20% o Usually heal within several weeks with adequate drainage o Prophylactic somatostatin analogue : not beneficial Delayed gastric emptying o 15% to 40% o almost always resolves with time(several weeks/months) o the result of removing the cells in the duodenum that secrete the promotility hormone motilin o Erythromycin. but it may be associated with a higher incidence of and more prolonged delayed gastric emptying. acts as an agonist at motilin receptors and has been used to treat these patients Pancreatic malabsorption and steatorrhea->(excess fat in feces) o common long-term problems . o Reconstruction Pancreaticojejunostomy (PJ) Hepaticojejunostomy (HJ) Gastrojejunostomy (standard Whipple) or duodenojejunostomy (pyloruspreserving Whipple) Extended Pancreaticoduodenectomy extensive retroperitoneal lymphadenectomy and in some cases.Surgery for Pancreatic Head and Uncinate Process Tumors: Tumors of the head.
by itself. nerves. Only 10% of cancers involving the tail or body of the pancreas are resectable at the time of diagnosis o have already metastasized to distant sites or extended locally to involve nodes. US guided celiac plexus block o Intraoperative celiac plexus block . Endoscopic biliary stent(plastic or metallic) o Choledochojejunostomy Duodenal obstruction o Endoscopic placement of expandable endoluminal metal stent o Gastrojejunostomy Cancer pain o Painkiller. o Involvement of the splenic/superior mesenteric vein confluence generally precludes resection. Biliary tract obstruction o PTBD. is not a sign of nonresectability. Complications of distal pancreatectomy o Subphrenic abscess(5~10%). or major vessels by the time of diagnosis o Splenic vein involvement is common and. pancreatic duct leak(20%) o Usually nonoperatively managable Appleby operation: Indication for operation!!! Palliative Management of Pancreatic Cancer: Most of symptoms experienced by patients with unresectable pancreatic cancer can be relieved by nonsurgical means.
Chemoradiation therapy: Recurrent or unresectable disease: o Radiation therapy + (5-FU or Gemcitabine) Adjuvant Chemoradiation : o Gastrointestinal Tumor Study Group(GITSG) 1985 the combination of 5-fluorouracil with radiation therapy could increase the 2-year survival rate for patients with tumor-free resection margins from 18% to 43% o European Study Group for Pancreatic Cancer 2004 A survival benefit was observed for those undergoing chemotherapy alone but not for those receiving either radiation therapy alone or combined chemoradiotherapy .
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