PANCREAS

PANCREAS
 Anatomy
• Retroperitoneal organ
• In adults- 15cm long & 70-100 GMS
• 80-90% is composed of exocrine acinar tissue.
• 3 portions- head, body and tail
• The head lies within the curve of
duodenum,overlying the body of 2nd lumbar
vertebra and the vena cava.
• Main pancreatic duct- Wirsung duct
• Acessory duct – Santorini duct
 Pancreatitis

Acute Chronic
presenting with abdominal pain and is usually
associated with raised pancreatic enzyme levels
in the blood or urine as a result of pancreatic
inflammation.
 Incidence
• 3 % of all cases of abdominal pain
• Hospital admission rate for is 9.8 per 100 000
population anually
• Worldwide, 50 per 100 000 cases anually.
• The disease may occur at any age, with a peak
in young men and older women.
 Etiology
Two major causes are :
• biliary calculi (50–70%)
• alcohol abuse (25%)

The remaining cases may be due to rare causes

or be idiopathic
 Gallstone Pancreatitis
• Transient blockage of common bile duct 
reflux of bile into pancreatic duct and impair
flow of normal pancreatic juice  premature
activation of pancreatic enzymes within duct
system.
 Alcohol Pancreatitis
• High risk in:
1. Long standing alcohol intake for at least 2 years
or single session of heavy drinking
2. Consumption >80g/day
• What Happened ?
1. Direct toxic effect of alcohol in genetically
predisposed individuals
2. Viscid secretion of pancreatic juice  formation
of protein plugs and impairment of flow
 Pathophysiology
• Premature activation of pancreatic enzymes within the
pancreas, leading to a process of autodigestion.
• Anything that injures the acinar cell and impairs the
secretion of zymogen granules, or damages the duct
epithelium and thus delays enzymatic secretion, can trigger
acute pancreatitis.
• Once cellular injury has been initiated, the inflammatory
process can lead to pancreatic oedema, haemorrhage and,
eventually, necrosis.
• As inflammatory mediators are released into the circulation,
systemic complications can arise.
ACUTE PANCREATITIS
History and Physical Examination
 Purpose of History Taking
• Pain
• Causes
• Complications
 History Taking
1) Abdominal Pain -
• Site: Diffuse, upper abdominal pain
• Onset: Sudden
• Character: Boring Pain
• Radiation: Radiates to the back
• Associated factor: Nausea, vomiting, dyspnea
• Timing: Pain escalates in intensity and peaks within
10-20 minutes of onset.
• Aggravating and relieving factor: Aggravated
by breathing with increased chest expansion
and relieved by leaning forward.
• Severity: Depending on severity, patient may
present in shock
2) History of underlying
causes:

• Idiopathic (10%)
• Gallstone (45%)
• Ethanol (35%)
• Trauma (10%)
• Steroids
• Mumps
• Autoimmune
• Scorpion / Snake
• Hyperlipidemia
• ERCP
• Drugs (10%)
3) History of Complications

Systemic :
• ARDS
• Renal Failure
• Shock, arrythmias
• Metabolic: hypocalcemia, hyperglycemia
• Encephalopathy
Local :
• Mostly develop silently
• Pancreatic abscess – high grade fever
• Pseudocyst
• Pancreatic effusion
 Physical Examination: Acute
Pancreatitis
• Elevation of body temperature is often is
acute pancreatitis
• Abdominal Examination
1. Inspection: abdominal distension
2. Palpation:
• Hepatomegaly
• Tenderness
• Cullen sign
• Gray turner sign
• Peritoneal signs
• Rigidity
• Guarding
• Percussion : Dullness suggesting ascites
• Auscultation: auscultate the abdomen
for hypoactive or an absent bowel sounds
or an abdominal bruit. Ileus is common in
pancreatitis.
• Ausculation of lungs: 10-20% of patients
have pulmonary findings, commonly left sided
findings.
1. Basilar rales
2. Atelectasis
3. Pleural effusion
 Differential Diagnosis
For Mild Acute Pain For Severe Acute Pain

Acute Cholecystitis Fecal Peritonitis due to

Perforated Colon
Peptic Ulcer Disease Ruptured Abdominal Aortic
Aneurysm
Inferior Myocardial Infarction Ruptured Ectopic Pregnancy

Acute Appendicitis Massive Bowel Infarction

INVESTIGATIONS
• The diagnosis if made on basis of clinical presentation, an
elevated serum Amylase level and characteristic Imaging
features.
• Biological :
- Serum Amylase increase 3x than normal or
more than 1000IU/mL (Peak within the first 24hours
after onset of Symptom)
- Serum Lipase has longer half life thus more
useful in delayed cases.
- Serum Lipase: more sensitive & specific for
Pancreatitis than Amylase
Other Causes of Increased Serum Amylase :
• Renal Failure
• Liver Cirrhosis
• Peritonitis
• GIT Inflammation
• Ruptured Ectopic Pregnancy/Salphingitis
• Salivary Gland Inflammation (Parotitis)
 Other Blood Tests..
Full Blood Elevated Leucocytes count for Ranson’s Criteria and
Count to predict prognosis
LFT To asses cause of Pancreatitis/obstructive jaundice

BUSE To determine level of dehydration

Random Damage to beta cells interferes with insulin
Blood production causing Hyperglycemia (in severe cases)
Glucose

Serum Hypocalcaemia suggests saponification

Calcium
 Role of Imaging in Acute
Pancreatitis

• To clarify diagnosis when the clinical picture is

confusing
• To determine possible causes
• To assess severity (Balthazar Score) and thus
to determine prognosis
• To detect complications
 ULTRASOUND
• Trans abdominal USG : Does not establish a diagnosis.
• USG should be performed within 24 hours in ALL
patients
- To detect gallstones
- To rule out Acute Cholecystitis
- To determine whether the common bile duct is
dilated
• To evaluate change on pancreas i.e. edema, mass in
Pancreas
• Transverse
Transbadominal
Ultrasound shows a
swollen pancreatic
body with ill-
defined
heterogeneous
hypoechoic
pattern.
 ERCP
• Diagnostic and therapeutic
• To look for Gallstones, CBD stones or CBD
dilatation
• In patient with severe acute gallstone
pancreatitis & signs of on going biliary
obstruction and cholangitis – an urgent ERCP
should be sought.
ERCP : Gallstone Pancreatitis
 Plain Abdominal X-Ray
• Plain erect chest & abdominal X-ray are not diagnostic
of Acute Pancreatitis but are useful in differential
diagnosis.
• Non specific findings in Pancreatitis : Generalized
or local ileus (Sentinel Loop), a colon cut off sign, and
calcified gallstones.
• Erect CXR. Look for pleural effusion. In severe cases,
a diffuse alveolar shadowing (Acute Respiratory
Distress Syndrome)
A focal dilated proximal jejunal loop in the left upper quadrant. A focal area of
adynamic ileus close to an intraabdominal inflammatory process The sentinel loop sign
may aid in localizing the source of inflammation.
Sentinel Loop in upper abdomen may indicate Pancreatitis
-Colon Cut-off Sign describes gaseous distension seen in proximal colon
-Associated with narrowing of splenic flexure in cases of Acute Pancreatitis
-This Appearance results from inflammatory process extending from Pancreas into
the phrenicolic ligament via transverse mesocolon
 CT Scan
• Not necessary for all patients.

• May reveal pseudo cyst or abscess (complication of acute

pancreatitis)
• A contrast-enhanced CT is indicated in following :
 If there is diagnostic uncertainty
 In Pt. with severe acute Pancreatitis to distinguish
interstitial from necrotizing pancreatitis.
 In Pt. with organ failure, signs of sepsis or
progressive clinical deterioration
 When a localized complication is suspected I.e. fluid collection,
pseudo cyst.
CT Anatomy Pancreatic Level
CT shows significant swelling &
Inflammation of the Pancreas
 Morphologic Types of Acute
Pancreatitis
THE REVISED ATLANTA CLASSIFICATION
1) Interstitial Edematous Pancreatitis
2) Necrotizing Pancreatitis
• Parenchymal necrosis
• Peripancreatic necrosis
• Combined Type
CT Severity Index: Balthazar + Necrosis Score

E
Management of Acute
Pancreatitis
 Mild Acute Pancreatitis
1. Nil by mouth
2. Fluid resuscitation
3. Analgesia
4. Treat underlying cause
5. No role for antibiotics
 Severe Acute Pancreatitis
• Admission to intensive care or high-
dependency unit
1. Oxygen supplementation
2. Analgesia
3. Aggressive fluid rehydration
4. Monitor vital signs
5.Monitor haematological & biochemical
parameters
6. Nasogastric drainage
7. Antibiotic prophylaxis
8. CT scan
9. ERCP within 72 hours
10. Supportive therapy for organ failure
11. Nutritional support
 Complications & their Management

 Acute fluid collection

 No intervention unless pressure effect
 Aspirate under US or CT guidance OR
 Transgastric drainage under EUS
guidance

 Pancreatic necrosis
 No intervention
 Infected pancreatic necrosis
 Aspirate under CT guidance
 Percutaneous drainage
 Prophylactic antibiotic
If patient deteriorates
 Necrosectomy
 Closed continuous lavage
 Closed drainage
 Open packing
 Closure and relaparotomy
 Pancreatic abscess
 Percutaneous drainage
 Antibiotic cover

 Pancreatic ascites
 Drainage
 Parenteral or jejunal feeding
 Pancreatic effusion
 Percutaneous drainage under CT guidance

 Portal or systemic vein thrombosis

 Aspirin in the early process
 Pseudocyst
Percutaneous transgastric cystogastrotomy
and place double-pigtail drain
 Endoscopic under EUS guidance and place
tube drain
 Surgical drainage – internal drainage into
gastric or jejunum lumen
 CHRONIC PANCREATITIS
• It is a progressive inflammatory disease in which
there is irreversible destruction of pancreatic tissue.
• Clinical course is characterised by severe pain
followed by exocrine and endocrine insufficiency.
• Male:female ratio=4:1
• Mean age of onset is >40 years.
ETIOPATHOGENESIS
Due to acute pancreatitis

Stimulation of myofibroblasts
TGF BETA activation.

TIGAR-O classification:
T-toxins (alcohol)
I-idiopathic (dietary)
G-genetic (spink 1 and PRSS gene)
A-autoimmune (Ig G4)
R-Recurrent
O-obstruction
DIAGNOSIS: HISORT CRITERIA
H-Histology(lymphocytic infiltration)
I-Imaging
S-Serology
O-Other organism
RT-Response to steroids
CARCINOMA OF PANCREAS
• 70% occurs in head of pancreas including
periampullary region.
• 30% occurs in the body and the tail.
• 70% of cases are ADENOCARCINOMA OF DUCT
CELL ORIGIN.
• It is 4th leading cause of death due to cancer in
males,after lung, colon, prostate.
 PATHOLOGY
Periampullary refers to carcinoma arising from
ampulla of vater,the duodenal mucosa or the lower
end of common bile duct.
Microscopically,the types are:
1. Mucus:
2. Non mucus:
3. Anaplastic:
4. Cystadenocarcinomas:
 CLINICAL FEATURES:
1. Obstructive jaundice (m/c)
2. Nausea and epigastric discomfort
3. Pruritis,dark urine and pale stools
4. Anorexia and weight loss

SIGNS:
5. Jaundice
6. Palpable gall bladder
COURVOISIERS LAW:obstructive jaundice with
palpable gall bladder is seldom due to stone disease.
3.Palpable mass,ascites,supraclavicular nodes