Dr A. Badrek-Amoudi FRCS Pancreatic Diseases Dr A. Badrek-Amoudi FRCS.
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Transcript of Dr A. Badrek-Amoudi FRCS Pancreatic Diseases Dr A. Badrek-Amoudi FRCS.
Pancreatic DiseasesDr A. Badrek-Amoudi Dr A. Badrek-Amoudi FRCSFRCS
Anatomy & Physiology I
Anatomy & Physiology II
Anatomy & Physiology III
1-2 L alkaline, clear, isoosmolar enzyme rich fluid Na & K at plasma levels (165mmol/L) 20 enzymes are secreted Secretion is regulated by: Secretin, CCK, Vagus
and low Ph Proteolytic enzymes (Tryp, Chemotryp, elastase …
etc Lipolytic (lipase, colipase, phospholipase..etc) amyloytic Endocrine function: insulin, glucagon,
somatostatin..etc)
Pancreatitis II
Oedametous pancreatitisOedametous pancreatitis
Necrotizin PancreatitisNecrotizin Pancreatitis
Infected Necrosis/ Hemorrhagic necrosisInfected Necrosis/ Hemorrhagic necrosis
AutodigestionActivation of neutrophils and macrophagesRelease of cytokinesEndocrine and exocrine function is usually preserved
Pancreatitis Pathogenesis
1.1. Obstruction- SecretionObstruction- Secretion
2.2. Common Channel theoryCommon Channel theory
3.3. Duodenal refluxDuodenal reflux
4.4. Increased permeability of pancreatic Increased permeability of pancreatic ductduct
5.5. Enzyme Auto-activationEnzyme Auto-activation
PancreatitisAetiology I1.1. Gall stoneGall stone
1. 90% of acute pancreatitis . 2. Life risk of 3-5% 3. Age 40’s . 4. F>m5. Transient obstruction
2.2. Alcohol 75% of chronic pancreatitisAlcohol 75% of chronic pancreatitis1. Spasm of the sphinctor of Oddi2. Increases the concentration of enzymes3. Structural damage caused by the precipitation of
calcium4. Transient reduction of blood flow
3.3. DrugsDrugs1. Steroids, AZT2. Sulphonomids, Tetracyclin3. Oestrogen
Pancreatitis Aetiology II
1.1. Trauma & Post op Trauma & Post op 5%5%2.2. Post ERCP Post ERCP 1-40%1-40%3.3. HyperparathyroidismHyperparathyroidism
1. Ca deposition2. Increases the activation of enzymes
4.4. MalnutritionMalnutrition : : Results in paranchymal fibrosis
5.5. HyperlipidaemiaHyperlipidaemiaMay interfere with the levels of amylase
Pancreatitis Aetiology III
1.1. Pancreatic DividismPancreatic Dividism
2.2. Duodenal obstructionDuodenal obstruction
3.3. InfectionInfectionViral : Mumps, Coxacki, Herpes
4.4. IschamiaIschamia
5.5. HereditaryHereditary Mutation in Trypsin formation
6.6. Scorapian VenomScorapian Venom
Acute Pancreatitis Clinical Presentation Abdominal Pain
• Constant, quick onset, variable in severity• Epigastric • Radiating to the back in 50% of patients• Associated with nausea, vomiting & retching • Relieved by lying on to the L side, legs-up
Other precipitating factors Fever in 70% Jaundice in 30% Shock +/_ in 10% Hematemasis & malena in 5%
Acute Pancreatitis Clinical Presentation II Dyspnoea in 10% Tender Abdomen: Mild to
severe Peritonitis,could be diffuse BS: hypoactive Abdominal Mass:
• Phlegmon
• Pseudocyst,
• Abcess Ascitis Cullen’s Gray-turner signs Erythametous skin lesions
Differential diagnosis Perforated DU Perforated GB Emphsymatous cholecystitis Mesenteric infarction AAA Others
Acute Pancreatitis Investigation Diagnostic Amylase: >1000 is diagnostic
• High levels do not correlate with the severity of pancreatitis
• False Low: 1. Rapid clearance by the kidney 2. Hyperlipidaemia. 3. Chronic pancreatitis
• False High: Salivary, Ovarian, Liver tumor Lipase
Acute Pancreatitis Investigation II
High amylase may be caused by:1. Perforated DU2. Cholecystitis3. Small bowel obstruction4. Perforated Small bowel5. Ectopic pregnancy
Acute Pancreatitis Investigation III Radiological:
• Plain X- rays: • AXR: calcification, sentinle
loop SB,colonic spasm• CXR: pleural effusion &
differntial• USS: GB stones, pancreatic
peripancreatic info• CT: Diagnosis, prognosis, F/U• Endoscopic USS• MRCP• ERCP
Others:
• FBC: Hct, WBC, Plat.• U&E, LFT, Ca, glucose.• ABG
Acute Pancreatitis Prognostic Indicators
Biochemical Markers: Sensitivity/ Specificity
1. Ranson’s / Emeri’s 75%
2. CRP 70% Physiological parameters
• Appache II Scoring 80% Radiological
• Spiral CT 87% Peritoneal Lavage
Ranson’s CriteriaRanson’s Criteria
0-2= 2%, 3-4=15%, 5-6= 40%, 7-8=100% Mortality rates
On admissionOn admission Age>55 WBC> 16 Glucose> 200 LDH>350 SGOT>250
11stst 48 Hours 48 Hours HCT Fall> 10% Ca< 8 PO2<60 Base def<4 Estimate
sequestration>600 ml
Only applies to the first 24 hoursMakes no distinction between derangements due to alcoholic disease
Acute Pancreatitis Complications I
Local and regionalLocal and regional Pseudocysts:
• Infection, Hemorrhage, Rupture, obstruction
Pancreatic Necrosis• Sterile/ Infected
Pancreatic Abscess Colonic infarction Pancreatic Fistula Chronic Pancreatitis
Vascular: • portal vein thrombosis• Aorto-pancreatic fistula
Acute Pancreatitis Complications IIComplications II
SystemicSystemicI. Metabolic
• Hypokalaemia, Hypochloraemia & Metabolic alkalosis
• Hypocalcaemia• Hypomagnesemia• Hypoxemia
Acute Pancreatitis Complications IIIComplications III
II. Respiratory• Respiratory insufficiency• Atelactesis• ARDS
III. Renal Failure
IV. Depressed myocardial contractility
V. Multiple organ Failure
Acute Pancreatitis TreatmentI. Conservative
( Admit in ICU VS Common Surgical Ward) • NBM vs Early nutrition• ? NGT• Analgesia: narcotic• Adequate fluid replacement ( Initial crystalloid then
colloid)• Antibiotics (organisms & penetration)• ??Anticholinergics, somatostatin have no proven
benifitII. Minimally invasive
• Early ERCP & sphinctorotmy for impacted stones• CT-guided drainage of Psedocusysts
Treatment II
The indications for surgical intervention areThe indications for surgical intervention are:1. Uncertain diagnosis2. Early cholecystectomy3. CBD stone extraction4. Debridement of necrotic pancreatic tissue5. Pancreatic abcess (Infected Necrosis)6. Complicated Pseudocysts
Surgery is contraindicated in uncomplicated attacks.
Chronic Pancreatitis Recurrent prolonged attacks of pancreatitis Associated with endocrine and exocrine
insufficiency, weight loss and abnormal glucose tolerance test
75% is caused by alcoholism, 20% stones Normal architecture is replaced by dense fibrous
tissue, dilated pancreatic duct with areas of narrowing, Cysts & Psuedocysts are common.
Amylase may remain normal with the acute attack.
Chronic PancreatitisComplications
1. Narcotic addiction
2. Loco-Regional
1. Pseudocyst, fistula formation.
2. Pseudoaneurysm, vascular thrombosis
3. Bile duct stenosis
3. Diabetes with associated neuropathies & myopathies
4. Malabsobtion
Chronic PancreatitisDiagnosis: Lab AXR: calcification in 20-50% CT Image of choice ERCP shows duct anomalies:
• Dilatation• Strictures• Stones• Cysts
FNAC: Occasionally difficult to
distinguish from cancer.
OGD: • varicies
Chronic PancreatitisManagementMedicalMedical Manage DM Pain control Exocrine replacement Dietary control
SurgerySurgery Drainage Pain control Pancreatectomy
Pancreatic Cancer Epedemiology
• 5th highest cancer related death• 13: 100000 population• 5 year mortality poor 5%• 20% survive post surgery• Median survival 4-6 months• Genda & race?• 40% are sporadic, 30% related to smoking, 5%
familial, 5% in chronic pancreatitis, 20% dietary and fat intake.
• 95% are exocrine in origin• 75% originate in head & neck of the pancrease
Clinical Manifestation
• Painless obstructive jaundice, • Weight loss, Anorexia.• Deep abdominal/ back pain (75%)• Ascending cholangitis, Pancreatitis (14%)• Onset of Diabetes mellitus• Hepatosplenomegaly, Ascitis• Migratory thrombophlebitis (Trousseaus)• Courvoiser’s sign• Sister Mary Joseph nodule• Evidence of pruritis• Depression
Diagnostic studies
• USS• Endo-USS• CT• ERCP, MRCP • Angiography• FNAC• Endoscopy• Laparoscopy• Tumor markers (CEA & CA 19-9)
Treatment
Palliative• Pain & Depression
• Good analgesia• Sympathetic neurolysis
• Jaundice• Stenting via ERCP• Surgery Dudenal obstruction• Bypass surgery
Curative• (Whipple)
Prognosis
In general poor
Post surgery:• < 3cm • Negative resection
margins• No LN
HistoryA 56 year old patient presented with painless jaundice and weight loss.
• What is your differential diagnosis
• What are the Investigations required
The laboratory results were:
Bili(D) 8mg/100ml, Bili(InD) 2.5mg/100ml, ALP 730 iu/L , AST 60 iu/L, GGT 200 iu/L,
Albumin 4mg/dl, Amylase 200 u/dl, INR 1.9
1.What are the investigations shown in A & B
2. What are the Abnormalities
3. How do you prepare patient for investigation A