CHRONIC PANCREATITIS Chronic pancreatitis is a progressive

inflammation of pancreas related to the process of autolysis, that presents by pain, by violation of exocrine and endocrine functions of gland with the result of fibrosis of organ and high risk of malignization

ETIOLOGY AND PATHOGENESIS Gallstone disease is the most frequent cause

of chronic pancreatitis (70%). Pathogenesis of cholangiogenic pancreatitis

is hypertension in pancreatic duct and reflux of infected bile or secretion of duodenum.

Spasms and stenosis of the Vater's papilla are instrumental in causing reflux. As result occur activates the enzymes of pancreas and progress inflammation. Development of pancreatitis potentiates infection.

CAUSES The CAUSES of such violations are - due to the

attack of acute pancreatitis in past, alcoholism, traumas of gland, pathology of its vessels, gastroduodenal ulcers, gastritis or duodenostasis, hyperparathyroidism, hyperlipidemia, virus infections, idiopathic pancreatitis.

CLASSIFICATION AND ETIOLOGY CHRONIC CALCIFIC

PANCREATITIS

CHRONIC OBSTRUCTIVE PANCREATITIS

CHRONIC INFLAMMATORY PANCREATITIS

CHRONIC AUTOIMMUNE

PANCREATITIS

ASYMPTOMATIC PANCREATIC

FIBROSIS

ALCOHOL PANCREATIC TUMORS

UNKNOWN Autoimmune disorders (primary sclerosing cholangitis)

CHRONIC ALCOHOLIC

HEREDITARY  

DUCTAL STRICTURE

SJOGREN'S SYNDROME

Endemic in asymptomatic residents in tropical climates

TROPICAL   GALLSTONE OR TRAUMA-INDUCED

Primary biliary cirrhosis

HYPERLIPIDEMIA

PANCREAS DIVISUM

HYPERCALCEMIADRUG-INDUCED

IDIOPATHIC

CLASSIFICATION (by O.O. Shalitnov) Chronic fibrous pancreatitis without violation of patency

of main pancreatic duct. Chronic fibrous pancreatitis with violation of patency of

main pancreatic duct and hypertension of pancreatic juice.

Chronic fibrous-degenerative pancreatitis.TAKING INTO ACCOUNT CLINICAL FEATURES

Chronic recurrent pancreatitis. Chronic pain pancreatitis Chronic painless (latent) pancreatitis. Chronic pseudo tumor-like pancreatitis. Chronic cholecystocholangiopancreatitis (cholangiogenic

pancreatitis). Chronic indurative pancreatitis.

PATHOMORPHOLOGYThe morphological changes in pancreas in chronic pancreatitis are mainly due to the development of degenerative process and atrophy of parenchyma

CLINICAL MANAGEMENT As the progress of the disease has cyclic

character with the periodic changes of remission and acute exacerbations.

Violation of exocrine and endocrine functions of pancreas, determine polymorphism of symptoms that are characteristic of the period of  exacerbations pancreatitis

PAIN

Patients with chronic pancreatitis complaining on dull pain that is in the epigastric and radiates to the back

PAINThe pathophysiology of the pain

associated with increase intraductal pressures, neural inflammation, formation of pseudocysts, bile duct strictures, and duodenal obstruction.

MALABSORPTIONWith sufficient loss of functional exocrine pancreas,

diarrhea, steatorrhea, and azotorrhea can develop.

Because of the 10-fold reserve of exocrine

pancreaticenzymes, malabsorption occurs only after 90%

of the functioning exocrine cell mass is lost. Pancreatic insufficiency resulting from alcohol-induced chronic

pancreatitis usually takes 10 to 20 years to develop. The

secretion of lipase is usually diminished earlier than the

secretion of the proteolytic enzymes, and as a result,

steatorrhea precedes protein-aqueous diarrhea.

CHRONIC UPPER ABDOMINAL PAIN AND WEIGHT LOSS should suggest a diagnosis of chronic pancreatitis.

Weight loss occurs with malabsorption, and of the fat-soluble vitamins develop.

Postprandial pancreatic bicarbonate secretion is

diminished. The duodenal pH may decrease (pH<4)

and an acidic milieu with precipitation of bile salts

and inactivation of pancreatic enzymes results in a

decrease intestinal digestion.

ENDOCRINE INSUFFICIENCYGlucose intolerance frequently develops early

Endocrine insufficiency develops in up to 60% of patients, but in general not until after the diagnosis of chronic pancreatitis has been made.

STOOL EXAMINATION Steatorrhea and creatorrhea are characteristic for Chronic Pancreatitis (plenty of muscle fibres).Examination of endocrine function includes: 1) determination of sugar in blood and urine (hyperglycemia and glycosuria);2) radioimmunoassay of hormones (insulin, C-peptide and glucagon).SKIAGRAPHY survey of organs of abdominal cavity in two projections exposes the existent calculus in the ducts and calcification of parenchyma of pancreas.Relaxation duodenography. The development of "horseshoe" of duodenum and change of its mucosa can be seen Cholecystocholangiography the purpose of diagnosis of gallstone disease and damaging of biliary tract is conducted

Ultrasonic examinationSonography is one of the basic methods of diagnosis. With the help of symptoms of chronic pancreatitis it is possible to expose inequality of contours of gland, increase of density of its parenchyma, it sizes, dilatation of pancreatic duct and wirsungolithiasis or presence of calculus in parenchyma. It is necessary to inspect gallbladder, liver and extra-hepatic biliary tracts for diagnosis of gallstone disease and choledocholithiasis

Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography

CT-scan showing multiple, calcified intraductal stones in a patient with

chronic pancreatitis

CT-scan

Routine Laboratory Findings Secondary anemia to malnutrition can occur in chronic

pancreatitis, to the steatorrhea of chronic pancreatitis are also uncommon.

Leukocytosis can occur during acute exacerbations of chronic pancreatitis.

Serum amylase and lipase concentrations may be elevated in chronic pancreatitis. Even during an acute attack with seemingly significant abdominal pain, the amylase and lipase levels may be only slightly elevated because of depletion of the exocrine pancreatic parenchyma.

Abnormalities of liver function, manifested by elevations in the liver enzymes, may be a result of either liver disease or obstruction of the common bile duct.

Fibrotic process may result from compression by a pseudo cyst or mass in the head of the pancreas.

TESTS FOR CHRONIC PANCREATITISMEASUREMENT OF PANCREATIC PRODUCTS IN BLOOD

I A Enzymes

B Pancreatic polypeptide

MEASUREMENT OF PANCREATIC EXOCRINE SECRETIONII A Direct measurements

1 Enzymes

2 Bicarbonate

B Indirect measurement

1 Bentiromide test

2 Schilling test

3 Fecal fat, chymotrypsin, or elastase concentration

4 [14C]-olein absorption

IMAGING TECHNIQUES III A Plain film radiography of abdomen

B Ultrasonography

C Computed tomography

D Endoscopic retrograde cholangiopancreatography

E Magnetic resonance cholangiopancreatography

F Endoscopic ultrasonography

G Relaxation duodenogram

CLINICAL VARIANTS Chronic recurrent pancreatitis. The changes of periods of acute

attacks and remission are characteristic for it. Chronic pain pancreatitis. Intensive pain in the superior half of

abdomen with radiation to loins and region of heart is inherent for this form. Also belt-like pain often appears.

Chronic painless (latent) pancreatitis. In this patients the pain is either absent in general or arises after the intake of spicy rich food and can be insignificantly expressed Violation of exocrine or endocrine function of pancreas present.

Chronic pseudo tumor-like pancreatitis. Dull pain in the projection of head of pancreas, dyspeptic disorders and syndrome of biliary hypertension are its clinical signs.

Chronic cholangiogenic pancreatitis. The features of chronic cholecystitis and cholelithiasis and features of pancreatitis are characteristic for this form.

Chronic indurative pancreatitis. In patients with this diseases symptoms of exocrine and endocrine insufficiency of pancreas are present. With sclerosis of head of pancreas with involvement by the process of common bile duct, development of mechanical jaundice is possible.

COMPLICATIONS OF CHRONIC PANCREATITIS

INTRAPANCREATIC COMPLICATIONSPseudo cysts

Duodenal or gastric obstruction

Thrombosis of splenic vein

Abscess

Perforation

Erosion into visceral artery

Inflammatory mass in head of pancreas

Bile duct stenosis

Portal vein thrombosis

Duodenal obstruction

Duct strictures and/or stones

Ductal hypertension and dilatationPancreatic carcinoma

EXTRAPANCREATIC COMPLICATIONS

1.Pancreatic duct leak with ascites or fistula

2.Pseudocyst extension beyond sac into mediastinum, retroperitoneum, lateral pericolic spaces, pelvis

SURGICAL METHODS OF TREATMENT OF CHRONIC PANCREATITIS

The major indications for treatment are: 1. Intractable pain; 2. Fear of carcinoma; 3. The development of structural complications

Indication to operation and its volume depend on the form of pancreatitis. Acute exacerbation of chronic cholangiogenic pancreatitis with presence of gallstone disease must be seen as an indication for operation in first 24 hours since the onset of disease

OPERATIVE TREATMENT IS DONE IN CASES OF:

calcinosis pancreas with the expressed pain syndrome; violation of patency of duct of pancreas; presence of cyst or fistula, resistance to conservative

therapy in 2-4 months; mechanical jaundice due to tubular stenosis of distal part

of common bile duct; compression and thrombosis of portal vein; gallstone disease complicated by chronic pancreatitis; ulcer disease of stomach and duodenum complicated by

secondary pancreatitis; duodenostasis, complicated by chronic pancreatitis;

CHOLECYSTECTOMY is performed in presence of calculous cholecystitis and secondary pancreatitis, acute destructive cholecystitis or

hydropsy of gall-bladder.

CHOLEDOCHOLITHOTOMY is performed for patients with cholangiolithiasis:

Papillosphincterotomy: a) execute transduodenal with papillosphinctero-

plasty; b) endoscopy is recommended in the isolated

cases or connected with choledocholithiasis stenosis of large duodenal papilla, fixed calculus of large papilla of duodenum.

Wirsungoplasty is plastic of main pancreatic duct. Lately in the isolated stenosis of entrance of main pancreatic duct. Execute transduodenal or endoscopic methods

Papillosphincterotomy, papillosphincteroplasty

PANCREATOJEJUNOSTOMY:

a) LONGITUDINAL (it is performed in considerable dilatation of pancreatic duct)

Technique of pancreaticojejunal drainage originally described by Puestow and Gillesby. The distal pancreas was mobilized, the tail amputated, the duct opened longitudinally, and the pancreas was

partially invaginated into a Roux-en-Y jejunal limb

RESECTION OF PANCREAS MAY BE: a) distal; b) pancreatoduodenal (PDR) c) total duodenopancreatectomy (execute

in case of fibrous-degenerative pancreatitis)

b) Distal (by Duval) with the resection of distal part of pancreas

Procedure: Pancreatoduodenectomy

Operations on the nervous system are used in case of pain of chronic

indurative pancreatitis, resistant to conservative therapy:

a) left-sided splanchnicectomy; b) bilateral pectoral splanchnicectomy and

sympathectomy; c) postganglionic neurotomy of pancreas

Anatomic landmarks for videoscopic transthoracic left splanchnicectomy. Diagram of the left plural cavity after clipping and division of the splanchnic nerves, showing the sympathetic chain, the intercostal vessels, and the aorta

CYSTS OF PANCREAS

Cyst of pancreas is a cavity, filled by fluid (pancreatic juice, exudation, pus), which has epithelium on internal surface.

Pseudocyst (false cyst) is a cavity in pancreas which appears as a result of its destruction, limited by capsule, that does not have epithelium on internal surface

Etiology and pathogenesisTHE CAUSES OF PSEUDOCYSTS ARE:destructive pancreatitis, traumas of pancreas, occlusion of

Wirsung's duct by parasite, calculus, tumors, innate anomalies of development.

TRUE CYSTS ARE: innate cysts which are anomalic in development; retention

cysts which develop as a result of obstruction to outflow of pancreatic juice, cystadenoma and cystadenocarcinoma

The mechanism of development of pseudocysts consists necrosis of gland, obliterated normal outflow of its secretions, destruction of walls of pancreatic ducts, inflammation reaction of surrounding organs which form the walls of pseudocyst

PATHOMORPHOLOGY Morphologically the cysts of pancreas are

divided into: pseudocysts, retention cyst, single and multiple

Pseudocysts are fresh and old. Epithelium in pseudocysts is absent.

Retention cysts is seen in connection with an obturated duct

Innate cysts are multiple and shallow. Rarely there are echinococcus cysts

localized in the area of head of pancreas

CLASSIFICATION (by A.N. Bakulev and V.V. Vinogradov) I. Innate cysts of pancreas: II. Inflammatory cysts:

Pseudocysts Retention cysts

III. Traumatic cysts: IV. Parasitic cysts: V. Neoplasty cysts:

Pathomorphologically cysts are divided into: The true cyst Pseudocysts

CLINICAL MANAGEMENT PAIN (dull, permanent, cramp-like and belt-like). It is localized

in right hypochondrium, epigastric area, left hypochondrium Pain radiates into the back, left shoulder-blade, shoulder and spine.

DYSPEPSIA characterised by nausea and vomiting. FUNCTIONAL INSUFFICIENCY OF PANCREAS by disorders of

exocrine and endocrine insufficiency, alternating diarrhea with constipation, steatorrhea and creatorrhea, secondary diabetes

COMPRESSION SYNDROME. As a result of compression of neighbouring organs are: partial obstruction of common bile duct (mechanical jaundice), veins (portal hypertension), splenic vein (splenomegaly)

During the CLINICAL EXAMINATION patients with large cysts there is marked asymmetry of abdomen in the epigastria and mesogastric areas.

SONOGRAPHY examination shows echofree formation

SONOGRAPHY

A contrast-injected CT- scan reveals active bleeding (B) into a pseudocyst (arrows)

Contrast roentgenologic EXAMINATION OF STOMACH and duodenum in the cyst of head of pancreas reveals "horseshoe" duodenum

CHOLECYSTOCHOLANGIOGRAPHY exposes calculous cholecystitis and cholelithiasis

RETROGRADE PANCREATOCHOLANGIOGRAPHY exposes the deformed, extended pancreatic duct, there can be cavity of cyst by the contrast matter

LABORATORY EXAMINATIONS exposes hyperamylasemia, steatorrhea and creatorrhea, sometimes - hyperglycemia and glycosuria

COMPLICATIONS 1. Perforation into free abdominal cavity and

peritonitis 2. Perforation into stomach, duodenum, small or large

intestine is accompanied by decrease of size of cyst 3. Suppuration of cystic fluid 4. Erosive bleeding appears suddenly and is

accompanied by the symptoms of internal bleeding (general weakness, dizziness, melena)

5. Mechanical jaundice arises as a result of compression of cyst on the terminal part of choledochus

6. Portal hypertension as a result of compression of portal vein

7. Reactive exudation pleurisy 8. Malignization

DIFFERENTIAL DIAGNOSIS Cancer of pancreas. Aneurysm of abdominal

aorta The cyst of mesentery The cyst of liver

DIAGNOSIS PROGRAMME Anamnesis. Biochemical blood test

(amylase, sugar, bilirubin). Analysis of urine for

diastase. Coprograma. Sonography. Contrasting skiagraphy of

stomach and duodenum Retrograde

pancreatocholangiography. Computer tomography.

TACTICS AND CHOICE OF TREATMENT METHODConservative treatment. Treatment of acute or chronic pancreatitis is conducted in accordance with principles.

Surgical treatment Is the method of choice of treatment of cysts of pancreas. The choice of treatment method depends on the stage of development of pancreatic cysts.

SURGICAL TREATMENT

MORE FREQUENTLY SURGEON MAKES CYSTOJEJUNOSTOMY ON THE ELIMINATED LOOP OF SMALL INTESTINE BY ROUX

DISTAL PANCREATECTOMY, MARSUPIALIZATION MARSUPIALIZATION -

opening and suturing of cyst capsule to the parietal peritoneum and skin is used infrequently (because suppuration of cyst is can lead to sepsis peritonotis).

External and internal draining of cyst and radical operations are applied:

a) enucleation of cysts;b) distal resection of

pancreas with cyst

CANCER OF PANCREAS

The cancer of pancreas is a malignant tumor of epithelium tissue. Its incidence among all malignant tumors is 10 %. Etiology and pathogenesisShortage of vitamins, especially В and C, harmful habits (alcohol, smoking), presence of carcinogenic matters in food (nitrite, nitrates) is one of etiological factors. The cancer of pancreas can arise due to prolonged chronic pancreatitis.

Molecular biology of pancreatic cancer

PATHOMORPHOLOGY The cancer is usually localized in the head

(80%). Rarely - in the area of body or tail. A tumor has resembles epithelium of

pancreatic ducts or epithelium of acinous tissue, sometimes - the Langerhans' islet.

Adenocarcinoma (60%) is exposed microscopically, carcinoid (32-35%), epidermoid cancer or skir is seldom met.

Classification of cancer of pancreas after the TNM stages

T1 - tumor size of diameter 2 cm, is confined interior parts of pan creas. T2 - tumor, spreads the gland and spreads to surrounding cellular tissue

and duodenum. T3 - tumor, that spreads to neighbouring organs (stomach, spleen,

colon). N0 - absent signs of metastatic damage of regional lymph nodes. N1 - metastases in regional lymph nodes. M0 - absent signs of remote metastases. M1 - remote metastases present.

GROUP BY STAGES Stage I - Tl NO MO. Stage II - T2 NO MO. Stage III- T3 N0-1 MO. Stage IV is some T, some N, Ml. The cancer of pancreas metastasises rapidly by lymphogenic route

parapancreatic lymph nodes, and afterwards - into the liver. The hematogenic metastases are into the lungs, bones, kidneys and brain Also possible are remote metastases of Virhov's, Shnitsler's, Krukenberg's.

Clinical management The symptoms of cancer of pancreas depend on localization

of tumor and the relations of pathological process with surrounding organs.

PAIN is a permanent symptom which affects 90 % of patients. Pain localization in epigastria and radiation to the back.

The LOSS OF WEIGHT makes progress and in a short duration of time becomes considerable enough.

JAUNDICE is characteristic of the cancer of head of pancreas, as a result of obliteration of common bile duct. Bilirubinemia grows gradually, due to direct bilirubin.

On palpation of abdomen COURVOISIER'S sign is positive (large gallbladder).

Obliteration of duct of pancreas causes DYSPEPTIC DISORDERS: belching, nausea, vomiting, diarrhea.

Distributions of tumor on duodenum and narrowing of its lumen show up by the signs of STENOSIS (belching and vomiting)

By sonography examination and computer tomography one can expose sign of mechanical jaundice by localization the tumor in the head.

Scanning is an informing method of examination with the use of 75 Se-methionine.

During laparoscopy is visualized dissemination into peritoneum and its metastatic focus in liver.

The changes of main duct of pancreas as segmental stenosis or rupture are done on retrograde endoscopic pancreatography

Skiagraphy of gastro-intestinal tract can expose the cancer of head of pancreas

Computer tomography, sonography

ENDOSCOPIC HOLANGIOPANCREATOGRAPHY

Radionuclide octreotide scan demonstrating pancreatic endocrine tumor in the body of the pancreas (arrow).

TACTICS AND CHOICE OF TREATMENT METHOD

Treatment of cancer of pancreas is mainly surgical. The choice of method and volume of operation depends on localization of tumor, stage of process, age of patient and his general condition.

Radical surgical treatment performed only in 15-20 % of patients. Pancreatoduodenal resection is the method of choice of operation in patients with the cancer of head of pancreas.

Pancreaticoduodenectomy (Whipple Resection)

PALLIATIVE OPERATIONS

Surgical palliation in patients with cancer of the head of the pancreas is directed toward relief of obstructive jaundice, gastric obstruction, and pain.

Patients with cancer of body and tail are less likely to have jaundice or duodenal obstruction, but pain is often significant.

Obstructive jaundice develops in about 70 percent of patients with pancreatic cancer. Cholecystojejunostomy and choledochojejunostomy are both safe and are the procedures of choice to relieve the biliary obstruction

Hepaticojejunostomy