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THE PANCREAS
INVESTIGATIONS OF PANCREAS
• SERUM ENZYME LEVELS
• PANCREATIC FUNCTION TESTS
• MORPHOLOGY
• ULTRASOUND SCAN
• COMPUTERISED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
• ENDOSCOPIC ULTRASOUND
• PLAIN RADIOGRAPHY
• CHEST
• UPPER ABDOMEN
Forth stage
SURGERY
Lec-4
Dr.Samer
16/12/2015
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INJURIES TO THE PANCREAS
• THE PANCREAS, THANKS TO ITS SOMEWHAT PROTECTED LOCATION
IN THE RETROPERITONEUM, IS NOT FREQUENTLY DAMAGED.
ACUTE PANCREATITIS
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ACUTE INFLAMMATION OF PANCREAS IS ONE OF CAUSES OF ACUTE ABD.PAIN .
IT’S A SERIOUS CONDITION THAT LEADS TO DEATH IN 10% OF CASES .
AETIOLOGY
1.BILE DUCT STONES ( 50% )
2.EXCESS ALCOHOL INTAKE (20%)
3.TRAUMA ( 5% ) ACCIDENTAL ,OPERATIVE , ERCP.
4.RARE CAUSES : VIRAL , HYPERPARATH , CORTICOSTEROID.
5.IDIOPATHIC .
CLINICAL FEATURES
• SYMPTOMS
1.SEVERE AGONIZING UPPER ABDOMINAL PAIN RADIATED TO BACK.
2.VOMTING &RETCHING.
• SIGNS
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MAY SHOW HYPOVOL. SHOCK ,TINGE OF JAUDICE ,CYNOSIS.
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PATIENT SITS LEANING FORWARD.
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MILD TENDERNESS &RIGIDITIY,
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BRUISING AROUND UMBLICUS (CULLEN SIGN) & IN THE LOIN(GREY TURNER SIGN) ARE
RARE LATE FEATURE.
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UPPER ABD. SWELLING AFTER 2-3 WK (PANCREATIC PSEUDOCYST) .
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COMPLICATIONS
• SYSTEMIC
1.SHOCK (LOSS OF PLASMA OR BLOOD)
2.ADRS
3.RENAL FAILURE
4.CONSUMPTION COAGULOPATHY
5.PARALYTIC ILEUS.STRESS ULCER
6.TETANY
• LOCAL
1.PSEUDOCYST
2.ABSCESS
DIFFERENTIAL DIAGNOSIS
• 1.PERFORATED PEPTIC ULCER
• 2.ACUTE CHOLECYSTITIS & BILIARY COLIC
• 3. ACUTE MESENTERIC VASCULAR OCCLUSION
• 4.LEAKING AORTIC ANEURYSM
• 5. ACUTE M.I
INVESTIGATIONS
1.SERUM AMYLASE ELEVATE WITHIN FEW HOURS>1000 IU/DL. NR 100_300.
2.ARTERIAL BLOOD GASES .
3.BIOCHEMICAL : BILIRUBINELEVETED.HYPOCAL.HYPOPROT.ELEVETEDB.UREA.HYPERGL.
4.BLOOD PICTURE :- LEACOCYTOSIS.ELEVATED HAEMATOCRIT .
5.PLAIN X-RAY OF ABDOMEN SHOWS DILATED SHORT SEGMENT OF SMALL
INTESTINE(SENTINEL LOOP).COLON CUT-OFF SIGN .
6.U/S GALL STONE .
7.CT VERY HELPFUL SHOWS ENLARGEMENT OF PANCREAS,OEDEMA,NECROSIS.
8.ECG &CARDIAC ENZYME TO EXCLUDE M.I
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RANSON CRITERIA
At admission:
• 1-age > 55 years.
• 2- WBC > 16000 cells/mm.
• 3- blood glucose > 11 mmol/L (>200 mg/dL )
• 4- serum AST > 250 IU/L.
• 5- serum LDH >350 IU/L.
Within 48 hours:
• 1- serum calcium < 2 mmol/L ( <8 mg/dL ).
• 2- hematocrit fall > 10%.
• 3- PaO2 <60% mmHg.
• 4- BUN increased by 1.8 or more mmol/L( 5 or more mg/dL ) after IV fluid hydration.
• 5- base deficit > 4 mEq/L.
• 6- sequestration of fluid > 6 L.
--- If score > or = 3 severe pancreatitis.
--- If score < 3 severe pancreatitis is unlikely.
TREATMENT
CONSERVATIVE
SEVERE CASES ADMITTED TO ICU.TREATMENT IS SUPPORTIVE TO BODY SYSTEM
”R”REGIMEN:
1.RELIEF OF PAIN BY PETHIDINE WITH ATROPINE
2.REPLACEMENT OF THE LOST FLUIDS BY CRYSTALLOIDS,PLASMA EVEN BLOOD
3.REST OF PANCREAS &BOWEL BY NIL ORAL&NG SUCTION.SOMATOSTATIN
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4.RESPIRATORY SUPPORT BY OXYGEN MASK,OR MECHANICAL VENTILATION
5.RESISTANCE OF INFECTION BY PROPHYLACTIC ANTIBIOTIC
6.REASSESSMENT BY ERCP
7.IF VOMITING IS PROLONGED ,IV HYPERALIMENTATION
SURGICAL
1.DOUBTFUL DIAGNOSIS EXPLORATORY LAPAROTOMY.
2.DRAINGE OF PANCREATIC ABSCESS ,OR PERSISTENT PSEUDOCYST.
3.EXCISION OF NECROTIC TISSUE IN SEVERE NECROTIZING PANCREATITIS.
PANCREATIC PSEUDOCYST
• NATURE COLLECTION OF PANCREATIC SECRETION &INFLAMMATORY EXUDATE WITHIN A
LINING OF INFLAMMATORY TISSUE.
• AETIOLOGY DEVELOPS IN 10% OF CASES OF ACUTE PANCREATITIS AFTER 2-3 WK.NEXET
CAUSE PANCREATIC TRAUMA.
• SITE LESSER SAC.
• COMPLICATIONS INFECTION ,HAEMORRHAGE,RUPTURE.
CLINICAL FEATURES
• SMALL PAINLESS DISCOVERED BY U/S .
• LARGE CAUSE DISCOMFORT ,UPPER ABD. SWELLING .
INVESTIGATIONS
1-BA-MEAL FORWARD DISPLACEMENT OF STOMACH .
2-U/S & CT .
TREATMENT
1.MOST OF CYSTS RESOLVE SPONT .
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2.PERSISTANT CYST .DRAINED AFTER 6WK TO STOMACH OR JEJUNAM.
PANCREATIC CARCINOMA
MALE>FEMLE -- AGE 55-70 --PROGNOSIS POOR
AETIOLOGY UNKOWN.SMOKING,HIGH PROTEIN,HIGH FAT FOOD
SPREAD
DIRECT CBD,LYMPH,BLOOD LIVER LUNG,TRANSPERITONEAL
CLINICAL FEATURES
1.CA OF HEAD PAINLESS OBST.JAUNDICE, HEPATOMEGALLY, PALPABLE GB,ANOREXIA
&WT LOSS
2.CA OF BODY &TAIL EPIGASTRIC PAIN , HEPATOMEGALLY,ANOREXIA &WT LOSS
INVESTIGATONS
1.LFT ELEVATED DIRECT BIL.&ALK.PH.LOW PROTHOMBIN
2.U/S DILATED INTRA &EXTRA HEPATIC DUCT,METASTASES
3.CT
4.ERCP .
TREATMENT
1.UN FIT FOR SURGERY :- ENDOSCOPIC STENT
2.FIT FOR SURGERY & OPERABLE :- WHIPPLE OPERATION
3.INOPERABLE TUMOR :- CHOLECYSTOJEJENOSTOMY.