Surgical diseases of the Pancreas
Dr. Hamid HindiAnatomy of the Pancreas
Physiology of the PancreasExocrine pancreasTrypsinChymotrypsinElastaseCarboxypeptidase ACarboxypeptidase BColipasePancreatic lipaseCholesterol ester hydrolasePancreatic α amylaseRibonucleaseDeoxyribonucleasePhospholipase AІ Endocrine Pancreas Insulin
Acute Pancreatitis
Def. Acute inflammation, usually with rapid onset of pain and tenderness, often accompanied by vomiting, and systemic inflammatory responses. Regional tissues and remote organ systems are sometimes involved. Elevated pancreatic enzymes in blood or urine usually occur, but not invariably.Etiology of A.P.
MetabolicMechanical
Vascular
Infection
Alcohol Hyperlipoproteinemia Hypercalcemia Drugs Genetic Scorpion venom
Cholelithiasis Postoperative Pancreas divisum Post-traumatic E.R.P. Pancreatic duct obstruction Pancreatic duct bleeding Duodenal obstruction
Post-operative Periarteritis nodosa Atheroembolism
Mumps Coxsakie B Cytomegalovirus Cryptococcus
PATHOGENESIS
Clinical Picture
CLINICAL PICTUREHISTORY
SYMPTOMS
SIGHNS
History
Risk factors Previous attacks?Symptoms
Pain- upper abdominal,constant,radiates to the back(50%),Often starts after alcohol binge or heavy meal,increases in intensity rapidly. Dominant symptom in 85%-100%. Nausea Vomiting- not coupious,gastric and duodenal contentsSigns
Restlessness Rapid pulse Rapid respiratory rate Arterial hypotension Abdomen moderately distended, epigastric fullness. Grey-turner sign Cullen sign Fox signSpecial investigations
Confirm diagnosis S-amilase ( remember diff.) U-amilase S-lipase CRP ABG FBC S-Calsium
RADIOLOGY
CXR Sympathetic pleural effusion Atelectasis A.R.D.S. AXR Sentinal loop Colon cutoff sign Duodenal ileus Calcifications Obscured psoas lines 79% will have radiological signs !!!HOW DO WE DETERMINE PROGNOSIS? ( TREATMENT)
80% Will recover without any complications 20% Will develop severe cardio-pulmonary complications or septic complications Prognostic assessment : Ranson Imrie APACHE 2 CRP Classify into mild or severe acute pancreatitis ( Atlanta clessification 1992)TREATMENT OF ACUTE PANCREATITIS
NON-OPERATIVE To limit severity of pancreatic inflammation Inhibition of pancreatic secreation Nasogastric suction Pharmacologic Hypothermia Pancreatic irradiation Inhibition of pancreatic enzymes Corticosteroids Prostaglandins To interrupt the pathogenesis of complications Antibiotics Antacids Heparin Low molecular weight dextran Vasopressin Peritoeal lavageTREATMENT OF ACUTE PANCREATITIS
To support the patient and treat complications Restoration and maintenance of intravascular volume Electrolite replacement Respiratory support Nutritional support Analgesia HeparinTREATMENT OF ACUTE PANCREATITIS
Operative treatment Diagnostic laparotomy To limit the severity of the pancreatic inflammation Biliary procedures To interrupt the pathogenesis of complications Pancreatic drainage Pancreatic resection Pancreatic debridement Peritoneal lavage To support the patient and treat complications Drainage of pancreatic infection Feeding jejenostomy To prevent recurrent pancreatitisSummary of treatment
All patients Nasogastric suction NPO Monitor and maintenance of intravascular volume Respiratory monitoring and support Antibiotics(selective) Early laparotomy only fordiagnosis Estimate prognosis by early signs Patients with severe pancreatitis Peritoneal lavage Nutritional support Suspect and treat pancreatic sepsis Heparin if hypercoagulableComplications of acute pancreatitis
Systemic complications: Fluid imbalance Electrolite imbalance Cardiac impairmant Renal impairmant Respiratory impairmand Liver failure Local complications: Ileus Duodenal obstruction Biliary obstruction Pseudocyst formation Infected necrosis Colon necrosisPancreatic pseudocyst
Def. Pseudocysts are localized collections of pancreatic juice occurring as a result of pancreatic inflammation, trauma or duct obstruction.They are distinguished from other types of pancreatic cysts by their lack of an epithelial lining. Presenting symptoms: Epigastric pain Nausea Vomiting Weight loss Epigastric mass Fever JaundicePancreatic pseudocyst
Investigations: Elevated s-amylase (50%) Ultrasound CT ? E.R.C.P. Natural history: Most will resolve spontaneously Treatment: Only if symptomatic Treatment options: Drainage External Internal Endoscopic surgicallyCHRONIC PANCREATITIS
DEF. Chronic pancreatitis is an inflammatory disease of the pancreas characterized by destruction of its exocrine and endocrine tissue and by their replacement with fibrous scar. It is the difference in the ability to recover that is the basis for the classification of pancreatitis into acute and chronic forms.ETIOLOGY OF CHRONIC PANCREATITIS
Alcohol Ductal obstruction Congenital or acquired strictures of the pancreatic duct Pancreas divisum Ductal obstruction due to tumors Inflammation of the ampulla of Vater Protein malnutrition Cyctic fibrosis Hypercacemic states Hereditary pancreatitis Idiopathic pancreatitisCLINICAL MANIFESTATIONS
Abdominal pain (95%) Exocrine dysfunction (steatorrhea & creatorrhea) Endocrine dysfunction ( DM) Weight loss (75%) Few clinical findingsSPECIAL INVESTIGATIONS
Blood testsRadiology (mainstay of the diagnosis)AXRPancreatic calcifications (30-50%)CTDilated pancreatic ductCalcification of pancreasPseudocyctsE.R.C.P.“Chain of lakes” appearanceDistal bile duct stenosisEXTRAPANCREATIC INVOLVEMENT
Common bile duct obstruction (10%) Duodenal obstruction (1%) Colonic obstructionTREATMENT OF CHRONIC PANCREATITIS
MEDICAL Pancreatic insufficiency Diabetes mellitis PainSURGICAL Resections Drainage procedures