PANCREAS

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• I. Pancreas
• A. Anatomy
• - retroperitoneal
• - extends transversely behind the stomach
• - weight approximately 85 grams
• - length 12-15 cm.

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• 1. Anatomic relationships
• a. head of the pancreas lies over the
  aorta and under the stomach and transverse
  colon, posteromedial to the IVC
• i. superior limit portal vein
• ii. anterior limit gastro-duodenal
  artery
• iii. CBD courses posteriorly to the head
  and partially within
• iv. Common blood supply with the duodenum

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• b. uncinate process lies posterior
  to the SMV and anterior to the IVC
• c. tail closely related to the spleen
• d. neck lies at the confluence of splenic
  and mesenteric veins

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• B. Blood supply
• 1. Anterior and posterior arcades supply the
  head of the pancreas superior component comes
  from the gastroduodenal artery and the inferior
  component comes from the superior mesenteric
  artery
• 2. Inferior pancreatic artery runs inferior
  to the organ, in intimate contact with the
  pancreas

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• 3. Superior pancreatic artery present in
  50-90 of patients
• a. arises from the splenic artery, hepatic
  artery, superior mesenteric or iliac artery
• b. postero-superior portion of the neck and
  body of the pancreas
• 4. Splenic and left gastroepiploic artery
  supplies body and tail of the pancreas

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• 5. Venous drainage
• a. follows the course of the arteries
• b. confluence of right gastroepiploic
  vein, anterosuperior pancreaticoduodenal vein,
  middle colic vein
• c. forms the gastrocolic trunk which empties
  directly to the SMV at the inferior border of
  the neck of the pancreas

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• 6. Ductal system drains into the duodenum
• a. Duct of Wirsung empties into the
  ampulla of Vater together with the
  CBD
• b. Duct of Santorini drains into the minor
  papilla approximately 2 cm above and medial
  to the ampulla of Vater (minor ductal system)

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• II. Pancreatitis
• A. Acute pancreatitis
• 1. Gallstone pancreatitis
• a. needs a common channel between the CBD
  and the pancreatic duct
• b. high proportion of causes with gallstone
  pancreatitis have recoverable biliary calculi
  in the stools
• c. spasm of the sphincter of Odi as a stone
  passes causes reflux of bile into the
  pancreatic duct which results in the
  destruction of the pancreatic parenchyma

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• 2. Alcohol pancreatitis
• a. alcohol causes increase in protein
  concentration in the pancreatic juice ?
  calcifications in the duct
• b. ductal obstruction causes inflammation
  ? destruction of parenchyma

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• 3. Post-operative pancreatitis
• a. occurs ususally after gastric, biliary
  tract surgery, or splenectomy
• b. ligation or laceration of the duct may
  be the cause of the pancreatitis
• c. mortality approximately 50

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• B. Clinical manifestations of acute pancreatitis
• 1. mild abdominal discomfort to profound
  shock
• 2. epigastric pain radiating to the back with
  nausea and vomiting
• 3. discomfort may be relieved by sitting and
  aggravated by lying down

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• 4. may have mild to moderate abdominal
  tenderness
• 5. may present with a surgical abdomen
• 6. severe pancreatitis may lead to
  retroperitoneal hemorrhage which leads to
• a. 3rd space fluid loss
• b. hypovolemia
• c. hypotension
• d. tachycardia e. blood dissection Grey
  Turners sign (flank ecchymosis)
• - Cullens sign (periumbilical ecchymosis

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• 7. pain usually follows 1-4 hours after a
  heavy meal and intake of alcohol
• C. Diagnosis
• 1. History and Physical Exam
• a. serum amylase increased in 95 of
  cases 5 false negative
• i. 75 of patients with abdominal pain
  and increased amylase have pancreatitis

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• ii. other causes of increased amylase
• - acute cholecystitis
• - CBD stone with or without cholangitis
• - Perforated peptic ulcer
• - Strangulated small bowel
• - acute alcoholism
• - Cancer of the pancreas
• - Mumps

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• iii. amylase level over 1,000
  Somogyi-Nelson units often indicates
  biliary tract disease with panceatitis
• iv. 200-500 units indicates alcoholic
  pancreatitis

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• b. amylase creatinine ratio
• - diagnostic when amylase output in the
  urine exceeds 300 u in one hour and ratio of
  amylasecreatinine clearance of gt5
• c. serum calcium - lt7.5 mg/dl generally
  indicates poor prognosis
• d. radiology (x-ray) relatively insensitive
• e. barium studies
• i. widened duodenal C-loop
• ii. Pad sign obliteration of the
  duodenal mucosal folds

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• f. ultrasound swelling of the pancreas
  and loss of tissue planes
• g. CT scan findings similar to ultrasound
  but with a higher resolution

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• D. Treatment
• 1. Resuscitation replacement of fluid losses
  and electrolytes
• 2. Blood transfusion in hemorrhagic
  pancreatitis
• 3. Calcium gluconate through IV
• 4. NGT suction decrease GIT distension and
  pancreatic stimulation

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• 5. Antibiotics reduce risk of abscess
  formation
• 6. Meperidine
• 7. Surgery
• a. confirm diagnosis in cases which do not
  respond medically
• b. relieve ductal obstruction
• c. drain the lesser sac

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• E. Prognosis Ransons Criteria
• 1. Admission
• a. gt 55 years old
• b. WBC count gt 16000
• c. FBS gt 200 mg/dl
• d. LDH gt 350 units/ml
• e. SGOT gt 250

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• 2. 48 hours after admission
• a. drop in hematocrit by gt 10
• b. increase in BUN of 5 mg/dl
• c. calcium level lt 8 mg/dl
• d. PaO2 below 60 mmHg
• e. base deficit gt 4 meq/L
• f. third space fluid loss gt 6 L

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• Prognosis
• Number of criteria present Mortality rate
• 0-2 0.9
• 3-6 33
• 7-8 100

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• III. Chronic Pancreatitis
• - clinical entity rather than a pathologic
  process
• - organ becomes small, indurated and nodular and
  edges become rounded
• - alternating areas of strictures and
  dilatations in the duct with calcifications
• -primary etiology chronic alcoholic
  pancreatitis with progressive fibrosis without
  ductal dilatation or calcification

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• A. Clinical manifestation
• 1. late 30s or 40s
• 2. history of alcoholism and recurrent
  attacks of pancreatitis
• 3. pain
• 4. may diabetes or steatorrhea
• 5. frequent finding of pseudocyst
• 6. anorexia and weight loss

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• B. Diagnosis
• 1. upper GI series
• 2. ERCP
• 3. ultrasound/CT scan
• 4. calcifications on x-rays

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Calcifications of Chronic Pancreatitis
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Calcifications of Chronic Pancreatitis
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• C. Treatment
• 1. analgesics
• 2. endocrine and exocrine replacement
• 3. stop alcohol intake
• 4. surgery (Peustow procedure)

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• IV. Psedocyst of the Pancreas
• A. Causes
• 1. pancreatitis 75
• - alcoholic pancreatitis
• - 4th and 5th decade of life
• 2. trauma 25

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• B. Pathology
• 1. fibrous wall surrounding a collection of
  pancreatic juice and necrotic or suppurative
  pancreatic juice
• 2. unilocular and located in the lesser sac
• 3. fluid varies from clear and colorless to
  brown or green

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• C. Clinical manifestations
• 1. pain, fever, and ileus appearing 2-3
  weeks after an initial attack of pancreatitis
• 2. pain radiating to the back
• 3. jaundice
• d. non-tender palpable mass (75 of
  patients)
• 4. change in size of the mass due to partial
  drainage

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• D. Diagnosis
• 1. continued elevation of serum amylase
• 2. CT scan diagnostic tool of choice
• 3. ultrasound
• 4. upper GI series
• 5. ERCP

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• E. Treatment
• 1. surgery
• a. to prevent complications such as
  infection, hemorrhage, rupture
• b. pseudocysts rarely resolve once thick
  fibrous wall has developed
• c. pseudocyst should be treated only after
  5-6 weeks from discovery

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• 2. types of surgery
• a. external drainage
• b. internal drainage - best
• i. cystenterostomy
• ii. cystgastrostomy
• c. cyst wall should be excised for
  histopathology to rule out malignancy

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• V. Pancreatic Tumors
• A. Etiology
• 1. cigarette smoking
• 2. coffee
• 3. biliary lithiasis

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• B. Pathology
• 1. Cystadenoma/Cystadenocarcinoma
• a. rare predilection for females
• b. cystic spaces divided by firbous septa
  vascular
• c. better prognosis than adenocarcinoma
• d. Tx. - resection

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• 2. Adenocarcinoma
• a. 90 of cases usually at the head
• b. periampullary malignancy
• i. head of the pancreas 83
• ii. Ampulla of Vater 10
• iii. Duodenum 4
• iv. Common bile duct 3

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• c. Clinical manifestations
• i. weight loss most common
• ii. pain dull epigastric pain that
  radiates to the back aggravated by eating
• iii. progressive jaundice 75 head of
  the pancreas

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• iv. anorexia and weakness 50
• v. pruritus
• vi. hepatomegally
• vii. enlarged palpable gallbladder
  Courvesiures gallbladder

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• d. Laboratory work-up
• i. alkaline PO4, transaminases, Bilirubin
• ii. UGIS
• iii. CT scan CT scan guided biopsy
• iv. ERCP/PTC

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• e. Treatment
• i. Prior to surgery improve overall
  condition of the patient
• ii. Whipples surgery for resectable
  lesions renal failure most common
  complication
• iii. Cholecystojejunostomy/ Gastro-
  jejunostomy bypass for unresectable
  lesions
• iv. injection of 95 alcohol to the celiac
  plexus relief of pain

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• v. poor risk patients
• - PTC/PTBD
• - 5-FU/external beam radiation

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• 3. Zollinger-Ellison Sybdrome Ulcerinogenic
  Tumors of the Islets
• a. malegtfemale 3rd to 4th decade
• b. slow growing tumor of the Islets of
  Langerhan
• c. associated with Multiple Endocrine
  Neoplasia adenoma of the pituitary,
  parathyroid, pancreatic islets (beta
  cells), and adrenal cortex
• d. secretes GASTRIN

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• e. Triad
• i. fulminant and complicated peptic ulcers
  often in atypical locations
• ii. Extreme gastric hypersecretion
• iii. Non- beta cell tumor of the Islets

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• f. signs and symptoms
• i. acid peptic disease
• ii. Distressing watery diarrhea
• iii. steatorrhea

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• g. diagnosis
• i. UGIS
• ii. Gastroscopy
• iii. Serum gastrin determination
• iv. CT scan

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• h. treatment
• i. total gastrectomy
• ii. Resection of the tumor
• iii. Proton pump inhibitor
• iv. Streprozotocin - metastasis

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• 4. Hyperinsulinism Islet cell tumor
• - b-cells hypersecretion of insulin causing
  hypoglycemia
• a. pathology
• i. benign adenoma 75
• ii. Suspected malignant 13
• iii. Clearly malignant 12
• iv. Diffuse adenomatosis
• v. size of the tumor has no relation to
  severity

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• b. clinical manifestation
• i. 4th-7th decade
• ii. Associated with MEA-I hyperinsulinism
  
• iii. Two general forms
• - rapid fall of blood sugar
• - gradual fall in blood sugar

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• iv. Whipple Triad
• - hypoglycemic attack during fasting or
  exertion
• - FBS gt 50 mg/dl
• - symptoms relieved by intake of glucose

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• c. diagnosis
• i. blood sugar and insulin levels
• ii. Pancreatic angiography and venous
  sampling
• iii. CT scan

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• d. treament
• i. pre-operative management
• - adequate provision of glucose
• - ACTH and Cortisol
• - Diazoxide inhibits release of insulin

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• ii. Surgery
• - benign excision
• - malignant pancreatic resection
• - improvement seen 30 minutes after
  excision of the lesion
• - Streptozoticin - metastasis