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🫁 PANCREAS - Complete Notes (pp. 109-118)

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ACUTE PANCREATITIS (pp. 109-112)

Definition

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Causes - Mnemonic: GET SMASH'D

Gallstones + Alcohol = 80% of all cases

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Clinical Features

• Severe upper abdominal pain radiating to back, relieved by sitting/leaning forward
• Retching, nausea, hiccoughs
• Grey Turner's sign - bluish discoloration of flanks (sub-fascial bleeding)
• Cullen's sign - discoloration around umbilicus
• Pleural effusion in 10-20% of cases
• Abdominal distension and ileus

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Investigations

• Level increases immediately, remains elevated 3-5 days
• In acute pancreatitis, rises up to 4x normal
• Mild elevation also seen in duodenal ulcer perforation and other acute abdominal conditions
• Serum lipase is elevated in 76-90% of cases, remains elevated longer, and is more specific than amylase
• Normal amylase does NOT exclude pancreatitis

• Bowel gas limits usefulness
• Must be performed within 24 hours in all patients - to detect gallstone, rule out cholecystitis, check if CBD is dilated

• Gold standard investigation
• Not used routinely - indicated when:
  • Diagnosis uncertain
  • Severe acute pancreatitis (to distinguish interstitial from necrotizing)
  • Progressive clinical deterioration
  • Local complications suspected (abscess, necrosis, pseudocyst)

• Sometimes done by mistake thinking it's peritonitis
• Fat necrosis (small islands of saponification) may be seen over the omentum → liberation of lipase → splits glycerol into fatty acids → combines with calcium to form soaps → hypocalcemia

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Assessment of Severity

Ranson's Criteria (11 parameters total):

• Age > 55 years
• WBC > 16,000/µL
• Blood glucose > 200 mg/dL
• Serum LDH > 700 units
• AST > 250 IU/L

• Hematocrit decrease > 10%
• BUN elevation > 5 mg/dL
• Serum calcium < 8 mg/dL
• Arterial PO₂ < 60 mmHg
• Base deficit > 4 mEq/L
• Estimated fluid sequestration > 6L

• APACHE II score ≥ 8
• Glasgow score ≥ 3
• C-Reactive protein > 150 mg/L + worsening clinical condition = severe disease

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Complications

1. Acute fluid collection - no wall of granulation/fibrous tissue; resolves in 50% or becomes abscess/pseudocyst
2. Sterile pancreatic necrosis - focal/diffuse non-viable parenchyma, >30% of gland on contrast CT
3. Acute pseudocyst - collection of pancreatic juice walled off by fibrous/granulation tissue
4. Pancreatic abscess - circumscribed intra-abdominal pus collection near pancreas with necrotic material
5. Pancreatic ascites
6. Pancreatic effusion
7. Portal/splenic vein thrombosis

• Pulmonary: Pneumonia, atelectasis, ARDS, pleural effusion
• Cardiovascular: Hypotension, hypovolemia, pericardial effusion
• Hematologic: DIC
• GI hemorrhage: Peptic ulcer, portal/splenic vein thrombosis with varices
• Renal: Oliguria, renal failure, renal artery/vein thrombosis
• Metabolic: Hyperglycemia, hypocalcemia
• CNS: Psychosis, fat emboli
• Fat necrosis: Intra-abdominal saponification, subcutaneous tissue necrosis

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Management

• IV fluid administration
• Monitoring of vitals
• Analgesia
• Anti-emetics (if nausea)
• Antibiotics NOT indicated
• Recovery in majority within 72 hours

• Admit to ICU
• Replace fluid and electrolytes
• Oxygenation
• Analgesia
• Monitor vitals, CVP, intake/output, ABGs
• Nasogastric aspiration
• Biochemical monitoring (LFTs, RFTs, serum calcium, sugar, TLC, LDH)
• Antibiotic prophylaxis
• CT scan if organ failure or signs of sepsis
• If cause is gallstone/cholangitis → ERCP to extract stone from CBD + cholecystectomy before discharge
• Nutritional support (conditional)
• Systemic support: inotropes (CVS), dialysis (renal), ventilation (respiratory), IV calcium + IM magnesium (metabolic)

• If infective necrosis/abscess → CT-guided needle aspiration + drain placement

• If sepsis worsens despite above measures
• High morbidity/mortality - done in specialist unit
• Post-necrosectomy necrotic tissue managed by:
  • Closed continuous drainage (Beger) - 2 drains placed, raw area flushed
  • Closure and re-laparotomy - abdomen closed, reopened every 48-72 hours until raw area granulates

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PANCREATIC ABSCESS (p. 112-113)

• Intra-abdominal pus collection near pancreas with necrotic material
• Consequence of acute pancreatitis

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CHRONIC PANCREATITIS (p. 113-114)

Definition

Causes

1. Alcohol (60-70%) - most common
2. Idiopathic (20%)
3. Pancreatic duct obstruction (stone/stricture)
4. Congenital anomalies (pancreatic division, annular pancreas)
5. Cystic fibrosis
6. Infantile malnutrition
7. Hereditary pancreatitis - mutation in cationic trypsinogen gene on chromosome 7
8. Idiopathic chronic pancreatitis
9. Autoimmune pancreatitis - autoantibodies present, IgG-4 elevated

Clinical Features

• Pain in epigastrium/hypochondrium radiating to back
• Nausea, vomiting
• Analgesic abuse is common
• Malabsorption occurs when >90% of pancreas destroyed → weight loss, steatorrhea, metabolic bone disease, vitamin deficiency (A, B, E, K, B12)

Investigations

• Pancreatic function tests
• X-ray abdomen - pancreatic calcification and stones
• CT and MRCP - outline gland and main area of damage
• ERCP - most accurate for delineating pancreatic duct anatomy and level of obstruction
• EUS - shows stones, side branches, irregular/distorted main pancreatic duct, dilatation

Complications of Chronic Pancreatitis

• Pseudocyst - duodenal/gastric obstruction, splenic vein thrombosis, abscess, erosion into visceral artery
• Inflammatory mass in head - bile duct stenosis (obstructive jaundice), portal vein thrombosis, duodenal obstruction
• Duct strictures and/or stones → ductal hypertension and dilatation
• Pancreatic carcinoma

• Pancreatic duct leak with ascitic fistula
• Pseudocyst extension into mediastinum, retroperitoneum, lateral pericolic spaces, pelvis, or adjacent viscera

Treatment - Chronic Pancreatitis

1. Malabsorption & steatorrhea - pancreatic enzyme supplementation, low fat high protein and high carbohydrate diet, fat soluble vitamins, medium chain triglycerides (for severe fat malabsorption - absorbed directly by small intestine without digestion)
2. Treat pain - analgesics, eliminate obstructive factors, CT/EUS-guided celiac block for intractable pain
3. Stop alcohol and tobacco
4. Control diabetes mellitus

• Endoscopic or surgical decompression of pancreatic duct
• Indications for surgery:
  • Severe intractable pain
  • Dilated pancreatic duct
  • Multiple relapses
  • Inability to rule out neoplasm
  • Complications (pseudocyst, obstruction)
• Aim: Adequate drainage of pancreatic juice by relieving obstruction
• Surgical options:
  • Endoscopic pancreatic sphincterotomy and stone extraction
  • Stent placement (not >4-6 weeks or it blocks)
  • Puestow procedure - transverse/longitudinal pancreaticojejunostomy for stones causing duct obstruction
  • Frey's procedure - head of pancreas resected + transverse pancreaticojejunostomy
  • Whipple's procedure in selected patients
  • Distal pancreatectomy when distal portion involved

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PANCREATIC CANCER / NEOPLASMS OF EXOCRINE PANCREAS (pp. 115-117)

Key Facts

• Worst prognosis of all malignancies
• >80% are ductal adenocarcinoma
• Location: 70% head, 20% body, 10% tail
• Spreads along main pancreatic duct and bile duct; invades duodenum, local lymph nodes, portal vein, mesenteric artery; metastasizes to liver, peritoneum, lungs

Ampullary & Peri-ampullary Carcinoma

• Ampulla = junction of biliary and pancreatic duct within duodenum
• Peri-ampullary tumors - arise within 2 cm of ampulla (distal bile duct, duodenal mucosa, pancreatic head)
• Better prognosis than pancreatic adenocarcinoma because they obstruct CBD early → early jaundice = early diagnosis

Risk Factors

• Age >65 years, male gender, Black ethnicity
• Smoking, diabetes, adenomas
• Familial adenomatous polyposis
• Positive family history
• Chronic pancreatitis
• Familial breast-ovarian syndrome

Clinical Features

• Obstructive jaundice (distal bile duct obstruction)
• Pruritis, dark urine, pale (clay-colored) stool
• Back pain = retroperitoneal infiltration
• Weight loss, anorexia
• Palpable gall bladder (Courvoisier's Law)
• Advanced tumor → gastric outlet obstruction
• Tumors of neck/body/tail diagnosed late (no early jaundice)

Courvoisier's Law

In obstruction by stones, the gall bladder is NOT palpable (already fibrosed). A palpable gall bladder in obstructive jaundice = malignant obstruction (most likely).

Investigations

1. Bilirubin, ALP, GGT elevated (biliary obstruction)
2. USG - initial non-invasive investigation; identifies dilated biliary tree, cholelithiasis, mass lesion; EUS is more useful - allows transduodenal/transgastric biopsy
3. CT - investigation of choice - dilated biliary channels, level/size/site of tumor, lymph node involvement, vascular involvement (portal vein, celiac, SMA), liver/lung metastasis
4. MRI and MR angiography - comparable to CT
5. Laparoscopy - peritoneal and hepatic metastasis
6. CA 19-9 - not highly specific/sensitive; used to monitor treatment response

Treatment

• 80% are unresectable at presentation (too advanced)
• Curative treatment possible only in 15-20% of cases

(A) Curative Treatment - Surgical Resection

• Liver/lung metastasis
• Peritoneal metastasis
• Encasement of superior mesenteric, hepatic, or celiac artery
• Complete encasement of portal vein (partial encasement is NOT absolute contraindication)

• Tumor size
• Invasion of duodenum, stomach, or colon
• Lymph node involvement within operative field
• Minimal invasion of portal/superior mesenteric vein (vein can be resected)

1. IV fluids (maintain renal perfusion, prevent renal failure)
2. Vitamin K IM injections (fat soluble vitamins A, D, E, K not absorbed due to lack of bile salts)
3. 10% D/W IV + encourage oral fluids (liver loses glucose storage function in obstructive jaundice)
4. Prophylactic antibiotics (prevent cholangitis)
5. Pre-operative biliary drainage via ERCP if bilirubin >15 mg/dL

Surgical Options - Tumor of Head & Ampulla: Whipple's Procedure

1. Tumor + head of pancreas
2. Entire duodenum
3. Proximal jejunum (10-15 cm)
4. Lower end of stomach
5. Common bile duct
6. Gall bladder
7. Lymph nodes around pancreas

• Done only in specialist centres; mortality <5%, morbidity 15-30%

(B) Palliative Treatment (when curative resection not possible):

1. Relieve jaundice - Stenting (via ERCP/PTC) OR Surgical bypass (Choledochojejunostomy)
2. Relieve gastric obstruction - Gastrojejunostomy or stent into duodenum
3. Relieve pain - Analgesics, celiac axis block
4. Quality of life - normal activities, pancreatic enzyme replacement, treat diabetes
5. Chemotherapy - limited role in adenocarcinoma

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Tumors of Body & Tail

• Distal pancreatectomy with splenectomy is standard treatment
• Chemotherapy/radiotherapy limited role

Prognosis

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CYSTIC NEOPLASMS OF PANCREAS (p. 117)

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PANCREATIC LYMPHOMA (p. 118)

• Primary involvement of pancreas without disease elsewhere possible
• Similar clinical features to adenocarcinoma; large mass should raise suspicion
• Biopsy via percutaneous or EUS
• Jaundice relieved by endoscopic stenting + chemotherapy = standard treatment

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PANCREATIC INJURIES (p. 118)

Causes

1. Blunt trauma
2. Penetrating abdominal trauma
3. Iatrogenic - splenectomy, Billroth II gastrectomy, enucleation of islet cell tumor, ERCP

Clinical Features

Diagnosis

1. CT scan - investigation of choice (pancreatic parenchyma damage, main duct intact or transected, associated injuries)
2. Serum amylase level
3. ERCP/MRCP in doubtful cases

Grading & Treatment

• ATLS guidelines
• IV fluids + analgesics
• Haemodynamically stable: ascertain damage to main pancreatic duct (difficult to assess during surgery)

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Quick memory tips:

• Gallstones + Alcohol = 80% of acute pancreatitis
• Amylase rises fast, lipase is more specific and lasts longer
• Grey Turner = flanks, Cullen = umbilicus
• Ranson >6 = 70-90% mortality
• Antibiotics NOT indicated in mild pancreatitis
• Courvoisier's palpable GB = malignant obstruction
• CT is investigation of choice for both acute pancreatitis and pancreatic injury
• 80% of pancreatic cancers are unresectable; curative only in 15-20%
• Whipple's: head + duodenum + proximal jejunum + lower stomach + CBD + GB + lymph nodes
• Hereditary pancreatitis = cationic trypsinogen gene, chromosome 7
• Autoimmune pancreatitis = IgG-4 elevated