PANCREATIC DISEASE

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PANCREATIC DISEASE

• ACUTE PANCREATITIS

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Facts of Exocrine Pancreas

• 1.5 liters of enzyme-rich fluid every day
  digests of fats, starch, and protein.
• Normal pancreatic juice is clear, colorless,
  isotonic, and alkaline.
• Neutralizes acidic gastric contents in duodenum

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ACUTE PANCREATITIS ESSENTIALS

• Abrupt onset of deep epigastric pain
• Often with radiation to the back.
• History of previous episodes, often related to
  alcohol intake.
• Nausea, vomiting, sweating, weakness.
• Abdominal tenderness and distention and fever.
• Leukocytosis
• Elevated serum amylase
• Elevated serum lipase.

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Etiology

• Reflux of bile into pancreatic duct
• Injury to pancreatic gland cells
• Hypercalcemia
• Hyperlipidemias
• Drugs- Chemo/ HIV
• Infections- Mumps/ CMV
• Cystic fibrosis

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Pain characteristics

• Abrupt epigastric/ upper abdo. pain (dull and
  boring)
• Radiates to the back
• Worse on recline walking
• Better when sitting and leaning forward
• Weakness, sweating, and anxiety present
• Preceded by alcohol intake

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Symptoms and Signs

• Tender distended upper abdomen
• Bowel sounds absent (ileus)
• Fever (38-39?C)
• Tachycardia/ Shock/ Pallor

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Severe Pancreatitis

• gt55 yrs
• WBC gt16,000
• Blood glucose gt200 mg/dL
• Serum LDH gt350 u/L
• AST gt250 u/L

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Lab Workup

• Serum amylase and lipase gt 3 x normal
• Urine- protein , casts , glycosuria
• AXR

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CT Acute Pancreatitis
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CT Pseudocyst
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Pancreatic Pseudocyst Draining into Stomach
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Therapy

• ICU
• Pain relief
• Fluid Volume control
• Prevent complications
• Fatal- 5-20

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PANCREATIC DISEASE

• CHRONIC PANCREATITIS

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Essentials

• Chronic or intermittent epigastric pain
• Steatorrhea
• Weight loss
• Abnormal pancreatic imaging.

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Predisposing Factors

• Toxic-metabolic- Alcoholic (80)/ Tobacco
• Idiopathic (20)
• Genetic- chr.7
• Autoimmune
• Recurrent and severe acute pancreatitis or
• Obstructive

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Steatorrhea bulky, foul, fatty stools
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Signs Symptoms

• Episodic epigastric and left upper quadrant pain
  radiating to the upper left lumbar region are
  typical
• Anorexia
• Nausea, vomiting, constipation, flatulence, and
• Weight loss

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Lab Workup

• Serum amylase and lipase / -
• ALP and Bili may be elevated
• Excess fecal fat pancreatic insufficiency
• AXR- calcification
• ERCP

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ERCP
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Therapy

• Correct strictures
• Low fat diet
• Forbid alcohol
• Avoid narcotics
• Pancreatic enzyme supplements
• Raniitidine, Omeprazole suppress acid- help
  pancreatic enzymes

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Commonly Available Pancreatic Enzyme Preparations Commonly Available Pancreatic Enzyme Preparations Commonly Available Pancreatic Enzyme Preparations Commonly Available Pancreatic Enzyme Preparations Commonly Available Pancreatic Enzyme Preparations
Preparation Form Enzyme Content (USP Units) Enzyme Content (USP Units) Enzyme Content (USP Units)
Preparation Form Lipase Protease Amylase
Uncoated Uncoated Uncoated Uncoated Uncoated
Cotazym Capsule 8,000 30,000 30,000
Pancreatin Tablet 12,000 60,000 60,000
Viokase Tablet 8,000 30,000 30,000
Coated Coated Coated Coated Coated
Creon5/10/20 Enteric-coatedmicrospheres 5,00010,00020,000 18,75037,50075,000 16,60033,20066,400
Pancrease MT4/10/16/20 Enteric-coatedmicrotablets 4,00010,00016,00020,000 12,00030,00048,00044,000 12,00030,00048,00056,000
Ultrase MT6/12/16/20 Enteric-coatedmicrotablets 6,00012,00018,00020,000 19,50039,00058,50065,000 19,50039,00058,50065,000
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COMPLICATIONS

• Opioid addiction
• DM
• Pseudocyst / Abscess
• Steatorrhea / Malnutrition
• Pancreatic cancer (4 after 20 yrs)

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Treatment of Steatorrhea
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Prognosis

• Leads to chronic disability

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PANCREATIC DISEASE

• CANCER PANCREAS

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Essentials

• Obstructive jaundice (may be painless).
• Enlarged gallbladder (may be painful).
• Late Manifestations
• Upper abdominal pain with radiation to back
• Weight loss and
• Thrombophlebitis

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Cancer Pancreas

• Location
• 75 in the head of pancreas
• 25 in the body tail
• Ampulla of Vater / CBD / Head of Pancreas have
  similar presentation
• 90 of these are due to Cancer head of Pancreas

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Risk Factors

• Age
• Obesity
• Tobacco use
• Chronic pancreatitis
• Prior abdominal radiation and
• Family history
• New Diabetic after 50 yrs of age (suspect)

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Symptoms and Signs

• Vague, diffuse epigastric / LUQ pain (70)
• Pain indicates tumor spread beyond pancreas
• Maldigestion / diarrhea are early signs
• Weight loss a late sign
• Painless jaundice obstructive
• Sister Joseph's (Umbilical nodule)

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Diagnostic Test

• Multiphase thin-cut spiral CT scanning (80)
• FNAC
• PET scanning
• Endoscopic US scanning

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Therapy

• Explorative surgery (30) / Laparoscopy
• If localized - Radical pancreaticoduodenal
  (Whipple) resection
• Adjuvant chemo
• Gemcitabine (Gemzar)
• Fluorouracil, 5-FU (Adrucil)
• Stenting of the duct

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Prognosis

• Body Tail poor (lt2-5 5 year survival)
• Ampulla better (20-40)
• Jaundice and lymph node involvement poor
• Palliative care are essential