01 msu disorders of pancreas hajhamad m

Dr. Mohammed Hajhamad,

MB.ChB. M.S

Department of Surgery

International Medical School

MSU

Introduction (anatomy and physiology)

Diabetes mellitus

Pancreatitis

Neoplasms

Benign

Malignant

Cysts and Pseudocysts

12-Feb-16 2Diseases of the pancreas

Gland with both exocrine and endocrinefunctions.

15-25 cm long

60-100 g

Location: retro-peritoneum, 2nd lumbar vertebral level

Extends in an oblique, transverse position

Parts of pancreas: head, neck, body and tail


Rich periacinar network that drain into 5 nodal groups

Superior nodes

Anterior nodes

Inferior nodes

Posterior PD nodes

Splenic nodes


Sympathetic fibers from the splanchnic nerves

Parasympathetic fibers from the vagus

Both give rise to intrapancreatic periacinar plexuses

Parasympathetic fibers stimulate both exocrine and endocrine secretion

Sympathetic fibers have a predominantly inhibitory effect


Exocrine pancreas Trypsin Chymotrypsin Elastase Carboxypeptidase A Carboxypeptidase B Colipase Pancreatic lipase Cholesterol ester hydrolase Pancreatic α amylase Ribonuclease Deoxyribonuclease Phospholipase A

Endocrine Pancreas Insulin


Alpha cells produce glucagon.

Beta cells produce insulin.

Delta cells produce somatostatin.


Alpha cells secrete glucagon. Stimulus is decrease in blood

[glucose].

Stimulates glycogenolysis and lipolysis.

Stimulates conversion of fatty acids to ketones.

Beta cells secrete insulin. Stimulus is increase in blood

[glucose].

Promotes entry of glucose into cells.

Converts glucose to glycogen and fat.

Aids entry of amino acids into cells.


Diabetes Mellitus is a chronic disorder of carbohydrate, fat, and protein metabolism .

In which there is impaired glucose utilization due to defective or deficient insulin secretory response inducing hyperglycemia


Primary (idiopathic) Diabetes Mellitus Type-1 (Insulin Dependent Diabetes Mellitus)

Type-2 (Non-insulin Dependent Diabetes Mellitus) * Non-obese NIDDM

* Obese NIDDM

* Maturity onset diabetes of the young (MOD)

* Gestational DM


Insert table 19.6


Secondary (idiopathic) Diabetes Mellitus Chronic pancreatitis

Post pancreatectomy

Hormonal tumours (acromegaly, Cushing’s)

Drugs (corticosteroids)

Haemochromatosis

Genetic disorders e.g. lipodystrophy

Gestational DM


By far the most common in Malaysia and worldwide.

Type 1 and type2 have different pathogenesis and metabolic characteristics.

Similar long term complications occur in both types.


Young

Rare

Linked to chrom. 7 & 20

Autosomal dominant

Mild hyperglycemia


1. Diabetic Ketoacidosis coma (DKA)

In Type I Diabetes Mellitus

Due to severe insulin deficiency with increaseglucagons

2. Non ketotic Hyperosmolar Coma In Type II DM (NIDDM) Elderly Uncontroled DM

Sustained hyperglycemic diuresis

Severe dehydration coma


Depends on :

- Duration

- Metabolic control

- Genetic factors


Microangiopathy:

Thickening of basement membrane

- Renal Glomeruli nephropathy

- Retinaretinopathy

- Nerves neuropathy


Atherosclerosis:

- Myocardial infarction

- Cerebral stroke .

- Aortic aneurysm .

- Gangrene of lower extremities


Neuropathy:

- Symmetric peripheral neuropathy .

- Sexual impotence .

- Bowel and bladder dysfunction.


Change in lifestyle:

Increase exercise: Increases the amount of membrane GLUT-4 carriers in

the skeletal muscle cells.

Weight reduction.

Increased fiber in diet.

Reduce saturated fat

Pharmacotherapy, insulin and oral agents

Surgery, pancreatic transplant and bariatric surgery.


Inflammatory process in the pancreas

Types:

1. Acute pancreatitis

2. Acute relapsing pancreatitis

3. Chronic relapsing pancreatitis

4. Chronic pancreatitis


Common Causes Gallstones (including microlithiasis)

Alcohol (acute and chronic alcoholism)

Hypertriglyceridemia

Endoscopic retrograde cholangiopancreatography (ERCP), especially after biliary manometry

Trauma (especially blunt abdominal trauma)

Postoperative (abdominal and nonabdominal operations)

Drugs (azathioprine, 6-mercaptopurine, sulfonamides, estrogens, tetracycline, valproic acid, anti-HIV medications)

Sphincter of Oddi dysfunction


Uncommon Causes Vascular causes and vasculitis (ischemic-hypoperfusion

states after cardiac surgery)

Connective tissue disorders

Thrombotic thrombocytopenic purpura (TTP)

Cancer of the pancreas

Hypercalcemia

Periampullary diverticulum

Pancreas divisum

Hereditary pancreatitis

Cystic fibrosis

Renal failure


Abdominal pain

Vomiting

Nausea

Lethargy


Grey Turner sign Cullen’s sign


Requires two of the following:

typical abdominal pain,

threefold or greater elevation in serum amylase and/or lipase level,

and/or confirmatory findings on cross-sectional abdominal imaging. Plain X-rayUSGCT ScanMRI


IV fluids

Analgesia

Supportive management

Surgery- to relieve biliary obstruction- to drain collection


Benign v/s malignant

Exocrine v/s Endocrine ( Pancreatic islet cell tumors )


Cell Hormone Tumor

Alpha cell Glucagon Glucagonoma

Beta cell Insulin Insulinoma

Delta cell Somatostatin Somatostatinoma

Delta-2-cells VIP WDHA (Vipoma)

G-cells Gastrin ZES (Gastrinoma)


Usually diabetic patient

Weight loss

Dermatitis

Anemia

Stomatitis

70% malignant


Peptic ulceration

Abdominal pain

Diarrhea

GI bleed

Perforation of ulcer

Dehydration and malnutrition

Diagnosis: 12 hour overnight acid output and increased serum gastrin


They are adenomas, 90% benign 10% malignant.

Whipple’s triad- episodes of illness precipitated by fasting- hypoglycemia- relief of symptoms by oral or intraveinous glucose.

Diagnosis: fasting insulin and glucose levels

Treatment: surgical, resection of tumor, medical for incurable patients or malignant disease.


Adenocarcinomas Most common pancreas tumor Etiology unknown Risk factors Cigarette smoking High intake animal fat and meat Chronic pancreatitis Several hereditary disorders

Hereditary pancreatitis Von Hippel-Lindau syndrome Lynch-syndrome Ataxiatelangiectasia


Symptoms: Early non-specific Anorexia Weight loss Abdominal discomfort Nausea Specific symptoms Jaundice Purities Moderate pain DM Unexplained attack of pancreatitis


Physical findings Jaundice

Enlarged liver

Courvoisier`s law

Palpable mass)

Ascites

Virchow-Troisier node

Sister Josephs node

Wasting


LFT ( raised ALP, Bili.)

CA 19-9

CA 494


Ultrasound

CT scan

MRI

Cholangiography

E.R.C.P.

P.T.C.

M.R.C.P.


Palliation Jaundice ( pruritis)

Pain

Duodenal obstruction

Curative Resection of the tumor (Whipple procedure /

Pancreaticoduodenectomy )


12-Feb-16Diseases of the pancreas 48

1) Pseudocyst (75-80%)

2) Common cystic pancreatic neoplasms Mucinous cystic neoplasm (10-45%) Serous cystic neoplasm (32-39%) IPMN (21-33%)

3) Rare cystic pancreatic neoplasms Solid pseudopapillary tumor (<10%) Acinar cell cystadenocarcinoma (<1%) Lymphangioma Hemangioma Paraganglioma

4) Solid pancreatic lesions with cystic degeneration

Pancreatic adenocarcinoma (<1%)

Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma) (<10%)

Metastasis

Cystic teratoma

Sarcoma

5) Hydatid cyst

6) Lymphatic cyst

7) True epithelial cysts, associated with:

von Hippel–Lindau disease

Autosomal-dominant polycystic kidney disease

Symptoms Abdominal pain (80 – 90%)

Lump in abdomen

Nausea / vomiting ( due to gastric or duodenal compression)

Early satiety

Bloating, indigestion

Jaundice ( due to compression of bile duct)

Hemorrhage

Signs Tenderness

Abdominal fullness

Palpable mass

Blood test: amylase, lipase

Ultrasonography

Most practical & Sensitivity 75 – 90%

limited by patient habitus, operator experience and air in stomach

CT scan

Gold standard for initial assessment and follow-up

Sensitivity 90- 100%

MRI

Better detail of content of cyst

MRCP

Establish the relationship of the pseudocyst to the pancreatic ducts

Endoscopic Ultrasonography (EUS +/- FNA)

Distinguishing pancreatic cystic lesions, helps in FNA

12-Feb-16Diseases of the pancreas 56

Most common, 10% to 45%

> 95% in women

Mean age 50 years

Typically involve the body and tail of the

pancreas

Never multifocal, occurring only in one

location within the pancreas.

Asymptomatic in 75% cases

If symptoms, usually due to mass effect

Addominal pain

Palpable mass

CT or MRI of the abdomen

Complex macrocystic mass with internal septations

MRCP no communication between duct and the cyst

Presence of mural nodule and septal calcification suspicion of malignancy

Complex macrocystic lesion with internal septations

Peripheral and septal calcification indicative of malignancy (arrowheads)

Second MC Cystic tumor of the pancreas

Occurring mostly in women (75%) with a mean

62 years

Most (50% to 70%) occur in the body or tail of the

pancreas

An association with von Hippel-Lindau disease

Mostly asymptomatic

being detected during evaluation for other unrelated

conditions

Can present with a palpable mass - size (10 to

25 cm)

Lesion with numerous

microcysts giving a

“honey-comb”

appearance

Lobulated outline

Central stellate scar

Pathognomonic image by CT scan is that of a

spongy mass with a central “sunburst”

calcification - only 10% of patients

location in the pancreatic body and tail

wall thickness < 2 mm

lobulated contour

lack of communication with the pancreatic duct

minimal wall enhancement

Types - depend on involvement of duct

main pancreatic duct, isolated side branches, or a combination of

both

Benign (adenoma), borderline, or malignant

Malignant neoplasms account for 60% of IPMNs

Equal frequency in men and women

Median age at diagnosis - about 65 years

75% of patients are symptomatic

Abdominal pain and weight loss – MC complaints

Recurrent pancreatitis or

Acute pancreatitis

Patients with malignant neoplasms are more likely to be

older and more likely to present with jaundice or new-onset

diabetes

Differentiation of IPMN from other cystic

pancreatic masses may be difficult at CT

Most reliable findings for the diagnosis

Presence of a communication between the cystic lesion

and the main pancreatic duct

Presence of mural nodules projecting into the

main pancreatic duct or cystic lesions

Pathognomonic for IPMN in ERCP

A wide and gaping papilla with secretion of mucin and filling

defects in the dilated pancreatic duct –FISH MOUTH

AMPULLA

01 msu disorders of pancreas hajhamad m

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