8. The Pancreas
• Endocrine pancreas:
– Diabetes Mellitus (DM)
– Islet Cell Tumors
• Exocrine pancreas:
– Acute pancreatitis
– Chronic pancreatitis
– Carcinoma of the pancreas
9. Endocrine Pancreas
• 1 million microscopic units – the islets of
Langerhans
• 4 most important cell types of the islets are:
– Β (beta): constitute 70% of the cells and contain
insulin
– A (alpha): 20% of the cells and elaborate glucagon
– D (delta): secrets somatostatin which suppresses
the insulin and glucagon secretion
– PP (pancreatic polypeptide): unknown physiologic
function
17. Acute pancreatitis
• Clinical finding
• Abdominal pain
• Abdominal distention
• Nausea and vomiting
• Respiratory failure, confusion, or coma.
• Low-grade to moderate fever
• Tachycardia and hypotension
• Mild jaundice,
• Pleural effusion.
• Shock
18. Acute pancreatitis
• Peritoneal irritation sign （ Abdominal
tenderness ， rebound tenderness and
rigidity ）
• Shifting dullness
• Decreased bowel sounds
• Cullen’ sign: discoloration of periumbilical
area
• Grey Turner’ sign:discoloration of flanks
19.
20. Acute pancreatitis
• Laboratory finding
• Amylase and lipase (elevations of amylase are
more sensitive but less specific than lipase in the
diagnosis of acute pancreatitis )
• 500
• 400 Urine amylase
• 300
• 200 Blood amylase
• 100
• 0
• 0 1H 24H 48H 5DAY
21. Acute pancreatitis
• Serum calcium
• Serum glucose
• Blood gas analysis
• CRP(C-reactive protein)
• Imunolipase, trypsinogen ,and immuno
elastase.
• ALT and AST (gallstone pancreatitis )
22. Acute pancreatitis
• Imaging finding
• X-ray
• Dilated loop of small bowel (sentinel loop)
• Abrupt cessation of gas in the distal transverse colon
(colon cutoff sign)
• Radioopaque densities (biliary calculi)
• Left-sided pleural effusion
• B-US: pancreatic edema, ascites----
• CT: Important
23. •CT is the best
diagnostic test for
the diagnosis of
acute pancreatitis.
•Contrast-enhanced
CT is excellent for
diagnosis of
pancreatic necrosis
24. Acute pancreatitis
• Assessment of severity of acute pancreatitis
Ranson's criteria
On Admission Within 48 Hours
Age > 55 years Hematocrit decrease by >10%
WBC > 16,000 mm³ Urea nitrogen increase > 5 mg/dl
LDH > 350 IU/L Serum calcium < 8 mg/dl
Glucose > 200 mg/dl Arterial PO² < 60 mm Hg
AST > 250 IU/L Base deficit > 4 mEq/L
Estimated fluid sequestration > 6 L
28. Acute pancreatitis
• Treatment
• Acute edematous pancreatitis—internal
medicine (Emergency surgery is not indicated
in mild acute pancreatitis)
• Acute hemorrhagic necrotizing pancreatitis
• Supportive care
• Replacement of fluid and electrolytes
• Correction of metabolic abnormalities
• Nutritional support
• Other measures :nasogastric suction and
antibiotics
29. • Agents to inhibit pancreatic secretion
• Have not been found to be useful in altering
the course in acute pancreatitis
• Somatostatin(sandostatin stilamin)
• Glucagon.
• Protease inhibitors (trasylol)
• Surgical therapy
• Inefficiency by internal medicine
• Complication (pancreatic or/and peripancreatic
Infection and abscess)
• Combined wit biliary diseases(Gallstone ASP)
• Diagnosis unclear
30. Surgical approach
Rresection of necrotic tissue and peritoneal lavage
severe, progressive necrotizing pancreatitis or
pancreatic abscess.
Cholecystectomy
recurrent acute pancreatitis and microlithiasis.
Surgical sphincteroplasty of the pancreatic
sphincter
pancreatic sphincter dysfunction
outcome is the same as for the endoscopic pancreatic
sphincterotomy
more invasive
requiring laparotomy and duodenotomy
31. Acute pancreatitis
• Endoscopic therapy
• 1) acute gallstone pancreatitis
• 2) recurrent pancreatitis due to
pancreatic sphincter dysfunction,
• 3) recurrent pancreatitis due to pancreas
divisum.
• The rationale for endoscopic therapy in
each area is the relief of obstruction to
flow of pancreatic juice
52. Tumors of Pancreas
• Treatment of pancreatic carcinoma
• Radical operation
• Pancreatoduodenectomy ---- tumor in pancreatic
head
• Resection of pancreatic body and tail---tumor in
pancreatic body or tail
• Palliative operation: to relieve jaundice
• Biotherapy
53. Tumors of Pancreas
• Pancreatic endocrine neoplasm(PEN)
• Insulinoma
• Arise from B cell
• Symptoms: whipple’s triad
• Spontaneous hypoglycemia accompanied by central
nervous system, psychiatric,or vasomotor symptoms
• Repeated blood sugar levels below 2.8mmol/L(50mg%)
• Relief of symptoms by oral or intravenous
administration of glucose
• Diagnosis: symptom and IRI/G>0.3,B-us,CT,MRI,
Endo-US,Angiography,PTPC,ASVS
• Treatment:operation(resection)
54. Carcinoma of periampulla
• Arise from:
• Papilla of duodenum
• Vater ampulla
• Distal CBD
• Symptom: obstructive
jaundice
• Diagnosis
• Treatment :similar to
pancreatic carcinoma
55. Carcinoma of the Pancreas
• Carcinoma of the pancreas refers to
carcinoma of the exocrine pancreas, almost
always arising from ductal epithelial cells
(adenocarcinoma).
• It is the fourth most common cause of death
in the US and accounts for 5% of all cancer
death.
• Survival rates are 18% at 1 year and only 2%
at 5 years.
• Incidence rates are higher in smokers (2-3 x)
than in nonsmokers; alcohol consumption
imposes a modestly increased risk.
• 65-80 y/o, M>F, B>W.
56.
57. Morphology
• Distribution:
– Head 60%
– Body 15%
– Tail 5%
– Diffuse or widely spread 20%
• small and ill defined or large (8-10 cm), with
extensive local invasion and regional metastases.
• Microscopically, more or less differentiated glandular
patterns (adenocarcinoma) arise from ductal
epithelium, mucous or non-mucous secreting.
58.
59.
60.
61. Clinical features
• fatigue, anorexia, weight loss, and painless jaundice. Pain
may develop later in the course.
• local extension or metastases at the time of diagnosis.
• With tumors in the head of the pancreas, the ampullary
region is invaded, obstructing the outflow of the bile;
patients usually die of obstructive jaundice and
hepatobilliary dysfunction while the tumor is still relatively
small and not widely disseminated.
• In marked contrast, carcinoma of the body and tail of the
pancreas remain silent for some time and may be quite
large and widely disseminated by the time they are
discovered.
• Migratory thrombophlebitis (Trousseau sign) may occur,
particularly with carcinoma of the body and tail.
62. Diagnosis of pancreatic
adenocarcinoma
• Tumor markers, including carcinoembryonic antigen
(CEA), CA 19-9, and CA 125, are associated with
pancreatic cancer but are not accurate enough to rule
in or rule out a clinical diagnosis.
• CT is the principal diagnostic test, although MRI,
endoscopic ultrasonography, and ERCP each have a
role.
• Cytologic and histologic specimens can be obtained
by ERCP. The aim is to determine if curative
resection (pancreaticoduodenectomy – Whipple
procedure) is possible.
64. • About half of the patients who are deemed to have
operable disease by imaging studies are found to
have unresectable tumors at laparatomy.
• In most instances, therapy is palliative, with the aim
of relieving jaundice, pain, and duodenal obstruction.
ERCP with billiary stent placement relieves jaundice
in most patients with unresectable tumors.
• Survival is related to functional status and is usually
6-12 months.
Editor's Notes
Fig. 15.30 C, Mucus-hypersecreting intraductal carcinoma. There is marked dilatation of a major pancreatic duct accompanied by fibrosis and atrophy of the surrounding parenchyma. This duct contained large amounts of mucin in its lumen. ( A and C courtesy of Dr. David S. Klimstra, Memorial Sloan-Kettering Cancer Center)
