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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
12-Feb-16 3Diseases of the pancreas
Rich periacinar network that drain into 5 nodal groups
Superior nodes
Anterior nodes
Inferior nodes
Posterior PD nodes
Splenic nodes
12-Feb-16 8Diseases of the pancreas
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
12-Feb-16 9Diseases of the pancreas
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
12-Feb-16 10Diseases of the pancreas
Alpha cells produce glucagon.
Beta cells produce insulin.
Delta cells produce somatostatin.
12-Feb-16 11Diseases of the pancreas
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.
12-Feb-16 12Diseases of the pancreas
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
12-Feb-16 14Diseases of the pancreas
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
12-Feb-16 15Diseases of the pancreas
Secondary (idiopathic) Diabetes Mellitus Chronic pancreatitis
Post pancreatectomy
Hormonal tumours (acromegaly, Cushing’s)
Drugs (corticosteroids)
Haemochromatosis
Genetic disorders e.g. lipodystrophy
Gestational DM
12-Feb-16 17Diseases of the pancreas
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.
12-Feb-16 18Diseases of the pancreas
Young
Rare
Linked to chrom. 7 & 20
Autosomal dominant
Mild hyperglycemia
12-Feb-16 19Diseases of the pancreas
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
12-Feb-16 20Diseases of the pancreas
Microangiopathy:
Thickening of basement membrane
- Renal Glomeruli nephropathy
- Retinaretinopathy
- Nerves neuropathy
12-Feb-16 22Diseases of the pancreas
Atherosclerosis:
- Myocardial infarction
- Cerebral stroke .
- Aortic aneurysm .
- Gangrene of lower extremities
12-Feb-16 23Diseases of the pancreas
Neuropathy:
- Symmetric peripheral neuropathy .
- Sexual impotence .
- Bowel and bladder dysfunction.
12-Feb-16 25Diseases of the pancreas
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.
12-Feb-16 26Diseases of the pancreas
Inflammatory process in the pancreas
Types:
1. Acute pancreatitis
2. Acute relapsing pancreatitis
3. Chronic relapsing pancreatitis
4. Chronic pancreatitis
12-Feb-16 28Diseases of the pancreas
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
12-Feb-16 29Diseases of the pancreas
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
12-Feb-16 30Diseases of the pancreas
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
12-Feb-16 33Diseases of the pancreas
IV fluids
Analgesia
Supportive management
Surgery- to relieve biliary obstruction- to drain collection
12-Feb-16 34Diseases of the pancreas
Benign v/s malignant
Exocrine v/s Endocrine ( Pancreatic islet cell tumors )
12-Feb-16 36Diseases of the pancreas
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)
12-Feb-16 37Diseases of the pancreas
Usually diabetic patient
Weight loss
Dermatitis
Anemia
Stomatitis
70% malignant
12-Feb-16 38Diseases of the pancreas
Peptic ulceration
Abdominal pain
Diarrhea
GI bleed
Perforation of ulcer
Dehydration and malnutrition
Diagnosis: 12 hour overnight acid output and increased serum gastrin
12-Feb-16 39Diseases of the pancreas
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.
12-Feb-16 40Diseases of the pancreas
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
12-Feb-16 42Diseases of the pancreas
Symptoms: Early non-specific Anorexia Weight loss Abdominal discomfort Nausea Specific symptoms Jaundice Purities Moderate pain DM Unexplained attack of pancreatitis
12-Feb-16 43Diseases of the pancreas
Physical findings Jaundice
Enlarged liver
Courvoisier`s law
Palpable mass)
Ascites
Virchow-Troisier node
Sister Josephs node
Wasting
12-Feb-16 44Diseases of the pancreas
Ultrasound
CT scan
MRI
Cholangiography
E.R.C.P.
P.T.C.
M.R.C.P.
12-Feb-16 46Diseases of the pancreas
Palliation Jaundice ( pruritis)
Pain
Duodenal obstruction
Curative Resection of the tumor (Whipple procedure /
Pancreaticoduodenectomy )
12-Feb-16 47Diseases of the pancreas
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
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.
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