Pancreas short note by S.

Wichien (SNG KKU)

Anatomy -retroperitoneal organ -oblique position--slope upward -75-100 gm -15-20 cm Region 1.head -nest in c-loop -uncinate+head--wrap rt of PV 2.neck -L1,2 -directly over portal v 3.body+4.tail -ant to splenic a/v Pancreatic duct 1.duct of wirsung -main duct -usually fuse 2 at pancreatic head -normal 4 mm 2.duct of santorini -accessory duct -60%--minor papilla -30%--blind accessory duct -10%--not fuse2--as major drain :pancreatic divisum :inadequate drain--pancreatitis :Tx--sphincterotomy minor papilla Vascular -sup ant/post PDA <--GDA -inf ant/post PDA <--SMA -inf pancreatic a <--SMA Vein -sup ant/post PDV--> PV -inf post PDV--> SMV inf ant PDV + rt GEV + mCV-->SMV -SV--> PV Lymphatic -SMA & celiac node Nerve SympT5-9splancnic nceliac gg Parasympvagus n Physiology 1.Pancreatic enzyme Carbo -amylase : starchglucose Protein Endopeptidase -trypsinogenektrypsin -chymotrypsinogenekchymotrypsin -proelastaseekelastase Exopeptidase -procarboxy peptidaseekcarboxy p Fat -pancreatic lipase -phospholipase A2 -choles esterase 2.hormone 1.insulin 2.glucagon 3.somatostatin 4.pancrea polypeptide 5.amylin (IAPP) 6.pancreastatin 7.ghrelin b cell alpha cell delta cell PP cell/F cell b cell b cell epsilon cell

4--inh exocrine 5--counterregulate insulin 6--dec insulin/somato/exocrine, inc glucagon 7--dec insulin *normal pancreas 20% = can survive Heterotopic pancreas -abnormal location of pancreatic tissue -exocrine+endocrine -stomach/duodenum/meckel -submucosal lesion, yellow, central umbilical -Sx in symptom/incidental finding Annular pancreas -congenital anomaly -band of ventral pancreas -duodenal obstruction - infant 40yr -1st choiceduodenoduodenostomy -not reect bandpancreatic fistula

Pancreas short note by S.Wichien (SNG KKU)

Acute pancreatitis -inflam.ds of pancreas -little/no fibrosis of gland Etiology 1.Biliary tract ds --stone -common channel hypothesis -sphinc of oddi icompetent--duo reflux -colocalized--inactive-->active enz 2.alcohol --blockage mechanism -spasm sphincter of oddi -elevate enz prot 3.tumor 4.iatrogenic -ERCP -pancreatic biopsy -bile duct exploration -distal gastrectomy -B.II gastrectomy 5.drugs 6.infection -mumps,m.pneumoniae,coxsackie 7.hyperlipidemia -hype TGA 8.miscellaneous -hyperparathyroid-->hypercal -ascaris, c.sinensis -hereditary pancreatitismutate PRSS1 -pancreatic divisum -azotemia -vasculitis -triniidadian scorpion S+S -knife pain/boring through to back -relief by leaning forward -pleural effusion--Lt side -intravascu fluid loss into retroperi -bleeding from necrotize pancreatitis :cullen sign, grey turner sign :fox sign (inguinal echymosis) Serum amylase -peak within hour -3-5 d -no relate to severity False +ve -gut obstr/perforate -DU/intraabdo inflam False -ve -hyperlipidemia -severe pancreatitis serum lipase--highest spec Severity assess 1.early prognosis sign A.Ranson criteria 1-2--mortality 0 3-5--mortaliy 10-20% >7--mortality >50% B.APACHE II ->7--severe pancreatitis 1.non GS Age>55 wBc>16000 glC>200 lDh>350 AST>250 2.GS Age>70 wBc>18000 glC>220 lDh>400 AST>250 hct fall10 BUN elevate >5 ca<8 PaO2<60 base deficit>4 fluid >6 l hct fall10 BUN elevate >2 ca<8 fluid >4 l base deficit>5

2.biochemical marker Assess severity--mild or severe -CRP -uri trypsinogen activate peptide--TAP 3.CT -gold std for assess severity CT severity index Barthaza A=normal B=pancreatic enlarge C=pancreatic inflammation D=1 collection E=>=2 collection Necrosis No <30% 30-50% >50% CTSI 0-3 4-6 7-10 c/p 8% 35% 92% mortality 3% 6% 27%

point 0 1 2 3 4 0 2 4 6

Pancreas short note by S.Wichien (SNG KKU)

Acute pancreatitis Tx Mild pancreatitis resting pancreas -restrict oral food--3-7d :if improve--low prot/low fat diet -NG suction ,H2 blocker -fluid balance -avoid morphine--Oddi spasm -no document infect--no ATB Severe pancreatitis -may develop ARDS :PLP-A2 :ICAM-1,PMN,sub-P,chemokine -peritoneal lavage--unclear Infection

-most common of death

I/C of infection -retroperi air -CT,u/s guide FNA +ve

Sterile necrosis 3 degree aggressive 1.no systemic c/p -as mild pancreatitis 2.systemic c/p, suspect infection -FNA confirm 3.very ill, hi APACHE/Ranson -aggressive debridement Pancreatic abscess -2-6 wk -external drainage Biliary pancreatitis 1.Urgent intervention -48-72hr 2.Delayed intervention ->72hr, but in hospitalization favor 1 as 2 cholecystectomy + CBD clearance (in obstructive pancreatitis) hi risk--ERCP 3.obstruction persist>24hr -emer ERCP+EST+remove stone routine ERCP--not use suspect persist CBD stone--imaging

Pancreas short note by S.Wichien (SNG KKU)

Chronic pancreatitis risk ca 10x Etiology -alcohol 70% -idiopathic 20% -other--hereditary,hyperparathyroid hyperTGA,autoimmune,divisum Classification 1.chronic calcify (lithogenic) P -alcoholic,hereditary,hyperlipid, hypercal,drug induce,idiopathic 2.chronic obstructive P -pancreatic tumor -stricture -pancreatic divisum -GS related 3.chronic inflam P -unknown (diffuse fibrosis and loss of acinar c mononuclear infiltrate the gland) 4.chronic autoimmune P -asso PSC,PBC,sjogren synd 5.asymp pancreatic fibrosis -alcoholic,Tropical (nutrition) P (diffuse perilobar fibrosis) Tropical (nutrition) pancreatitis -indonesia,india,africa -toxic product--cassava root :+HCL-->hydrocyanide -asso mutate PSTI or SPINK1 gene Hereditary pancreatitis -AD -chronic nonalcoholic pancreatitis -childhood/adolescence -calcify pancreas, pancreatic d obstr -PRSS1, SPINK1, CFTR gene Idiopathic pancreatitis -no obvious cause -young adult, no fam.hx -spon.gene mutation Histology -nodular scarring -perilobular fibrosis--panc stellate cell -loss of acinar cell -dilate ductular structure -stone formation--caco3 :lithostathine are inhibited (lithostathine--inh caco3 formation) Imaging for 1.dx 2.assess severity 3.c/p 4.Tx option u/s -screening methods EUS -can small lesion <1cm -can cytology,chemical sample ERCP -Dx + can Tx maneuver -invasive procedure -gold std for chronic pancreatitis CT -earliest change--dilate 2duct and heterogenous paren change MRCP -hi risk pt S+S 1.pain -steady,constant pain -penetrate to back -exacerbate by eating/alc (alc-->tempo relief-->more severe) -typical flex abdo,sit with hip flexd -n/v, anorexia Pain etiology 1.ductal HT--stricture,stone 2.retro.inflam--chronic pain 3.acute inc duct P--acute exacerbate Strategy to relief pain 1.decompress secretory compartment 2.resect focus of inflam change 3.neural ablative procedure Burned out pancreatitis -dec/absent pain over period of year -appear symp of exo/endo.def -correlate with mild-->severe form 2.malabsorp+wt loss -<10%exocrine fxndiarrhea/steatorrhea -lipase def earlier > trypsin def 3.apancreatic diabetes--DM type3 -<20%endocrine fxnimpair glc metabo -hypoglycemia > hypergly -brittle diabetes--difficult to control -global def 3 H--insulin+gluca+PP

Pancreas short note by S.Wichien (SNG KKU)

Chronic pancreatitis (cont) Lab 1.blood -lipase/amylase--endo.fxn -PP (test meal)--exo.fxn 2.secretion Direct -enz,bicarbonate Indirect 1.bentiromide test -urine PABA -proteolytic metabol p-aminobenzoic 2.schilling test -urine cobalamine -absorb b12 by panc exocrine 3.fecal fat/chymotrypsin/elastase 4.14CO2-olein absorption -triolein breath test Chronic pancreatitis c/p 1.pseudocyst -most common c/p -acute = 3-4wk chronic = >6wk -non-epi wall of granu/fibrosis -50%--can spon resolve ->6cm--less resolve -compress adjacent organ :SMV/PV thrombosis :pseudoaneurysm of GDA -perforate--peritonitis/bleeding Tx 1.asymp--expectant Tx 2.suspect infect--FNA -if infect--sx/percu drain 3.fail1,symp -internal drain > ext drain (fistula) Methods 1.Percu.cath based -transgastric puncture -stent placement--cysto-gastros 2.Endoscopic -transgastric/duo puncture -stent placement 3.Sx -cystogastros -Roux en Y cystojejunos -cystoduodenos 4.ERCP--in commu c duct system Transpapillary stent 1.direct into pseudocyst or 2.left across duct leakage 5.resection -tail pancreas --distal pancreatectomy 2.pancreatic ascitis -subacute progress abdo.swelling paracenthesis -fluid hi prot >25g/dl -hi amylase pancreatic pleural effusion -fluid track into chest -internal pancreatic fistula Non-sx Tx -antisecretory--octreotide -bowel rest,PPN -pancreatic plural effusion--ICD Sx Tx -ERCP--locate leak site +/- stent -Roux en Y pancreaticojejunostomy -distal pancreatectomy 3.pancreatic enteric fistula Transverse/splenic flexure colon -most common -colonic bleeding/sepsis -require sx Stomach/duodenum -close spontaneous -persist as internal fistula 4.pancreatic head mass -30% of advance CP -inflammatn process -severe pain -stenosis of distal CBD/duo/PD/PV -can transform to dysplasia Tx -DPPHR 5.PV/SV thrombosis -consequence of 4 -varices formation -SV thrombosis + GV -->lt side or sinsitral portal HT Tx -splenectomy--prevent EGV bleeding

Pancreas short note by S.Wichien (SNG KKU)

Chronic pancreatitis Tx 1.analgesia -narcotic -gabapentin -stop alcohol 2.enzyme Tx Non enteric coat (conventional) -bind CCK releasing peptide -downregulate release CCK Enteric coat -protect acid degradation 3.antisecretory Tx -somatostatin--inh exocrine + CCK :200 mcg sc q 8 hr 4.neurolytic Tx -celiac plexus neurolysis -alcohol injection -EUS guide -short life (6mo) 5.endoscopic Tx Pancreatic duct stent -prox P duct stenosis -decomp P duct leak -drain P pseudocyst Pancreatic divisum -minor papilla sphincterotomy Chronic pancreatitis Sx 1.sphincteroplasty -sclerosing papillitis :pancreatitis :passage of gall stone -endoscopic or transduodenal 2.drainage procedures Peustow procedure -side to side Roux en Y PJ -in ductal HT--max.diameter 6mm 3.resection procedure Distal pancreatectomy -40-80% -focal change to body,tail -no signi.duct dilatation -hi recurrece 95%Distal pancreatectomy -sclerotic dz--small duct -preserve in PD groove Proximal pancreatectomy -whipple--std or PPPD Total pancreatectomy -no pain relief than PD -hyper/hypoglycemia Hybrid procedure 1.DPPHR -Duodenum Preserving Pancreatic HR -Beger procedure -resect neck,subtotal head -preserve duodenum,CBD -roux limb of jejunum 2.LR-LPJ -Local Resection pancreatic head c longitudinal PJ -Frey procedure -side to side Roux en Y PJ -complete decompress entire duct :excavation head :distal pancreatic dochotomy

-preserve pancreatic neck -preserve post capsule -not touch PV/SMV

3.OPPHR -Organ preserving PHR -excavation pancreatic head

-without LPJ

4.denervation procedure -symptomatic relies -poor candidate for resect/drainage -Neurolytic tx--neural ablation -Direct infiltraton of celiac GG -Operative celiac gangliectomy -Transhiatal splanchniectomy -Transthorasic splanchniectomy -Videoscopic transthorasicsplanchniectomy

Pancreas short note by S.Wichien (SNG KKU)

Cystic neoplasm 1.pseudocyst -most common cystic lesion -fuid--hi amylase 2.serous cystadenoma -benign lesion -50% asymptom -older women -1/2--head, 1/2--neck/body/tail -spong appearance -microcystic -fluid--low CEA(<200) ,amylase -asso VHL 17% Imaging -well circum,small septate central scar,calcification Sx -symptomatic ->= 4 cm -can not r/o ca 3.mucinous cystadenoma/ca -benign/malignant -2/3 body/tail -fluid--hi CEA suggest ca Imaging -thick wall, not commu PD -may nodule,calcify in wall -viscous mucin Patho -submu--highly cellular stroma of spindle cell w elongate nuclei -->similar--ovarian stroma (key pathology) Tx -resection = Tx of choice -distal pancreatectomy 4.IPMN -head pancreas -arise in PD -recurrent pancreatitis Classification 1.main duct typeca 75% 2.branch duct typeca 20% -uncinate/less malignancy 3.combined type Pre-op -EUS,MRCP,ERCP ERCP -mucin extrude from ampulla -->fish eye lesion Sx Main duct typeSx -extent resection based on intraop -can intraop P.ductoscope / frozen Branch duct typeca f/u if - no symp -<3 cm -no mural nodule/thick septum 5.solid pseudopapillary tumor -solid cystic tumor -young women -not true epi lining -histo similar NE tumor, but not stain 6.NE tumor 7.pancreatic lymphoma

Pancreas short note by S.Wichien (SNG KKU)

Ca pancreas -worst prognosis of all malignant -80% of pt asso DM -new onset DM--can early manifest -2/3--head/uncinate Patho -ductal adenoca--75% -adenosquamous ca -acinar cell ca--large tumor Risk -fam hx -smoking 2x -chro pancreatitis 20x--esp fam.CP Genetic -K-ras oncogene--most common -HER2/neu oncogene -p53,p16,DPC4,BRCA2 Precursor lesion -Pancreatic intraepi neoplasia -PanIN 1A,1B,2,3 Staging T1 <=2cm T2 >2cm T3 beyond pancreas, no celiac involve T4 celiac/sma involve N1 LN metas Diagnostic study CT scan -dx/staging of choice -accuracy for unresect - hi--90-95% accuracy for resect - low--80% Unresect -distant metas -SMA/hepatic a involved -LN enlarge outside pancreas -ascites -PV/SMV not C/I PET scan -distinguish CP vs ca EUS -detect small lesion, miss by CT -no mass but hi suspicion -can transluminal bx -sens for PV/smv invasion , not sma Accuracy for resecectable 80% -but intra-op 20% = unresectable Dx lap+u/s -inc resectable to 98% Use in -tumor>4cm -body/tail -equivocal of metas/ascites in CT -ca19-9>1000 Periampullary adenoma Excised locally 1.endoscopic 2.longtitu.duodenotomy -2-3 mm margin I/C -<2cm -no malignant on bx -no invasion duo.wall--EUS can help FAP asso -hi incidence of ca -procedure of choice = whipple

Pancreas short note by S.Wichien (SNG KKU)

Whipple sx Finding C/I resection -liver metas, any size -celiac LN involves -peritoneal implant -hepatic hilar LN involves Finding not C/I resection -invade duo/stomach -invade pancreatic LN -invade porta LN, that can remove Procedure -incision :midline incision--xiphoid-umbilicus :bilat subcostal incision -assess resectability -open gastrohepatic lig--celiac LN -assess base of T.mesocolon,MC a. -mobilize off asc/hep flexure colon -kocher maneuver -SMV is identify -dissect up toward inf of neck of P -ligate GE vv--prevent traction injury -assess aberrant RHA :from sma--post of P--parallel PV :palpate HD lig -assess porta hepatis -identify GDA--ligate -HA is retracted medially CBD is retracted laterally -dissect ant surface of PV -mobilize GB,ligate cystic a/d -remove GB -dissect CHD circumferentially -PPPD--divide duo 2cm distal to pylo classic--antrum -divide jejunum beyond lig of Treitz -divide CHD just above cystic d and dissect down to sup duodenum -divide P neck ant to PV -ligate fragile v br to PV/smv Reconstruction step 1st--pancreas 2nd--bile duct 3rd--duo/stomach 1.pancreaticojejunostomy :duct to mucosa vs invagination :end to side vs end to end 2.choledochojejunostomy :10 cm jejunal limb from panc anas 3.duodenojejunostomy :10-15 cm from biliary anas Whipple c/p Cause of death -sepsis -hemorrhage -cardiovas event 1.delay gastric emptying time -conservative tx -erythromycin 2.pancreatic fistula Prevention -end to side vs end to end -duct to mucosa--large duct -invaginated--small duct -jejunum vs stomach -pancreatic duct stent -octreotide :in hi risk--duct<3mm :unclear 3.hemorrhage -dissect portal v

Pancreas short note by S.Wichien (SNG KKU)

Zollinger Ellison Synd (ZES) -uncontrol secrete of abnormal gastrin by duodenal or pancreatic NE tumor -80%=sporadic--solitary-->90% cure 20%=inherited--MEN1--multiple -80% in gastrinoma triangle :cystic d--jxn 2/3 duo--jxn neck/body -50%=malignant 2clinical syndrome by epi hyperplasia & giant gastric fold 1.ZES 2.Menetrier disease Symptom -epigastric pain -GERD -diarrhea -PU (90% of pt) Typical ulcer=proximal duodenum Atyp ulcer=distal duo,jejunum,multi DDx -recurrent PU -secrete diarrhea -gastric rugal hypertrophy -esophagitis c stricture -bleeding or perforate ulcer -familial ulcer -ulcer w hyperca -gastric carcinoid Dx -gastrin level (false+ve=antisecrete) :>1000 pg/mL :if equivocal case--secretin stimu test -BAO>15mEq/h, >5mEq/h (PU sx) -secretin stimulation test :confirm test :iv bolus of secretin (2u/kg) :gastrin level before/after injection :inc serum gastrin of 200 pg/ml -serum ca,parathyroid level r/o men1 Imaging 1.u/s--not very sensitive 2.CT--detect lesion>2cm 3.MRI 4.EUS -more sensitive -may miss smaller lesion -confuse normal LN 5.Somatostatin R.Scintigraphy--SRS -octreotide scan -imaging of choice -gastrinoma cell--type2 somato R 6.Dx angiography and transhepatic selective venous sampling of portal s. -a.catheter--gastroduodenal,splenic -v.catheter--hepatic v -inject secretin--gastrin in hepatic v -signi elevate in hepatic v gastrin indicate tumor is supplied by inject a. *most important locate tumor is intraop EL Rx 1.sporadic (nonfamilial) gastrinoma -usually solitary -intra op u/s -should sx resection--possible cure -explor gastrinoma triangle+pancreas -other site :liver,stomach,SMB,mesen,pelvis -if can't locate, should consider :longitudinal duodenotomy Operable dz Solitary tumor in pancreas -->pancreatic resection Involved pancreas not main duct -->enucleation Submu of duodenum -->full thickness excision duo wall exised all LN in passaro triangle Inoperable dz or can't localization -highly selective vagotomy -5FU, doxorubicin Liver metas -if can resect 1tumor-->metastec 2.MEN1 -rarely cure by operation -multiple lesion -HSV in unresectable gastrinoma

Pancreas short note by S.Wichien (SNG KKU)

Insulinoma -90% = benign/solitary/sporadic 10% = malignant/MEN1/multifoci -most common panc endocrine T whipple triads 1.BS<50 2.relief symptom by glc 3.symp fasting hypoglycemia Symptom 1.autonomic nervous overactivity -fatigue,weak,hunger,tremor,sweating 2.CNS disturbance -anxiety,agitate,coma,delirium Pathognomonic finding -serum insulin > 5mcU/mL (during sym hypoglycemic) -elevated c-peptide level :r/o admin of insulin or oral drug (proinsulin-->insulin+c-peptide) Dx ratio -Bl insulin:glc > 0.4 Localization -CT,MRI--locate 50-60% -selective angiogram Portovenous sampling insulin level -intra a.injection of ca (0.025meq/kg) (ca release insulin) -into GDa,SMa,RHa or Spa -obtain insulin from rt hepatic v Tx -typical cure by enucleation -close to panc duct and >2cm may require a distal pancreatectomy or pancreaticoduodenectomy Glucagonoma -DM asso dermatitis -malnutrition -body/tail Dermatitis -classic necrolytic migratory erythema -cyclic migration -lower abdo, perieum, perioral,feet -spreading margin, healing center Dx -serum glucagon >500 pg/ml Tx -control DM, PPN, octreotide -distal pancreatectomy+/-splenectomy Somatostatinoma -GS -DM--inh insulin -steatorrhea--inh exo Clinical -abdo.pain--25% -jx--25% -cholelithesis--19% Location -peiampullar area--60% -prox.pancreas / PD groove Dx -serum somatostatin level >10 ng/ml Tx -complete excision tumor -cholecystectomy VIPoma WDHA synd -watery diarrhea -hypokalemia -achlorhydria -most com--distal pancreas -most--outside pancreas Clinical -massive(5L/d), intermittent diarrhea Dx -serum VIP level :multiple time-->episodic dz -EUS--most sens -CT Tx -somatostatin--control diarrhea Outside pancreas -palliative debulking -HA embolization Nonfxn islet cell tumor -usually malignant -clinical silent until size produce symp -large tumor, metas when dx -marker of lesion = elevate PP -grow slowly -asso VHL

Pancreas short note by S.Wichien (SNG KKU)

Summary Gastrinoma Insulinoma Glucagonama Somatostatinoma VIPoma Location Pazzaro 1/3+1/3+1/3 body/tail head tail Benign:malignant 50:50 90:10 30:70 10:90 50:50 Lab Sporadic:MEN1 gastrin>1000pg/ml 80:20 insulin/glc>0.4 90:10 glucagon>500 pg/ml somato>10 ng/ml VIP>200 pg/ml