diseases of the pancreas victor politi, m.d., medical director svcmc, school of allied health...

Diseases of the Diseases of the PancreasPancreas

Victor Politi, M.D., Medical DirectorVictor Politi, M.D., Medical Director

SVCMC, School of Allied Health SVCMC, School of Allied Health Professions, Physician Assistant Professions, Physician Assistant ProgramProgram

Pancreas anatomyPancreas anatomy

The pancreas is an elongated, tapered The pancreas is an elongated, tapered organ located across the back of the organ located across the back of the abdomen, behind the stomach. abdomen, behind the stomach.

The right side of the organ (called the The right side of the organ (called the head) is the widest part of the organ and head) is the widest part of the organ and lies in the curve of the duodenum (the first lies in the curve of the duodenum (the first section of the small intestine). section of the small intestine).

The tapered left side extends slightly The tapered left side extends slightly upward (called the body of the pancreas) upward (called the body of the pancreas) and ends near the spleen (called the tail).and ends near the spleen (called the tail).

The pancreas is made up of two types of The pancreas is made up of two types of tissue: tissue:

exocrine tissueexocrine tissue– The exocrine tissue secretes digestive enzymes. The exocrine tissue secretes digestive enzymes.

These are secreted into a network of ducts that These are secreted into a network of ducts that join the main pancreatic duct, which runs the join the main pancreatic duct, which runs the length of the pancreas. length of the pancreas.

endocrine tissueendocrine tissue– The endocrine tissue, which consists of the islets The endocrine tissue, which consists of the islets

of Langerhans, secretes hormones into the of Langerhans, secretes hormones into the bloodstream. bloodstream.


The pancreas has digestive and hormonal The pancreas has digestive and hormonal functions: functions: – The enzymes secreted by the exocrine tissue in The enzymes secreted by the exocrine tissue in

the pancreas help break down carbohydrates, the pancreas help break down carbohydrates, fats, and proteins in the duodenum. fats, and proteins in the duodenum.

– These enzymes travel down the pancreatic These enzymes travel down the pancreatic duct into the bile duct in an inactive form. duct into the bile duct in an inactive form.

– When they enter the duodenum, they are When they enter the duodenum, they are activated. activated.

– The exocrine tissue also secretes bicarbonate The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum. to neutralize stomach acid in the duodenum.


The hormones secreted by the The hormones secreted by the endocrine tissue in the pancreas are endocrine tissue in the pancreas are insulin, glucagon (which regulate the insulin, glucagon (which regulate the level of glucose in the blood), level of glucose in the blood), somatostatin (which prevents the somatostatin (which prevents the release of the other two hormones), release of the other two hormones), and many others. and many others.


What is Pancreatitis?What is Pancreatitis?

Pancreatitis is an inflammatory Pancreatitis is an inflammatory process in which pancreatic enzymes process in which pancreatic enzymes autodigest the gland autodigest the gland

Normally, digestive enzymes do not Normally, digestive enzymes do not become active until they reach the become active until they reach the small intestine, where they begin small intestine, where they begin digesting food. digesting food.

But if these enzymes become active But if these enzymes become active inside the pancreas, they start inside the pancreas, they start "digesting" the pancreas itself "digesting" the pancreas itself

The gland can sometimes heal The gland can sometimes heal without any impairment of function without any impairment of function or any morphologic changes. or any morphologic changes. – This process is known as acute This process is known as acute

pancreatitis. pancreatitis. It can recur intermittently, It can recur intermittently,

contributing to the functional and contributing to the functional and morphologic loss of the gland. morphologic loss of the gland. – Recurrent attacks are referred to as Recurrent attacks are referred to as

chronic pancreatitis. chronic pancreatitis.

Acute pancreatitis occurs suddenly Acute pancreatitis occurs suddenly and lasts for a short period of time and lasts for a short period of time and usually resolves. and usually resolves.

Chronic pancreatitis does not resolve Chronic pancreatitis does not resolve itself and results in a slow itself and results in a slow destruction of the pancreas. destruction of the pancreas.

Either form can cause serious Either form can cause serious complications. complications.

In severe cases, bleeding, tissue In severe cases, bleeding, tissue damage, and infection may occur. damage, and infection may occur.

Pseudocysts, accumulations of fluid Pseudocysts, accumulations of fluid and tissue debris, may also develop. and tissue debris, may also develop.

Enzymes and toxins may enter the Enzymes and toxins may enter the bloodstream, injuring the heart, bloodstream, injuring the heart, lungs, and kidneys, or other organs.lungs, and kidneys, or other organs.

Acute edematous Acute edematous pancreatitispancreatitis

Since the pancreas is located in the Since the pancreas is located in the retroperitoneal space with no capsule retroperitoneal space with no capsule -inflammation can spread easily. -inflammation can spread easily.

In acute pancreatitis, parenchymal In acute pancreatitis, parenchymal edema and peripancreatic fat edema and peripancreatic fat necrosis occur first. necrosis occur first.

This process is known as acute This process is known as acute edematous pancreatitis edematous pancreatitis

Necrotizing pancreatitisNecrotizing pancreatitis

When necrosis involves the When necrosis involves the parenchyma, accompanied by parenchyma, accompanied by hemorrhage and dysfunction of the hemorrhage and dysfunction of the gland, the inflammation evolves into gland, the inflammation evolves into hemorrhagic or necrotizing hemorrhagic or necrotizing pancreatitis pancreatitis

Necrotizing pancreatitisNecrotizing pancreatitis

Pseudocysts and pancreatic Pseudocysts and pancreatic abscesses can result from necrotizing abscesses can result from necrotizing pancreatitis because of enzymes pancreatitis because of enzymes being walled off by granulation tissue being walled off by granulation tissue (ie, pseudocyst formation) or (ie, pseudocyst formation) or bacterial seeding of pancreatic or bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic peripancreatic tissue (ie, pancreatic abscess formation). abscess formation).

An ultrasound or, preferably, a CT An ultrasound or, preferably, a CT scan can be used detect both. scan can be used detect both.

The inflammatory process can cause The inflammatory process can cause systemic effects because of the presence of systemic effects because of the presence of cytokines, such as bradykinins and cytokines, such as bradykinins and phospholipase A. phospholipase A.

These cytokines may cause vasodilation, These cytokines may cause vasodilation, increase in vascular permeability, pain, and increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. leukocyte accumulation in the vessel walls.

Fat necrosis may cause hypocalcemia. Fat necrosis may cause hypocalcemia. Pancreatic B cell injury may lead to Pancreatic B cell injury may lead to

hyperglycemia.hyperglycemia.

Mortality/MorbidityMortality/Morbidity

Although acute pancreatitis should be Although acute pancreatitis should be noted, chronic pancreatitis has a more noted, chronic pancreatitis has a more severe presentation as episodes recur.severe presentation as episodes recur.

Acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive depression, hemorrhage, and hypotensive shock all may be systemic manifestations shock all may be systemic manifestations of acute pancreatitis in its most severe of acute pancreatitis in its most severe form.form.

Acute PancreatitisAcute Pancreatitis

Some people have more than one Some people have more than one attack and recover completely after attack and recover completely after each, but acute pancreatitis can be a each, but acute pancreatitis can be a severe, life-threatening illness with severe, life-threatening illness with many complications. many complications.

Acute PancreatitisAcute Pancreatitis

About 80,000 cases occur in the About 80,000 cases occur in the United States each year; some 20 United States each year; some 20 percent of them are severe. percent of them are severe.

Acute pancreatitis occurs more often Acute pancreatitis occurs more often in men than women. in men than women.

The risk for African American persons The risk for African American persons aged 35-64 years is 10 times higher aged 35-64 years is 10 times higher than for any other group. than for any other group.

African American persons are at African American persons are at higher risk than white persons in that higher risk than white persons in that same age group same age group

HistoryHistory

The main presentation of acute The main presentation of acute pancreatitis is epigastric pain or right pancreatitis is epigastric pain or right upper quadrant pain radiating to the upper quadrant pain radiating to the back back – The pain may be severe and may become The pain may be severe and may become

constant--just in the abdomen-or it may constant--just in the abdomen-or it may reach to the back and other areas. reach to the back and other areas.

– It may be sudden and intense or begin as a It may be sudden and intense or begin as a mild pain that gets worse when food is mild pain that gets worse when food is eaten. eaten.

HistoryHistory

Nausea and/or vomitingNausea and/or vomiting FeverFever Query the patient about recent surgeries Query the patient about recent surgeries

and invasive procedures (ie, endoscopic and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or retrograde cholangiopancreatography) or family history of hypertriglyceridemia.family history of hypertriglyceridemia.

Patients frequently have a history of Patients frequently have a history of previous biliary colic and binge alcohol previous biliary colic and binge alcohol consumption, the major causes of acute consumption, the major causes of acute pancreatitis.pancreatitis.

TachycardiaTachycardia TachypneaTachypnea HypotensionHypotension FeverFever Abdominal tenderness, distension, Abdominal tenderness, distension,

guarding, and rigidityguarding, and rigidity

PhysicalPhysical

Mild jaundiceMild jaundice Diminished or absent bowel soundsDiminished or absent bowel sounds Because of contiguous spread of Because of contiguous spread of

inflammation (effusion) from the inflammation (effusion) from the pancreas, lung auscultation may pancreas, lung auscultation may reveal basilar rales, especially in the reveal basilar rales, especially in the left lung.left lung.

Occasionally, in the extremities, Occasionally, in the extremities, muscular spasm may be noted muscular spasm may be noted secondary to hypocalcemia.secondary to hypocalcemia.

PhysicalPhysical

PhysicalPhysical

Severe cases may have a Grey Severe cases may have a Grey Turner sign (ie, bluish discoloration of Turner sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical discoloration of the periumbilical area) caused by the retroperitoneal area) caused by the retroperitoneal leak of blood from the pancreas in leak of blood from the pancreas in hemorrhagic pancreatitis. hemorrhagic pancreatitis.

This is Grey-Turner's sign with This is Grey-Turner's sign with haemorrhage appearing in both haemorrhage appearing in both flanks. It is due to extensive retro-flanks. It is due to extensive retro-peritoneal bleeding and typically peritoneal bleeding and typically occurs in haemorrhagic pancreatitis occurs in haemorrhagic pancreatitis

CausesCauses

The major causes are long-standing The major causes are long-standing alcohol consumption and biliary stone alcohol consumption and biliary stone disease.disease.

CausesCauses In developed countries, the most In developed countries, the most

common cause of acute pancreatitis common cause of acute pancreatitis is alcohol abuseis alcohol abuse– On the cellular level, ethanol leads to On the cellular level, ethanol leads to

intracellular accumulation of digestive intracellular accumulation of digestive enzymes and their premature activation enzymes and their premature activation and release. and release.

– On the ductal level, ethanol increases On the ductal level, ethanol increases the permeability of ductules, which the permeability of ductules, which allow enzymes to reach the allow enzymes to reach the parenchyma, resulting in pancreatic parenchyma, resulting in pancreatic damagedamage

CausesCauses

– Ethanol increases the protein content of Ethanol increases the protein content of the pancreatic juice and decreases the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor bicarbonate levels and trypsin inhibitor concentrations. This leads to the concentrations. This leads to the formation of protein plugs that block the formation of protein plugs that block the pancreatic outflow and obstruction pancreatic outflow and obstruction

CausesCauses

Another major cause of acute Another major cause of acute pancreatitis is biliary stone disease pancreatitis is biliary stone disease (eg, cholelithiasis, (eg, cholelithiasis, choledocholithiasis). choledocholithiasis).

A biliary stone may lodge in the A biliary stone may lodge in the pancreatic duct or ampulla of Vater pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, and obstruct the pancreatic duct, leading to extravasation of enzymes leading to extravasation of enzymes into the parenchyma. into the parenchyma.

Minor causes of acute Minor causes of acute pancreatitis pancreatitis

– Medications, Medications, including azathioprine, corticosteroids, including azathioprine, corticosteroids,

sulfonamides, thiazides, furosemides, NSAIDs, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclinesmercaptopurine, methyldopa, and tetracyclines

– Endoscopic retrograde Endoscopic retrograde cholangiopancreatography (ERCP)cholangiopancreatography (ERCP)

– Hypertriglyceridemia Hypertriglyceridemia (When the triglyceride (TG) level exceeds 1000 (When the triglyceride (TG) level exceeds 1000

mg/U, an episode of pancreatitis is more likely.)mg/U, an episode of pancreatitis is more likely.)

– Peptic ulcer diseasePeptic ulcer disease

– Abdominal or cardiopulmonary bypass surgeryAbdominal or cardiopulmonary bypass surgery may insult the gland by ischemiamay insult the gland by ischemia

– Trauma to the abdomen or back Trauma to the abdomen or back resulting in sudden compression of the gland against resulting in sudden compression of the gland against

the spine posteriorlythe spine posteriorly

– Carcinoma of the pancreasCarcinoma of the pancreas which may lead to pancreatic outflow obstructionwhich may lead to pancreatic outflow obstruction

– Viral infections, including mumps, Viral infections, including mumps, Coxsackievirus, cytomegalovirus (CMV), Coxsackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and hepatitis virus, Epstein-Barr virus (EBV), and rubellarubella

– Bacterial infectionsBacterial infections such as mycoplasmasuch as mycoplasma


– Intestinal parasites, such as ascaris, Intestinal parasites, such as ascaris, which can block the pancreatic outflowwhich can block the pancreatic outflow

– Pancreas divisumPancreas divisum– Scorpion and snake bitesScorpion and snake bites

Vascular factors, such as ischemia or Vascular factors, such as ischemia or vasculitisvasculitis


Acute Pancreatitis - Acute Pancreatitis - DiagnosisDiagnosis

History History Physical examPhysical exam Lab StudiesLab Studies

– During acute attacks, the blood contains at During acute attacks, the blood contains at least three times more amylase and lipase least three times more amylase and lipase than usual. Amylase and lipase are digestive than usual. Amylase and lipase are digestive enzymes formed in the pancreas. enzymes formed in the pancreas.

– Changes may also occur in blood levels of Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, glucose, calcium, magnesium, sodium, potassium, and bicarbonate. potassium, and bicarbonate.

– After the pancreas improves, these levels After the pancreas improves, these levels usually return to normal. usually return to normal.

Imaging StudiesImaging Studies– X-rayX-ray– ultrasound ultrasound – CT CT

Acute Pancreatitis - Acute Pancreatitis - DiagnosisDiagnosis

Lab StudiesLab Studies A complete blood count (CBC) demonstrates A complete blood count (CBC) demonstrates

leukocytosis (WBC >12000) with the differential leukocytosis (WBC >12000) with the differential being shifted towards the segmented being shifted towards the segmented polymorphs.polymorphs.

If blood transfusion is necessary, as in cases of If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and hemorrhagic pancreatitis, obtain type and crossmatch.crossmatch.

Measure blood glucose level because it may be Measure blood glucose level because it may be elevated from B cell injury in the pancreas.elevated from B cell injury in the pancreas.

Obtain measurements for BUN, creatine (Cr), and Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually disturbance in the electrolyte balance is usually found, secondary to third spacing of fluidsfound, secondary to third spacing of fluids

Lab StudiesLab Studies

Measure amylase levels, preferably the Measure amylase levels, preferably the Amylase P, which is more specific to Amylase P, which is more specific to pancreatic pathology. Levels more than 3 pancreatic pathology. Levels more than 3 times higher than normal strongly suggest times higher than normal strongly suggest the diagnosis of acute pancreatitisthe diagnosis of acute pancreatitis

Lipase levels also are elevated and remain Lipase levels also are elevated and remain high for 12 days. In patients with chronic high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol pancreatitis (usually caused by alcohol abuse), lipase may be elevated in the abuse), lipase may be elevated in the presence of a normal serum amylase levelpresence of a normal serum amylase level

Lab StudiesLab Studies

Perform liver function tests (eg, Perform liver function tests (eg, alkaline phosphatase, serum alkaline phosphatase, serum glutamic-pyruvic transaminase glutamic-pyruvic transaminase [SGPT], serum glutamic-oxaloacetic [SGPT], serum glutamic-oxaloacetic transaminase [SGOT], G-GT) and transaminase [SGOT], G-GT) and bilirubin, particularly with biliary bilirubin, particularly with biliary origin pancreatitis. origin pancreatitis.

In chronic pancreatitis the enzymes In chronic pancreatitis the enzymes may be normal or low due to may be normal or low due to pancreas burn outpancreas burn out

Imaging StudiesImaging Studies

Perform a plain KUB (Kidneys, Perform a plain KUB (Kidneys, ureters, bladder) with the patient in ureters, bladder) with the patient in the upright position to exclude viscus the upright position to exclude viscus perforation (ie, air under the perforation (ie, air under the diaphragm). diaphragm).

In cases with a recurrent episode of In cases with a recurrent episode of chronic pancreatitis, peripancreatic chronic pancreatitis, peripancreatic calcifications may be noted. calcifications may be noted.


Ultrasound Ultrasound – can be used as a screening test. can be used as a screening test. – If overlying gas shadows secondary to If overlying gas shadows secondary to

bowel distention are present, it may not bowel distention are present, it may not be specific. be specific.


CT scan is the most reliable imaging CT scan is the most reliable imaging modality in the diagnosis of acute modality in the diagnosis of acute pancreatitis. pancreatitis.

Pancreatitis, Acute - CT Pancreatitis, Acute - CT Scan Scan

Pancreatitis, Chronic - CT Pancreatitis, Chronic - CT Scan Scan

Treatment depends on the severity Treatment depends on the severity of the attack. of the attack.

If no kidney or lung complications If no kidney or lung complications occur, acute pancreatitis usually occur, acute pancreatitis usually improves on its own. improves on its own.

Treatment, in general, is designed to Treatment, in general, is designed to support vital bodily functions and support vital bodily functions and prevent complications. prevent complications.

TreatmentTreatment

Most of the cases presenting to the Most of the cases presenting to the ED are treated conservatively, and ED are treated conservatively, and approximately 80% respond to such approximately 80% respond to such treatment treatment

TreatmentTreatment

Fluid resuscitationFluid resuscitation– Monitor accurate intake/output and Monitor accurate intake/output and

electrolyte balance of the patient.electrolyte balance of the patient.– Crystalloids are used, but other Crystalloids are used, but other

infusions, such as packed red blood cells infusions, such as packed red blood cells (PRBCs), are occasionally administered, (PRBCs), are occasionally administered, particularly in the case of hemorrhagic particularly in the case of hemorrhagic pancreatitis.pancreatitis.

– Central lines and Swan-Ganz catheters Central lines and Swan-Ganz catheters are used in patients with severe fluid are used in patients with severe fluid loss and very low blood pressure.loss and very low blood pressure.

TreatmentTreatment

Patients should have nothing by Patients should have nothing by mouth, and a nasogastric tube mouth, and a nasogastric tube should be inserted to assure an should be inserted to assure an empty stomach and to keep the GI empty stomach and to keep the GI system at rest.system at rest.

Begin parenteral nutrition if the Begin parenteral nutrition if the prognosis is poor and if the patient is prognosis is poor and if the patient is going to be kept in the hospital for going to be kept in the hospital for more than 4 days.more than 4 days.

TreatmentTreatment

Analgesics are used to relieve pain. Analgesics are used to relieve pain. Meperidine is preferred over morphine Meperidine is preferred over morphine because of the greater spastic effect of because of the greater spastic effect of the latter on the sphincter of Oddi.the latter on the sphincter of Oddi.

Antibiotics are used in severe cases Antibiotics are used in severe cases associated with septic shock or when associated with septic shock or when the CT scan indicates that a phlegmon the CT scan indicates that a phlegmon of the pancreas has evolved.of the pancreas has evolved.

TreatmentTreatment

Other conditions, such as biliary Other conditions, such as biliary pancreatitis associated with pancreatitis associated with cholangitis, also need antibiotic cholangitis, also need antibiotic coverage. coverage.

The preferred antibiotics are the The preferred antibiotics are the ones secreted by the biliary system, ones secreted by the biliary system, such as ampicillin and third such as ampicillin and third generation cephalosporins. generation cephalosporins.

TreatmentTreatment

Continuous oxygen saturation should Continuous oxygen saturation should be monitored by pulse oxymetry and be monitored by pulse oxymetry and acidosis should be corrected. When acidosis should be corrected. When tachypnea and pending respiratory tachypnea and pending respiratory failure develops, intubation should be failure develops, intubation should be performed. performed.

Perform CT-guided aspiration of Perform CT-guided aspiration of necrotic areas, if necessary. necrotic areas, if necessary.

An ERCP may be indicated for An ERCP may be indicated for common duct stone removal common duct stone removal

TreatmentTreatment

TreatmentTreatment

Surgical ConsultSurgical Consult– For phlegmon of the pancreasFor phlegmon of the pancreas– Hemorrhagic pancreatitis Hemorrhagic pancreatitis – Patients who fail to improve despite Patients who fail to improve despite

optimal medical treatmentoptimal medical treatment– Patients who push the Ranson score Patients who push the Ranson score

even further even further – Biliary pancreatitis Biliary pancreatitis

MedicationsMedications

AntibioticsAntibiotics– Used to cover the microorganisms that may Used to cover the microorganisms that may

grow in biliary pancreatitis and acute grow in biliary pancreatitis and acute necrotizing pancreatitis. necrotizing pancreatitis.

– The empiric antibiotic regimen usually is based The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. the cause of pancreatic infections.

– Once culture sensitivities are made, Once culture sensitivities are made, adjustments in the antibiotic regimen can be adjustments in the antibiotic regimen can be done. done.

AntibioticsAntibiotics– Ceftriaxone (Rocephin), Unasyn, Ceftriaxone (Rocephin), Unasyn,

Mefoxitin Mefoxitin – Ampicillin (Marcillin, Omnipen),Gent, Ampicillin (Marcillin, Omnipen),Gent,

Flagyl Flagyl AnalgesicsAnalgesics

– Meperidine (Demerol) Meperidine (Demerol)

Ranson ScaleRanson Scale

Ranson developed a series of Ranson developed a series of different criteria for the severity of different criteria for the severity of acute pancreatitis acute pancreatitis

For the following catagories- For the following catagories- – answer each question regarding the answer each question regarding the

patient then add up total score for patient then add up total score for prognosisprognosis If answer is no (o point) If answer is no (o point) If answer is yes (1 point)If answer is yes (1 point)


Present on admissionPresent on admission – Older than 55 yearsOlder than 55 years– WBC higher than 16,000 per mcLWBC higher than 16,000 per mcL– Blood glucose higher than 200 mg/dL Blood glucose higher than 200 mg/dL – Serum lactate dehydrogenase (LDH) Serum lactate dehydrogenase (LDH)

more than 350 IU/L more than 350 IU/L – SGOT (ie, aspartate aminotransferase SGOT (ie, aspartate aminotransferase

[AST]) greater than 250 IU/L[AST]) greater than 250 IU/L


Developing during the first 48 hoursDeveloping during the first 48 hours – Hematocrit fall more than 10% Hematocrit fall more than 10% – BUN increase more than 8 mg/dL BUN increase more than 8 mg/dL – Serum calcium less than 8 mg/dL Serum calcium less than 8 mg/dL – Arterial oxygen saturation less than 60 Arterial oxygen saturation less than 60

mm Hg mm Hg – Base deficit higher than 4 mEq/L Base deficit higher than 4 mEq/L – Estimated fluid sequestration higher Estimated fluid sequestration higher

than 600 mL than 600 mL

Ranson ScoreRanson Score

A Ranson score of 0-2 has a minimal A Ranson score of 0-2 has a minimal mortality rate.mortality rate.

A Ranson score of 3-5 has a 10%-A Ranson score of 3-5 has a 10%-20% mortality rate.20% mortality rate.

A Ranson score higher than 5 has a A Ranson score higher than 5 has a mortality rate of more than 50% and mortality rate of more than 50% and is associated with more systemic is associated with more systemic complicationscomplications

Other Disorders of Other Disorders of the Pancreasthe Pancreas

Pancreatic CancerPancreatic Cancer

Pancreatic cancer is the fourth most Pancreatic cancer is the fourth most common cancer in men and women common cancer in men and women in the US, according to the American in the US, according to the American Cancer Society. Cancer Society.

The majority of pancreatic cancer The majority of pancreatic cancer occurs in people 50 years of age or occurs in people 50 years of age or older older

In the United States, approximately In the United States, approximately 30,000 people die of pancreatic 30,000 people die of pancreatic cancer each year. cancer each year.

Among cancers of the Among cancers of the gastrointestinal tract, it is the third gastrointestinal tract, it is the third most common malignancy and the most common malignancy and the fifth leading cause of cancer-related fifth leading cause of cancer-related mortality. mortality.

About 95% of cancerous tumors of the About 95% of cancerous tumors of the pancreas are adenocarcinomas. pancreas are adenocarcinomas.

Adenocarcinomas usually originate in Adenocarcinomas usually originate in the glandular cells lining the the glandular cells lining the pancreatic duct. pancreatic duct.

Most adenocarcinomas occur in the Most adenocarcinomas occur in the head of the pancreas, the part head of the pancreas, the part nearest the first segment of the small nearest the first segment of the small intestine (duodenum).intestine (duodenum).

Adenocarcinoma usually does not develop Adenocarcinoma usually does not develop before age 50; the average age at before age 50; the average age at diagnosis is 55. diagnosis is 55.

These tumors are nearly twice as common These tumors are nearly twice as common in men as in women and are slightly more in men as in women and are slightly more common in blacks than in whites. common in blacks than in whites.

Adenocarcinoma of the pancreas is 2 to 3 Adenocarcinoma of the pancreas is 2 to 3 times more common in heavy smokers times more common in heavy smokers than in nonsmokers. than in nonsmokers.

People with chronic pancreatitis are at People with chronic pancreatitis are at greater risk as well greater risk as well

The disease is difficult to diagnose in The disease is difficult to diagnose in its early stages, and most patients its early stages, and most patients have incurable disease by the time have incurable disease by the time they present with symptoms. they present with symptoms.

The overall 5-year survival rate for The overall 5-year survival rate for this disease is less than 5%.this disease is less than 5%.

Pancreatic cancers can arise from both the Pancreatic cancers can arise from both the exocrine and endocrine portions of the exocrine and endocrine portions of the pancreas.pancreas.

Of pancreatic tumors, 95% develop from Of pancreatic tumors, 95% develop from the exocrine portion of the pancreas, the exocrine portion of the pancreas, including the ductal epithelium, acinar cells, including the ductal epithelium, acinar cells, connective tissue, and lymphatic tissue. connective tissue, and lymphatic tissue.

Approximately 75% of all pancreatic Approximately 75% of all pancreatic carcinomas occur within the head or neck carcinomas occur within the head or neck of the pancreasof the pancreas

Typically, pancreatic cancer first Typically, pancreatic cancer first metastasizes to regional lymph metastasizes to regional lymph nodes, then to the liver, and less nodes, then to the liver, and less commonly, to the lungs. It can also commonly, to the lungs. It can also directly invade surrounding visceral directly invade surrounding visceral organs such as the duodenum, organs such as the duodenum, stomach, and colon.stomach, and colon.

As in other organs, chronic As in other organs, chronic inflammation is a predisposing factor inflammation is a predisposing factor in the development of pancreatic in the development of pancreatic cancer. cancer.

Patients with chronic pancreatitis Patients with chronic pancreatitis from alcohol, especially those with from alcohol, especially those with familial forms, have much higher familial forms, have much higher incidence and an earlier age of onset incidence and an earlier age of onset of pancreatic carcinoma.of pancreatic carcinoma.

CystadenocarcinomaCystadenocarcinoma

Cystadenocarcinoma of the pancreas Cystadenocarcinoma of the pancreas is a rare type of pancreatic cancer is a rare type of pancreatic cancer that develops from a fluid-filled that develops from a fluid-filled noncancerous tumor called a noncancerous tumor called a cystadenoma. cystadenoma.

It often causes upper abdominal pain It often causes upper abdominal pain and may grow large enough for a and may grow large enough for a doctor to feel it through the doctor to feel it through the abdominal wall. abdominal wall.

Mortality/MorbidityMortality/Morbidity

Pancreatic carcinoma is unfortunately Pancreatic carcinoma is unfortunately usually a fatal disease. usually a fatal disease.

Most patients eventually succumb to Most patients eventually succumb to the consequences of local invasion the consequences of local invasion and metastatic cancer, and true long-and metastatic cancer, and true long-term cures are rare. term cures are rare.

Endocrine and cystic neoplasms of the Endocrine and cystic neoplasms of the pancreas have much better survival pancreas have much better survival rates than pancreatic rates than pancreatic adenocarcinoma. adenocarcinoma.

HistoryHistory

Unfortunately, the initial symptoms are Unfortunately, the initial symptoms are often quite nonspecific and subtle in often quite nonspecific and subtle in onset. onset.

Patients typically report the gradual Patients typically report the gradual onset of nonspecific symptoms such as onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, anorexia, malaise, nausea, fatigue, and midepigastric or back pain.and midepigastric or back pain.

Significant weight loss is a Significant weight loss is a characteristic feature of pancreatic characteristic feature of pancreatic cancer.cancer.

HistoryHistory

Pain is the most common presenting Pain is the most common presenting symptom in patients with pancreatic symptom in patients with pancreatic cancer. cancer.

Typically, it is midepigastric in Typically, it is midepigastric in location, with radiation of the pain location, with radiation of the pain sometimes occurring to the mid- or sometimes occurring to the mid- or lower-back region. lower-back region.

HistoryHistory

The most characteristic sign of The most characteristic sign of pancreatic carcinoma of the head of the pancreatic carcinoma of the head of the pancreas is painless obstructive pancreas is painless obstructive jaundice.jaundice.– Patients with this sign may come to Patients with this sign may come to

medical attention before their tumor grows medical attention before their tumor grows large enough to cause abdominal pain.large enough to cause abdominal pain.

Pruritus may accompany obstructive Pruritus may accompany obstructive jaundice. jaundice.

HistoryHistory

Migratory thrombophlebitis (ie, Trousseau Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis also occur sign) and venous thrombosis also occur with higher frequency in patients with with higher frequency in patients with pancreatic cancer. pancreatic cancer.

Depression is reported to be more Depression is reported to be more common in patients with pancreatic common in patients with pancreatic cancer than in patients with other cancer than in patients with other abdominal tumors. abdominal tumors. – In some patients, depression may be the most In some patients, depression may be the most

prominent presenting symptom. prominent presenting symptom.

PhysicalPhysical

The physical examination findings in The physical examination findings in a patient with pancreatic cancer are a patient with pancreatic cancer are usually limited to evidence of usually limited to evidence of significant weight loss and some significant weight loss and some mild-to-moderate midepigastric mild-to-moderate midepigastric tenderness. tenderness.

Patients with jaundice may have a Patients with jaundice may have a palpable gallbladder (ie, Courvoisier palpable gallbladder (ie, Courvoisier sign) and may have evidence of skin sign) and may have evidence of skin excoriations from pruritus.excoriations from pruritus.

PhysicalPhysical

Patients presenting with end-stage Patients presenting with end-stage disease may have ascites, a palpable disease may have ascites, a palpable abdominal mass, hepatomegaly from abdominal mass, hepatomegaly from liver metastases, or splenomegaly liver metastases, or splenomegaly from portal vein obstruction.from portal vein obstruction.

LabsLabs

– The laboratory findings in patients with The laboratory findings in patients with pancreatic cancer are usually pancreatic cancer are usually nonspecific. nonspecific. As with many chronic diseases, a mild As with many chronic diseases, a mild

normochromic anemia may be present.normochromic anemia may be present.

– Thrombocytosis is also sometimes Thrombocytosis is also sometimes observed in patients with cancer. observed in patients with cancer.

– The major useful tumor marker for The major useful tumor marker for pancreatic carcinoma is carbohydrate pancreatic carcinoma is carbohydrate antigen 19-9 (CA 19-9). antigen 19-9 (CA 19-9).

Gross section of an adenocarcinoma of the Gross section of an adenocarcinoma of the pancreas measuring 5 X 6 cm resected from the pancreas measuring 5 X 6 cm resected from the pancreatic body and tail. Although the tumor was pancreatic body and tail. Although the tumor was considered to have been fully resected and had considered to have been fully resected and had not spread to any nodes, the patient died of not spread to any nodes, the patient died of recurrent cancer within 1 year recurrent cancer within 1 year

CTshowing a pancreatic adenocarcinoma CTshowing a pancreatic adenocarcinoma of the pancreatic head. The gallbladder of the pancreatic head. The gallbladder (gb) is distended because of biliary (gb) is distended because of biliary obstruction. The superior mesenteric obstruction. The superior mesenteric artery (sma) is surrounded by tumor, artery (sma) is surrounded by tumor, making this an unresectable T4 lesion. making this an unresectable T4 lesion.

TreatmentTreatment

The only therapy that has definitively The only therapy that has definitively been shown to increase the survival of been shown to increase the survival of patients with pancreatic cancer is patients with pancreatic cancer is surgical resection. surgical resection.

For patients with disease not amenable For patients with disease not amenable to curative resection, little has been to curative resection, little has been shown to significantly impact survival. shown to significantly impact survival. – The mean survival for patients with The mean survival for patients with

unresectable disease remains 4-6 months. unresectable disease remains 4-6 months.

Other therapies for pancreatic cancer Other therapies for pancreatic cancer should include palliation of the major should include palliation of the major symptoms of disease.symptoms of disease.

ChemotherapyChemotherapy Radiation therapyRadiation therapy

TreatmentTreatment

Pancreaticoduodenectomy Pancreaticoduodenectomy (Whipple operation)(Whipple operation)

The standard operation for carcinoma The standard operation for carcinoma of the head of the pancreas is a of the head of the pancreas is a pancreaticoduodenectomy (Whipple pancreaticoduodenectomy (Whipple procedure). procedure).

This operation involves resection of This operation involves resection of the pancreatic head; the first, second, the pancreatic head; the first, second, and third portions of the duodenum; and third portions of the duodenum; the distal antrum; and the distal the distal antrum; and the distal common bile duct common bile duct

Deterrence/PreventionDeterrence/Prevention Smoking is the most significant reversible risk factor Smoking is the most significant reversible risk factor

for pancreatic cancer. Estimates indicate that smoking for pancreatic cancer. Estimates indicate that smoking accounts for up to 30% of cases of pancreatic cancer.accounts for up to 30% of cases of pancreatic cancer.

A diet high in energy intake and low in fresh fruits and A diet high in energy intake and low in fresh fruits and vegetables increases the risk of pancreatic cancer.vegetables increases the risk of pancreatic cancer.

Alcohol consumption does not increase the risk of Alcohol consumption does not increase the risk of pancreatic cancer unless it leads to chronic pancreatic cancer unless it leads to chronic pancreatitis. A multicenter study of more than 2000 pancreatitis. A multicenter study of more than 2000 patients with chronic pancreatitis showed a 26-fold patients with chronic pancreatitis showed a 26-fold increase in the risk of developing pancreatic cancer.increase in the risk of developing pancreatic cancer.

PrognosisPrognosis

The mean survival for patients with The mean survival for patients with unresectable disease remains 4-6 months, unresectable disease remains 4-6 months, with a 5-year survival rate of less than 3%.with a 5-year survival rate of less than 3%.

The median survival for patients who The median survival for patients who undergo successful resection (only 20% of undergo successful resection (only 20% of patients) is approximately 12-19 months, patients) is approximately 12-19 months, with a 5-year survival rate of 15-20%. with a 5-year survival rate of 15-20%.

Although discouraging, these results are Although discouraging, these results are still markedly better than those for still markedly better than those for patients with unresectable pancreatic patients with unresectable pancreatic carcinoma.carcinoma.

ManagementManagement The management of pancreatic carcinoma is a The management of pancreatic carcinoma is a

multidisciplinary process. multidisciplinary process. Most patients initially present to their primary Most patients initially present to their primary

care practitioner with general symptoms such as care practitioner with general symptoms such as abdominal pain, weight loss, or fatigue. abdominal pain, weight loss, or fatigue.

Patients may also be seen initially by a Patients may also be seen initially by a gastroenterologist if they present with obstructive gastroenterologist if they present with obstructive jaundice. jaundice.

Typically, the management of pancreatic cancer Typically, the management of pancreatic cancer would entail consultations with a would entail consultations with a gastroenterologist, medical oncologist, general gastroenterologist, medical oncologist, general surgeon or surgical oncologist, and possibly a surgeon or surgical oncologist, and possibly a radiation oncologist. radiation oncologist.

Benign Tumors of the Benign Tumors of the PancreasPancreas

– InsulinomaInsulinoma – – rare pancreatic tumorrare pancreatic tumor secretes insulinsecretes insulin 10% cancerous10% cancerous

– GastrinomaGastrinoma – – secretes above average levels of gastrinsecretes above average levels of gastrin can cause peptic ulcerscan cause peptic ulcers 50% cancerous50% cancerous

– GlucagonomaGlucagonoma – – secretes glucagonsecretes glucagon Causes rashCauses rash 80% cancerous80% cancerous

InsulinomaInsulinoma

An insulinoma is a rare type of An insulinoma is a rare type of pancreatic tumor that secretes pancreatic tumor that secretes insulin, a hormone that lowers the insulin, a hormone that lowers the levels of sugar (glucose) in the blood.levels of sugar (glucose) in the blood.

Only 10% of insulinomas are Only 10% of insulinomas are cancerous.cancerous.

Symptoms result from low levels of sugar in Symptoms result from low levels of sugar in the blood. the blood.

The symptoms include faintness, weakness, The symptoms include faintness, weakness, trembling, awareness of the heartbeat trembling, awareness of the heartbeat (palpitations), sweating, nervousness, and (palpitations), sweating, nervousness, and profound hunger. profound hunger.

Other symptoms include headache, Other symptoms include headache, confusion, vision abnormalities, confusion, vision abnormalities, unsteadiness, and marked changes in unsteadiness, and marked changes in personality. personality.

The low levels of sugar in the blood may The low levels of sugar in the blood may even lead to a loss of consciousness, even lead to a loss of consciousness, seizures, and coma.seizures, and coma.


Very low levels of sugar and high levels Very low levels of sugar and high levels of insulin in the blood can indicate the of insulin in the blood can indicate the presence of an insulinoma. presence of an insulinoma.

The location must be pinpointed. The location must be pinpointed. Imaging tests—such as CT, ultrasound, Imaging tests—such as CT, ultrasound, and arteriography of the intestinal and arteriography of the intestinal arteries—can be used to locate the arteries—can be used to locate the tumor, but sometimes exploratory tumor, but sometimes exploratory surgery is needed surgery is needed


The primary treatment for an The primary treatment for an insulinoma is surgical removal - cure insulinoma is surgical removal - cure rate of about 90%. rate of about 90%.

When the insulinoma cannot be When the insulinoma cannot be completely removed and symptoms completely removed and symptoms continue, several drugs (for example, continue, several drugs (for example, streptozocin (Zanosar) and streptozocin (Zanosar) and octreotide (Sandostatin)can be octreotide (Sandostatin)can be helpful helpful


GASTRINOMAGASTRINOMA

A gastrinoma is a tumor usually in A gastrinoma is a tumor usually in the pancreas or duodenum (the first the pancreas or duodenum (the first segment of the small intestine) that segment of the small intestine) that produces excessive levels of the produces excessive levels of the hormone gastrin, which stimulates hormone gastrin, which stimulates the stomach to secrete acid and the stomach to secrete acid and enzymes, causing peptic ulcers.enzymes, causing peptic ulcers.

Most people with gastrinomas have Most people with gastrinomas have several tumors clustered in or near the several tumors clustered in or near the pancreas. pancreas.

About half of the tumors are cancerous. About half of the tumors are cancerous. Sometimes a gastrinoma occurs as part Sometimes a gastrinoma occurs as part

of multiple endocrine neoplasia, a of multiple endocrine neoplasia, a hereditary disorder in which tumors hereditary disorder in which tumors arise from the cells of various arise from the cells of various endocrine glands, such as the insulin endocrine glands, such as the insulin producing cells of the pancreas.producing cells of the pancreas.


The excess gastrin secreted by the The excess gastrin secreted by the gastrinoma causes Zollinger-Ellison gastrinoma causes Zollinger-Ellison syndrome (ZES)syndrome (ZES)– a rare disorder that causes tumors in a rare disorder that causes tumors in

the pancreas and duodenum and the pancreas and duodenum and aggressive peptic ulcers in the stomach aggressive peptic ulcers in the stomach and duodenum and duodenum


Synonyms of Zollinger Synonyms of Zollinger Ellison SyndromeEllison Syndrome

Gastrinoma Gastrinoma Pancreatic Ulcerogenic Tumor Pancreatic Ulcerogenic Tumor

Syndrome Syndrome Z-E Syndrome Z-E Syndrome ZES ZES

However, as many as 25% of people However, as many as 25% of people with (ZES) Zollinger-Ellison syndrome with (ZES) Zollinger-Ellison syndrome may not have an ulcer when the may not have an ulcer when the diagnosis is made. diagnosis is made.

Rupture, bleeding, and obstruction of Rupture, bleeding, and obstruction of the intestine can occur and are life the intestine can occur and are life threatening.threatening.


For more than half of the people with For more than half of the people with a gastrinoma, symptoms are no a gastrinoma, symptoms are no worse than those experienced by worse than those experienced by people with ordinary peptic ulcer people with ordinary peptic ulcer disease. disease.

In 25 to 40% of people, diarrhea is In 25 to 40% of people, diarrhea is the first symptom. the first symptom.


a gastrinoma is suspected when a a gastrinoma is suspected when a person has frequent peptic ulcers or person has frequent peptic ulcers or several peptic ulcers that do not several peptic ulcers that do not respond to the usual ulcer respond to the usual ulcer treatments. treatments.

Blood tests to detect abnormally high Blood tests to detect abnormally high levels of gastrin are the most reliable levels of gastrin are the most reliable diagnostic tests. diagnostic tests.


High doses of proton pump inhibitors High doses of proton pump inhibitors may be effective for reducing acid levels may be effective for reducing acid levels and relieving symptoms temporarily. and relieving symptoms temporarily.

About 20% of people who do not have About 20% of people who do not have multiple endocrine neoplasia can be multiple endocrine neoplasia can be cured with surgical removal of the cured with surgical removal of the gastrinoma. gastrinoma.

If these treatments fail, a total If these treatments fail, a total gastrectomy may be necessary. gastrectomy may be necessary.


This operation does not remove the tumor, This operation does not remove the tumor, but the gastrin can no longer create ulcers but the gastrin can no longer create ulcers after the acid-producing stomach is after the acid-producing stomach is removed. removed.

If the stomach is removed, daily oral iron If the stomach is removed, daily oral iron and calcium supplements and monthly and calcium supplements and monthly injections of vitamin B12 are needed, injections of vitamin B12 are needed, because absorption of these nutrients is because absorption of these nutrients is impaired when stomach juices that prepare impaired when stomach juices that prepare these nutrients for absorption are no longer these nutrients for absorption are no longer available. available.


GastrinomaGastrinoma

If cancerous tumors have spread to If cancerous tumors have spread to other parts of the body, other parts of the body, chemotherapy may help reduce the chemotherapy may help reduce the number of tumor cells and the levels number of tumor cells and the levels of gastrin in the blood. of gastrin in the blood.

However, such therapy does not cure However, such therapy does not cure the cancer, which is ultimately fatal.the cancer, which is ultimately fatal.


GlucagonomaGlucagonoma

A glucagonoma is a tumor of the A glucagonoma is a tumor of the pancreas that produces the hormone pancreas that produces the hormone glucagon, which raises the level of glucagon, which raises the level of sugar (glucose) in the blood and sugar (glucose) in the blood and produces a distinctive rash.produces a distinctive rash.

About 80% of glucagonomas are About 80% of glucagonomas are cancerous. cancerous.

However, they grow slowly, and However, they grow slowly, and many people survive for 15 years or many people survive for 15 years or more after the diagnosis. more after the diagnosis.

The average age at which symptoms The average age at which symptoms begin is 50. begin is 50.

About 80% of people with About 80% of people with glucagonomas are women.glucagonomas are women.


High levels of glucagon in the blood High levels of glucagon in the blood cause the symptoms of diabetes cause the symptoms of diabetes mellitus. mellitus.

Often, the person loses weight. Often, the person loses weight. In 90% of people, the most distinctive In 90% of people, the most distinctive

features are a chronic reddish brown features are a chronic reddish brown skin rash (necrolytic migratory skin rash (necrolytic migratory erythema) and a smooth, shiny, bright erythema) and a smooth, shiny, bright red-orange tongue. red-orange tongue.


The mouth also may have cracks at The mouth also may have cracks at the corners. the corners.

The rash, which causes scaling, The rash, which causes scaling, starts in the groin and moves to the starts in the groin and moves to the buttocks, forearms, and legs.buttocks, forearms, and legs.


Glucagonoma syndrome -- Glucagonoma syndrome -- necrolytic migratory erythemanecrolytic migratory erythema

The diagnosis is made by identifying The diagnosis is made by identifying high levels of glucagon in the blood high levels of glucagon in the blood and then locating the tumor by and then locating the tumor by arteriography arteriography


Ideally, the tumor is surgically removed, Ideally, the tumor is surgically removed, which eliminates all symptoms. which eliminates all symptoms.

However, if removal is not possible or if However, if removal is not possible or if the tumor has spread, chemotherapy the tumor has spread, chemotherapy may reduce the levels of glucagon and may reduce the levels of glucagon and lessen the symptoms. lessen the symptoms.

However, chemotherapy does not However, chemotherapy does not improve survival. improve survival.


The drug octreotide also reduces The drug octreotide also reduces glucagon levels, may clear up the glucagon levels, may clear up the rash, and may restore appetite, rash, and may restore appetite, facilitating weight gain. facilitating weight gain.

Octreotide may elevate the levels of Octreotide may elevate the levels of sugar in the blood even more. sugar in the blood even more.


Zinc ointment may be used to treat Zinc ointment may be used to treat the skin rash. the skin rash.

Sometimes the rash is treated with Sometimes the rash is treated with intravenous amino acids or fatty intravenous amino acids or fatty acids.acids.


diseases of the pancreas victor politi, m.d., medical director svcmc, school of allied health...

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