lecture chronic pancreatitis
TRANSCRIPT
CHRONIC PANCREATITIS Chronic pancreatitis is a progressive
inflammation of pancreas related to the process of autolysis, that presents by pain, by violation of exocrine and endocrine functions of gland with the result of fibrosis of organ and high risk of malignization
ETIOLOGY AND PATHOGENESIS Gallstone disease is the most frequent cause
of chronic pancreatitis (70%). Pathogenesis of cholangiogenic pancreatitis
is hypertension in pancreatic duct and reflux of infected bile or secretion of duodenum.
Spasms and stenosis of the Vater's papilla are instrumental in causing reflux. As result occur activates the enzymes of pancreas and progress inflammation. Development of pancreatitis potentiates infection.
CAUSES The CAUSES of such violations are - due to the
attack of acute pancreatitis in past, alcoholism, traumas of gland, pathology of its vessels, gastroduodenal ulcers, gastritis or duodenostasis, hyperparathyroidism, hyperlipidemia, virus infections, idiopathic pancreatitis.
CLASSIFICATION AND ETIOLOGY CHRONIC CALCIFIC
PANCREATITIS
CHRONIC OBSTRUCTIVE PANCREATITIS
CHRONIC INFLAMMATORY PANCREATITIS
CHRONIC AUTOIMMUNE
PANCREATITIS
ASYMPTOMATIC PANCREATIC
FIBROSIS
ALCOHOL PANCREATIC TUMORS
UNKNOWN Autoimmune disorders (primary sclerosing cholangitis)
CHRONIC ALCOHOLIC
HEREDITARY
DUCTAL STRICTURE
SJOGREN'S SYNDROME
Endemic in asymptomatic residents in tropical climates
TROPICAL GALLSTONE OR TRAUMA-INDUCED
Primary biliary cirrhosis
HYPERLIPIDEMIA
PANCREAS DIVISUM
HYPERCALCEMIADRUG-INDUCED
IDIOPATHIC
CLASSIFICATION (by O.O. Shalitnov) Chronic fibrous pancreatitis without violation of patency
of main pancreatic duct. Chronic fibrous pancreatitis with violation of patency of
main pancreatic duct and hypertension of pancreatic juice.
Chronic fibrous-degenerative pancreatitis.TAKING INTO ACCOUNT CLINICAL FEATURES
Chronic recurrent pancreatitis. Chronic pain pancreatitis Chronic painless (latent) pancreatitis. Chronic pseudo tumor-like pancreatitis. Chronic cholecystocholangiopancreatitis (cholangiogenic
pancreatitis). Chronic indurative pancreatitis.
PATHOMORPHOLOGYThe morphological changes in pancreas in chronic pancreatitis are mainly due to the development of degenerative process and atrophy of parenchyma
CLINICAL MANAGEMENT As the progress of the disease has cyclic
character with the periodic changes of remission and acute exacerbations.
Violation of exocrine and endocrine functions of pancreas, determine polymorphism of symptoms that are characteristic of the period of exacerbations pancreatitis
PAIN
Patients with chronic pancreatitis complaining on dull pain that is in the epigastric and radiates to the back
PAINThe pathophysiology of the pain
associated with increase intraductal pressures, neural inflammation, formation of pseudocysts, bile duct strictures, and duodenal obstruction.
MALABSORPTIONWith sufficient loss of functional exocrine pancreas,
diarrhea, steatorrhea, and azotorrhea can develop.
Because of the 10-fold reserve of exocrine
pancreaticenzymes, malabsorption occurs only after 90%
of the functioning exocrine cell mass is lost. Pancreatic insufficiency resulting from alcohol-induced chronic
pancreatitis usually takes 10 to 20 years to develop. The
secretion of lipase is usually diminished earlier than the
secretion of the proteolytic enzymes, and as a result,
steatorrhea precedes protein-aqueous diarrhea.
CHRONIC UPPER ABDOMINAL PAIN AND WEIGHT LOSS should suggest a diagnosis of chronic pancreatitis.
Weight loss occurs with malabsorption, and of the fat-soluble vitamins develop.
Postprandial pancreatic bicarbonate secretion is
diminished. The duodenal pH may decrease (pH<4)
and an acidic milieu with precipitation of bile salts
and inactivation of pancreatic enzymes results in a
decrease intestinal digestion.
ENDOCRINE INSUFFICIENCYGlucose intolerance frequently develops early
Endocrine insufficiency develops in up to 60% of patients, but in general not until after the diagnosis of chronic pancreatitis has been made.
STOOL EXAMINATION Steatorrhea and creatorrhea are characteristic for Chronic Pancreatitis (plenty of muscle fibres).Examination of endocrine function includes: 1) determination of sugar in blood and urine (hyperglycemia and glycosuria);2) radioimmunoassay of hormones (insulin, C-peptide and glucagon).SKIAGRAPHY survey of organs of abdominal cavity in two projections exposes the existent calculus in the ducts and calcification of parenchyma of pancreas.Relaxation duodenography. The development of "horseshoe" of duodenum and change of its mucosa can be seen Cholecystocholangiography the purpose of diagnosis of gallstone disease and damaging of biliary tract is conducted
Ultrasonic examinationSonography is one of the basic methods of diagnosis. With the help of symptoms of chronic pancreatitis it is possible to expose inequality of contours of gland, increase of density of its parenchyma, it sizes, dilatation of pancreatic duct and wirsungolithiasis or presence of calculus in parenchyma. It is necessary to inspect gallbladder, liver and extra-hepatic biliary tracts for diagnosis of gallstone disease and choledocholithiasis
Endoscopic retrograde cholangiopancreatography
Endoscopic retrograde cholangiopancreatography
CT-scan showing multiple, calcified intraductal stones in a patient with
chronic pancreatitis
CT-scan
Routine Laboratory Findings Secondary anemia to malnutrition can occur in chronic
pancreatitis, to the steatorrhea of chronic pancreatitis are also uncommon.
Leukocytosis can occur during acute exacerbations of chronic pancreatitis.
Serum amylase and lipase concentrations may be elevated in chronic pancreatitis. Even during an acute attack with seemingly significant abdominal pain, the amylase and lipase levels may be only slightly elevated because of depletion of the exocrine pancreatic parenchyma.
Abnormalities of liver function, manifested by elevations in the liver enzymes, may be a result of either liver disease or obstruction of the common bile duct.
Fibrotic process may result from compression by a pseudo cyst or mass in the head of the pancreas.
TESTS FOR CHRONIC PANCREATITISMEASUREMENT OF PANCREATIC PRODUCTS IN BLOOD
I A Enzymes
B Pancreatic polypeptide
MEASUREMENT OF PANCREATIC EXOCRINE SECRETIONII A Direct measurements
1 Enzymes
2 Bicarbonate
B Indirect measurement
1 Bentiromide test
2 Schilling test
3 Fecal fat, chymotrypsin, or elastase concentration
4 [14C]-olein absorption
IMAGING TECHNIQUES III A Plain film radiography of abdomen
B Ultrasonography
C Computed tomography
D Endoscopic retrograde cholangiopancreatography
E Magnetic resonance cholangiopancreatography
F Endoscopic ultrasonography
G Relaxation duodenogram
CLINICAL VARIANTS Chronic recurrent pancreatitis. The changes of periods of acute
attacks and remission are characteristic for it. Chronic pain pancreatitis. Intensive pain in the superior half of
abdomen with radiation to loins and region of heart is inherent for this form. Also belt-like pain often appears.
Chronic painless (latent) pancreatitis. In this patients the pain is either absent in general or arises after the intake of spicy rich food and can be insignificantly expressed Violation of exocrine or endocrine function of pancreas present.
Chronic pseudo tumor-like pancreatitis. Dull pain in the projection of head of pancreas, dyspeptic disorders and syndrome of biliary hypertension are its clinical signs.
Chronic cholangiogenic pancreatitis. The features of chronic cholecystitis and cholelithiasis and features of pancreatitis are characteristic for this form.
Chronic indurative pancreatitis. In patients with this diseases symptoms of exocrine and endocrine insufficiency of pancreas are present. With sclerosis of head of pancreas with involvement by the process of common bile duct, development of mechanical jaundice is possible.
COMPLICATIONS OF CHRONIC PANCREATITIS
INTRAPANCREATIC COMPLICATIONSPseudo cysts
Duodenal or gastric obstruction
Thrombosis of splenic vein
Abscess
Perforation
Erosion into visceral artery
Inflammatory mass in head of pancreas
Bile duct stenosis
Portal vein thrombosis
Duodenal obstruction
Duct strictures and/or stones
Ductal hypertension and dilatationPancreatic carcinoma
EXTRAPANCREATIC COMPLICATIONS
1.Pancreatic duct leak with ascites or fistula
2.Pseudocyst extension beyond sac into mediastinum, retroperitoneum, lateral pericolic spaces, pelvis
SURGICAL METHODS OF TREATMENT OF CHRONIC PANCREATITIS
The major indications for treatment are: 1. Intractable pain; 2. Fear of carcinoma; 3. The development of structural complications
Indication to operation and its volume depend on the form of pancreatitis. Acute exacerbation of chronic cholangiogenic pancreatitis with presence of gallstone disease must be seen as an indication for operation in first 24 hours since the onset of disease
OPERATIVE TREATMENT IS DONE IN CASES OF:
calcinosis pancreas with the expressed pain syndrome; violation of patency of duct of pancreas; presence of cyst or fistula, resistance to conservative
therapy in 2-4 months; mechanical jaundice due to tubular stenosis of distal part
of common bile duct; compression and thrombosis of portal vein; gallstone disease complicated by chronic pancreatitis; ulcer disease of stomach and duodenum complicated by
secondary pancreatitis; duodenostasis, complicated by chronic pancreatitis;
CHOLECYSTECTOMY is performed in presence of calculous cholecystitis and secondary pancreatitis, acute destructive cholecystitis or
hydropsy of gall-bladder.
CHOLEDOCHOLITHOTOMY is performed for patients with cholangiolithiasis:
Papillosphincterotomy: a) execute transduodenal with papillosphinctero-
plasty; b) endoscopy is recommended in the isolated
cases or connected with choledocholithiasis stenosis of large duodenal papilla, fixed calculus of large papilla of duodenum.
Wirsungoplasty is plastic of main pancreatic duct. Lately in the isolated stenosis of entrance of main pancreatic duct. Execute transduodenal or endoscopic methods
Papillosphincterotomy, papillosphincteroplasty
PANCREATOJEJUNOSTOMY:
a) LONGITUDINAL (it is performed in considerable dilatation of pancreatic duct)
Technique of pancreaticojejunal drainage originally described by Puestow and Gillesby. The distal pancreas was mobilized, the tail amputated, the duct opened longitudinally, and the pancreas was
partially invaginated into a Roux-en-Y jejunal limb
RESECTION OF PANCREAS MAY BE: a) distal; b) pancreatoduodenal (PDR) c) total duodenopancreatectomy (execute
in case of fibrous-degenerative pancreatitis)
b) Distal (by Duval) with the resection of distal part of pancreas
Procedure: Pancreatoduodenectomy
Operations on the nervous system are used in case of pain of chronic
indurative pancreatitis, resistant to conservative therapy:
a) left-sided splanchnicectomy; b) bilateral pectoral splanchnicectomy and
sympathectomy; c) postganglionic neurotomy of pancreas
Anatomic landmarks for videoscopic transthoracic left splanchnicectomy. Diagram of the left plural cavity after clipping and division of the splanchnic nerves, showing the sympathetic chain, the intercostal vessels, and the aorta
CYSTS OF PANCREAS
Cyst of pancreas is a cavity, filled by fluid (pancreatic juice, exudation, pus), which has epithelium on internal surface.
Pseudocyst (false cyst) is a cavity in pancreas which appears as a result of its destruction, limited by capsule, that does not have epithelium on internal surface
Etiology and pathogenesisTHE CAUSES OF PSEUDOCYSTS ARE:destructive pancreatitis, traumas of pancreas, occlusion of
Wirsung's duct by parasite, calculus, tumors, innate anomalies of development.
TRUE CYSTS ARE: innate cysts which are anomalic in development; retention
cysts which develop as a result of obstruction to outflow of pancreatic juice, cystadenoma and cystadenocarcinoma
The mechanism of development of pseudocysts consists necrosis of gland, obliterated normal outflow of its secretions, destruction of walls of pancreatic ducts, inflammation reaction of surrounding organs which form the walls of pseudocyst
PATHOMORPHOLOGY Morphologically the cysts of pancreas are
divided into: pseudocysts, retention cyst, single and multiple
Pseudocysts are fresh and old. Epithelium in pseudocysts is absent.
Retention cysts is seen in connection with an obturated duct
Innate cysts are multiple and shallow. Rarely there are echinococcus cysts
localized in the area of head of pancreas
CLASSIFICATION (by A.N. Bakulev and V.V. Vinogradov) I. Innate cysts of pancreas: II. Inflammatory cysts:
Pseudocysts Retention cysts
III. Traumatic cysts: IV. Parasitic cysts: V. Neoplasty cysts:
Pathomorphologically cysts are divided into: The true cyst Pseudocysts
CLINICAL MANAGEMENT PAIN (dull, permanent, cramp-like and belt-like). It is localized
in right hypochondrium, epigastric area, left hypochondrium Pain radiates into the back, left shoulder-blade, shoulder and spine.
DYSPEPSIA characterised by nausea and vomiting. FUNCTIONAL INSUFFICIENCY OF PANCREAS by disorders of
exocrine and endocrine insufficiency, alternating diarrhea with constipation, steatorrhea and creatorrhea, secondary diabetes
COMPRESSION SYNDROME. As a result of compression of neighbouring organs are: partial obstruction of common bile duct (mechanical jaundice), veins (portal hypertension), splenic vein (splenomegaly)
During the CLINICAL EXAMINATION patients with large cysts there is marked asymmetry of abdomen in the epigastria and mesogastric areas.
SONOGRAPHY examination shows echofree formation
SONOGRAPHY
A contrast-injected CT- scan reveals active bleeding (B) into a pseudocyst (arrows)
Contrast roentgenologic EXAMINATION OF STOMACH and duodenum in the cyst of head of pancreas reveals "horseshoe" duodenum
CHOLECYSTOCHOLANGIOGRAPHY exposes calculous cholecystitis and cholelithiasis
RETROGRADE PANCREATOCHOLANGIOGRAPHY exposes the deformed, extended pancreatic duct, there can be cavity of cyst by the contrast matter
LABORATORY EXAMINATIONS exposes hyperamylasemia, steatorrhea and creatorrhea, sometimes - hyperglycemia and glycosuria
COMPLICATIONS 1. Perforation into free abdominal cavity and
peritonitis 2. Perforation into stomach, duodenum, small or large
intestine is accompanied by decrease of size of cyst 3. Suppuration of cystic fluid 4. Erosive bleeding appears suddenly and is
accompanied by the symptoms of internal bleeding (general weakness, dizziness, melena)
5. Mechanical jaundice arises as a result of compression of cyst on the terminal part of choledochus
6. Portal hypertension as a result of compression of portal vein
7. Reactive exudation pleurisy 8. Malignization
DIFFERENTIAL DIAGNOSIS Cancer of pancreas. Aneurysm of abdominal
aorta The cyst of mesentery The cyst of liver
DIAGNOSIS PROGRAMME Anamnesis. Biochemical blood test
(amylase, sugar, bilirubin). Analysis of urine for
diastase. Coprograma. Sonography. Contrasting skiagraphy of
stomach and duodenum Retrograde
pancreatocholangiography. Computer tomography.
TACTICS AND CHOICE OF TREATMENT METHODConservative treatment. Treatment of acute or chronic pancreatitis is conducted in accordance with principles.
Surgical treatment Is the method of choice of treatment of cysts of pancreas. The choice of treatment method depends on the stage of development of pancreatic cysts.
SURGICAL TREATMENT
MORE FREQUENTLY SURGEON MAKES CYSTOJEJUNOSTOMY ON THE ELIMINATED LOOP OF SMALL INTESTINE BY ROUX
DISTAL PANCREATECTOMY, MARSUPIALIZATION MARSUPIALIZATION -
opening and suturing of cyst capsule to the parietal peritoneum and skin is used infrequently (because suppuration of cyst is can lead to sepsis peritonotis).
External and internal draining of cyst and radical operations are applied:
a) enucleation of cysts;b) distal resection of
pancreas with cyst
CANCER OF PANCREAS
The cancer of pancreas is a malignant tumor of epithelium tissue. Its incidence among all malignant tumors is 10 %. Etiology and pathogenesisShortage of vitamins, especially В and C, harmful habits (alcohol, smoking), presence of carcinogenic matters in food (nitrite, nitrates) is one of etiological factors. The cancer of pancreas can arise due to prolonged chronic pancreatitis.
Molecular biology of pancreatic cancer
PATHOMORPHOLOGY The cancer is usually localized in the head
(80%). Rarely - in the area of body or tail. A tumor has resembles epithelium of
pancreatic ducts or epithelium of acinous tissue, sometimes - the Langerhans' islet.
Adenocarcinoma (60%) is exposed microscopically, carcinoid (32-35%), epidermoid cancer or skir is seldom met.
Classification of cancer of pancreas after the TNM stages
T1 - tumor size of diameter 2 cm, is confined interior parts of pan creas. T2 - tumor, spreads the gland and spreads to surrounding cellular tissue
and duodenum. T3 - tumor, that spreads to neighbouring organs (stomach, spleen,
colon). N0 - absent signs of metastatic damage of regional lymph nodes. N1 - metastases in regional lymph nodes. M0 - absent signs of remote metastases. M1 - remote metastases present.
GROUP BY STAGES Stage I - Tl NO MO. Stage II - T2 NO MO. Stage III- T3 N0-1 MO. Stage IV is some T, some N, Ml. The cancer of pancreas metastasises rapidly by lymphogenic route
parapancreatic lymph nodes, and afterwards - into the liver. The hematogenic metastases are into the lungs, bones, kidneys and brain Also possible are remote metastases of Virhov's, Shnitsler's, Krukenberg's.
Clinical management The symptoms of cancer of pancreas depend on localization
of tumor and the relations of pathological process with surrounding organs.
PAIN is a permanent symptom which affects 90 % of patients. Pain localization in epigastria and radiation to the back.
The LOSS OF WEIGHT makes progress and in a short duration of time becomes considerable enough.
JAUNDICE is characteristic of the cancer of head of pancreas, as a result of obliteration of common bile duct. Bilirubinemia grows gradually, due to direct bilirubin.
On palpation of abdomen COURVOISIER'S sign is positive (large gallbladder).
Obliteration of duct of pancreas causes DYSPEPTIC DISORDERS: belching, nausea, vomiting, diarrhea.
Distributions of tumor on duodenum and narrowing of its lumen show up by the signs of STENOSIS (belching and vomiting)
By sonography examination and computer tomography one can expose sign of mechanical jaundice by localization the tumor in the head.
Scanning is an informing method of examination with the use of 75 Se-methionine.
During laparoscopy is visualized dissemination into peritoneum and its metastatic focus in liver.
The changes of main duct of pancreas as segmental stenosis or rupture are done on retrograde endoscopic pancreatography
Skiagraphy of gastro-intestinal tract can expose the cancer of head of pancreas
Computer tomography, sonography
ENDOSCOPIC HOLANGIOPANCREATOGRAPHY
Radionuclide octreotide scan demonstrating pancreatic endocrine tumor in the body of the pancreas (arrow).
TACTICS AND CHOICE OF TREATMENT METHOD
Treatment of cancer of pancreas is mainly surgical. The choice of method and volume of operation depends on localization of tumor, stage of process, age of patient and his general condition.
Radical surgical treatment performed only in 15-20 % of patients. Pancreatoduodenal resection is the method of choice of operation in patients with the cancer of head of pancreas.
Pancreaticoduodenectomy (Whipple Resection)
PALLIATIVE OPERATIONS
Surgical palliation in patients with cancer of the head of the pancreas is directed toward relief of obstructive jaundice, gastric obstruction, and pain.
Patients with cancer of body and tail are less likely to have jaundice or duodenal obstruction, but pain is often significant.
Obstructive jaundice develops in about 70 percent of patients with pancreatic cancer. Cholecystojejunostomy and choledochojejunostomy are both safe and are the procedures of choice to relieve the biliary obstruction
Hepaticojejunostomy