Pancreatic Pancreatic diseasesdiseases

WU JIAN WU JIAN Department of hepatobiliary Surgery Department of hepatobiliary Surgery

First Affiliated HospitalFirst Affiliated HospitalZhejiang University School of MedicineZhejiang University School of Medicine

Pancreas: Anatomy and Pancreas: Anatomy and PhysiologyPhysiology

Retroperitoneal organRetroperitoneal organ 15-20cm in length15-20cm in length Head, neck, body and tailHead, neck, body and tail Uncinate process: curves behind the superior mesenteriUncinate process: curves behind the superior mesenteric vessels c vessels

PosteriorPosterior L1-2 vertebral cL1-2 vertebral columnolumn AnteriorAnterior stomach, omenstomach, omentumtum RightRight DuodenumDuodenum LeftLeft Splenic hilumSplenic hilum

Neighborhood of the Neighborhood of the pancreaspancreas

Main duct : Wirsung ( 1642)Main duct : Wirsung ( 1642) Ampula: Vater (1720)Ampula: Vater (1720) Accessory duct : Santorini( 173Accessory duct : Santorini( 1734)4)

Pancreas: blood Pancreas: blood supplysupply

HEADHEAD ：： Superior pancreatoduodSuperior pancreatoduodenal A. (from gastroduodenal A. (from gastroduodenal A.)enal A.) Inferior pancreatoduodeInferior pancreatoduodenal A. (from SMA)nal A. (from SMA) BODY AND TAILBODY AND TAIL ：： superior pancreatic A.superior pancreatic A. pancreatic magna A.pancreatic magna A. transverse pancreatic A.transverse pancreatic A. VEINVEIN ：： to splenic vein ,SMV and to splenic vein ,SMV and portal veinportal vein

Lymphatic drainage of Lymphatic drainage of pancreaspancreas

Common Common pathwaypathway

PhysiologyPhysiology

ExocrineExocrine ：： pancreatic juicepancreatic juice 。。 HCOHCO33-- and digestive enzyme and digestive enzyme EndocrineEndocrine ：：

A cellA cell ：： glycagonglycagon B cellB cell ：： insulininsulin D cell D cell ：： somatostatinsomatostatin G cell G cell ：： gastringastrin

Acute PancreatitisAcute Pancreatitis Chronic PancreatitisChronic Pancreatitis Pancreatic cancerPancreatic cancer Periampullary cancPeriampullary canc

erer Endocrinal tumor Endocrinal tumor

AcuteAcute PancreatitisPancreatitis

Common acute abdomenCommon acute abdomen Local inflammatory change in Local inflammatory change in

pancreaspancreas Systemic changeSystemic change Life-threatening inflammatory Life-threatening inflammatory

disorder of the pancreasdisorder of the pancreas Abrupt onset and Abrupt onset and

unpredictable courseunpredictable course Variable severity and durationVariable severity and duration Self-limited but remarkable Self-limited but remarkable

morbidity and mortalitymorbidity and mortality

EtiologyEtiology Biliary tract diseaseBiliary tract disease Abuse of ethanolAbuse of ethanol Endoscopic retrograde cholangioEndoscopic retrograde cholangio

pancreatographypancreatography Trauma and operation Trauma and operation Ischemia of pancreasIschemia of pancreas DrugsDrugs Idiopathic pancreatitisIdiopathic pancreatitis Hypercalcemia Hypercalcemia Hyperlipidemia Hyperlipidemia Infections and Parasites Infections and Parasites Scorpion sting Scorpion sting

PATHOGENESISPATHOGENESIS

““Self digestion”Self digestion” Reflux of bile or duodenal juiceReflux of bile or duodenal juice Trypsinogen was activatedTrypsinogen was activated Trypsin can activate the other zymogensTrypsin can activate the other zymogens Intraparenchymal enzyme activation, tissue dIntraparenchymal enzyme activation, tissue d

estruction, and ischaemic necrosis.estruction, and ischaemic necrosis.

Pathological and Pathological and clinical typeclinical type

Pathological type Pathological type Acute edematic pancreatitisAcute edematic pancreatitis Acute hemorrhgic and necrotic pancreatitis (AAcute hemorrhgic and necrotic pancreatitis (AHNP)HNP)

Clinical typeClinical type Mild Acute pancreatitis (MAP)Mild Acute pancreatitis (MAP) Severe Acute pancreatitis (SAP)Severe Acute pancreatitis (SAP) Fulminant Acute pancreatitis (FAP)Fulminant Acute pancreatitis (FAP)

Clinical manifestationsClinical manifestations

Abdominal painAbdominal pain Nausea, vomitingNausea, vomiting Distension Tenderness, rebound tenderness, muscular regaTenderness, rebound tenderness, muscular regardrd FeverFever ，， jaundicejaundice ， ， Gray-Turner sign: flank ecchymoses Gray-Turner sign: flank ecchymoses Cullen sign: periumbilical ecchymoses Cullen sign: periumbilical ecchymoses MODSMODS

laboratory testlaboratory test

Amylase level in serum and in urineAmylase level in serum and in urine Lipase assaysLipase assays Blood Rt, liver function, FBS, PaCO2 ,Blood Rt, liver function, FBS, PaCO2 ,

serum calcium, DICserum calcium, DIC Diagnostic paracentesisDiagnostic paracentesis

Image findingsImage findings

BUSBUS CT CT ERCPERCP MRCPMRCP Abdomen plain Abdomen plain

filmfilm

Pancreatic necrosisPancreatic necrosis Infective pancreatic necrosisInfective pancreatic necrosis Sterile pancreatic necrosisSterile pancreatic necrosis

Pancreatic abscessPancreatic abscess Pancreatic pseudocystPancreatic pseudocyst

Local complicationLocal complication

Acute pancreatic pseudocystAcute pancreatic pseudocyst

Peripancreatic fluid collections occur in 10-Peripancreatic fluid collections occur in 10-20 % of patients20 % of patients

Those persisting beyond the phase of acute iThose persisting beyond the phase of acute inflammation become pancreatic pseudocystnflammation become pancreatic pseudocystss

Collection surrounded by fibrous tissue or gCollection surrounded by fibrous tissue or granula tissueranula tissue

Diagnosed by PE or image test Diagnosed by PE or image test Round or ellipseRound or ellipse Clear cyst wallClear cyst wall

Severe Acute PancreatitisSevere Acute Pancreatitis

Severe Acute pancreatitis (SAP)Severe Acute pancreatitis (SAP) Complicated with MODSComplicated with MODS Necrosis, abscess, pseudocystNecrosis, abscess, pseudocyst Or bothOr both

ClassificationClassification systemsystem

General evaluationGeneral evaluation John Ranson score (1974):5 (on admission) +6 (48hr)John Ranson score (1974):5 (on admission) +6 (48hr) Imrie score:8 (WBC,Ca,sugar,PO2,LF) Imrie score:8 (WBC,Ca,sugar,PO2,LF) APACHE II score (1985):12+ageAPACHE II score (1985):12+age ＋＋ Chronic health+coma Chronic health+coma

Atlanta classification system(1992)Atlanta classification system(1992) Local evaluation Local evaluation

Beger’ criteria (1985) Beger’ criteria (1985) Balthazar CT classification system (1990):I, II, III GRADBalthazar CT classification system (1990):I, II, III GRADEE

MODS evaluationMODS evaluation Marshall MODS score system(1995):6 systems/organs inMarshall MODS score system(1995):6 systems/organs involved volved

Clinical manifestation of SAPClinical manifestation of SAP

Abdominal sign: obvious tenderness, rebound tendeAbdominal sign: obvious tenderness, rebound tenderness, muscular regard, distension, lose of bowl sourness, muscular regard, distension, lose of bowl soundnd

Mass in abdomen, GreyMass in abdomen, Grey －－ Turner, CullenTurner, Cullen MODSMODS Irreversible shockIrreversible shock CT: swellingCT: swelling ，， uneven density, invade to outside of uneven density, invade to outside of

pancreas(Balthazar CTpancreas(Balthazar CT>>II)II) APACHE valueAPACHE value>>88

MODSMODS

Cardiac functionCardiac function ：： quick pulsequick pulse 、、 shockshock Pulmonary function Pulmonary function ：： PaO2<60mmHgPaO2<60mmHg ，， ARARDSDS Liver functionLiver function ：： jaundicejaundice ， ， elevated ALTelevated ALT Renal functionRenal function ：： elevated BUN and Creatinielevated BUN and Creatininene Digestive functionDigestive function ：： GI bleedingGI bleeding Endocrinal function Endocrinal function ：： glucose>11.1mmol/Lglucose>11.1mmol/L Coagulation systemCoagulation system ：： DICDIC Nerve systemNerve system ：： unclear consciousnessunclear consciousness 、、 papancreatic brain disease ncreatic brain disease

Stage of SAPStage of SAP

Acute response stage ： within 2 weeks complicated with shock,ARDS,renal failure

Systemic infection stage ： 2 weeks to 2 months Bacteria or fungus infection

Post-infection stage ： after 2 3 months Abscess, fistula,

TREATMENTREATMENTT

I.I. Non-operative Non-operative therapytherapy

Acute Response StageAcute Response Stage

ICU ICU ：： to prevent MODSto prevent MODS fasting the patient, fasting the patient, nasogastric suctionnasogastric suction Minimizing pancreatic secretionMinimizing pancreatic secretion

antacidsantacids 5-FU5-FU somatostatin analoguessomatostatin analogues antiproteaseantiprotease

Fluid replacementFluid replacement and Nutritional support and Nutritional support maintenance of adequate hydrationmaintenance of adequate hydration TPNTPN ，， glucose ,lipid, amino acid, proteinglucose ,lipid, amino acid, protein

AnalgesiaAnalgesia AntibioticsAntibiotics Traditional Chinese MedicineTraditional Chinese Medicine Abdominal lavageAbdominal lavage

II. OperationII. Operation

Indication of OperationIndication of Operation

Biliary obstructionBiliary obstruction Secondary pancreatic infectionSecondary pancreatic infection Shock cannot be reversed,Shock cannot be reversed, multiple ogan deterioratemultiple ogan deteriorate Undetermined diagnosis, need Undetermined diagnosis, need

to laparotomyto laparotomy

Principle for treatment of Principle for treatment of pancreatitispancreatitis

MAPMAP SAPSAP

BiliaryBiliary Non-biliaryNon-biliary

ObstuctiveObstuctive Non-obstructiveNon-obstructive InfectionInfection No No infectioninfection

Conservative Conservative therapytherapy

Urgent operationUrgent operationOr ERCPOr ERCP Conservative Conservative

therapytherapyElective operationElective operation

Elective operationElective operation

Conservative Conservative therapytherapy

Chronic pancreatitisChronic pancreatitis

Recurrent upper abdominal painRecurrent upper abdominal pain

With dysfunction of endocrine and With dysfunction of endocrine and

exocrine of pancreasexocrine of pancreas

Clinical manifestitionClinical manifestition Four main symptomsFour main symptoms

Abdominal painAbdominal pain

Body weight lossBody weight loss

DiabetesDiabetes

Lipid diarrheaLipid diarrhea

Therapy of chronic Therapy of chronic pancreatitispancreatitis

Relieve painRelieve pain

Drainage of the pancreatic juiceDrainage of the pancreatic juice

Prevent acute attackPrevent acute attack

Ameliorate the nutritionAmeliorate the nutrition

Improve pancreatic functionImprove pancreatic function

Non-operation or operationNon-operation or operation

Pancreatic Cyst Pancreatic Cyst Pancreatic pseudocystPancreatic pseudocyst Congenital pancreatic cystCongenital pancreatic cyst Retention pancreatic cystRetention pancreatic cyst Neoplastic pancreatic cystNeoplastic pancreatic cyst

Pancreatic cystadenomaPancreatic cystadenoma Pancreatic cystadenocarcinomaPancreatic cystadenocarcinoma

Pancreatic pseudocystPancreatic pseudocyst Indication for operationIndication for operation

Associated with ongoing painAssociated with ongoing pain More than 6 cm in diameter which persist for 6 More than 6 cm in diameter which persist for 6

weeks weeks Cyst with haemorrhage and sepsisCyst with haemorrhage and sepsis

MethodsMethods Percutaneous drainagePercutaneous drainage Operative drainageOperative drainage Cystgastrostomy, cystjejunostomyCystgastrostomy, cystjejunostomy Resection of pancreatic body and tailResection of pancreatic body and tail

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