Learning objectives

• To understand: The anatomy and physiology of the pancreas

Investigations of the pancreas
Congenital abnormalities of the pancreas
Assessment and management of pancreatitis
Diagnosis and treatment of pancreatic cancer
 Pancreatic anatomy & physiology

• Anatomy:
• The pancreas is situated in the retro peritoneum. It is divided into a head, which occupies 30% of the
• gland by mass, and a body and tail, which together constitute 70%. The head lies within the curve of the
duodenum, overlying the body of the second lumbar vertebra and the vena cava. The aorta and
• the superior mesenteric vessels lie behind the neck of the gland. Clusters of endocrine cells, known as
islets of Langerhans, are distributed throughout the pancreas. Islets consist of different cell types: 75%
• are B cells (producing insulin); 20% are A cells (producing glucagon); and the remainder are D cells
producing somatostatin .
• The anatomy of the main duodenal papilla, also known as the ampulla of Vater, is also variable .
• The outlet of each duct is protected by a complex sphincter mechanism (sphincter of Oddi for the main
duct) .
Physiology: It secretes an alkaline (pH 8.4) bicarbonate-rich fluid.
the hormone secretin, which is released from the duodenal mucosa, evokes a bicarbonate-rich fluid.
. Approximately 6–20 g of digestive enzymes enters the duodenum each day
• During this phase, the proteolytic enzymes are in an inactive form, which is important in preventing
pancreatitis.
•
Pancreatic anatomy
 INVESTIGATIONS
Measurement of serum amylase is the most widely used test of pancreatic damage.
Lipase If confirmation of the diagnosis is required
computed tomography (CT) of the pancreas is of greater value
• Pancreatic function tests: The stimulus to secretion by intravenous injection of
secretin .
• Measurement of the enzyme elastase in stool is simple, specific and now used
widely. A low level of faecal elastase indicates exocrine insufficiency.
 Imaging investigations
• 1-Ultrasonography: Ultrasonography is the initial investigation of choice in patients with jaundice
to determine whether or not the bile duct is dilated, the coexistence of gallstones
• 2-Computed tomography : Most significant pathologies within the pancreas can be diagnosed on
high-quality CT scans, with three-dimensional reconstruction if necessary. CT-guided drainage is
helpful in the treatment of pancreatic collections, cysts and pseudo cysts, and facilitates
percutaneous fine-needle or Trucut biopsy
• 3-Magnetic resonance imaging (MRI) the pancreas can be clearly identified, and the anatomy of
the bile duct and the pancreatic duct, together with fluid collections, can be defined. Magnetic
resonance cholangiopancreatography (MRCP) has largely replaced diagnostic endoscopic
retrograde cholangiopancreatography (ERCP) as it is non-invasive and less expensive
• 4- Endoscopic retrograde cholangiopancreatography :
• Brush cytology taken from malignant strictures at the time of ERCP yields a positive diagnosis in
40–50% of patients.
• ERCP also allows the placement of biliary and pancreatic stents & immaging.
• 5- Endoscopic ultrasonography
 Endoscopic retrograde
cholangiopancreatography
ERCP showing dilated biliary tree due to
distal obstruction
CT showing Pseudo cyst of the pancreas
 CONGENITAL ABNORMALITIES of the pancreas
• 1-Cystic fibrosis :This is inherited as an autosomal recessive condition.
Cystic fibrosis (CF) develops when there is a mutation in the CFTR (cystic fibrosis
transmembrane conductance regulator) gene on chromosome 7 .
It is characterized by elevated sodium and chloride ion concentrations in sweat.
CF is a multisystem disorder of exocrine glands.
meconium ileus: causing neonatal intestinal obstruction
• The diagnosis can be done by the sweat test.
Levels of sodium and chloride ions in the sweat above 90 mmol/L confirm the diagnosis
• Treatment: is by supplementation of deficiencies & high salt diet
 Pancreas divisum
Pancreas divisum occurs when the embryological ventral and dorsal parts of the
pancreas fail to fuse
• The diagnosis can be arrived by MRCP, EUS .
pancreas divisum should be excluded in patients with idiopathic recurrent
pancreatitis.
Endoscopic sphincterotomy and stenting of the minor papilla may relieve the
symptoms.
Surgical intervention can take the form of sphincteroplasty, pancreatojejunostomy
or even
resection of the pancreatic head.
 annular pancreas
Annular pancreas :This is the result of failure of complete rotation of the
ventral pancreatic bud during development, so that a ring of pancreatic
tissue surrounds the second or third part of the duodenum
Duodenal obstruction typically causes vomiting in the neonate
The usual treatment is bypass (duodenoduodenostomy)
• Ectopic pancreas: Islands of ectopic pancreatic tissue can be found in the
submucosa in parts of the stomach, duodenum or small intestine (including
Meckel’s diverticulum), the gallbladder, adjoining the pancreas, in the hilum
of the spleen and within the liver
• Congenital cystic disease of the pancreas: This sometimes accompanies
congenital disease of the kidneys and liver
 Injury to the pancreas
• Presentation and management
• Iatrogenic injury
• Trauma The most important factor that determines treatment is whether the
pancreatic duct has been disrupted.
• The clinical presentation can be quite deceptive; careful serial assessments and a high
index of suspicion are required. A rise in serum amylase occurs in most cases. A CT
scan of the pancreas will delineate the damage that has occurred to the pancreas .
• If there is doubt about duct disruption, an urgent ERCP should be sought.
• There is no need to rush to a laparotomy if the patient is hemodynamically stable,
without peritonitis. It is preferable to manage conservatively at first, investigate and,
once the extent of the damage has been ascertained, undertake appropriate action.
Operation is indicated if there is disruption of the main pancreatic duct .
 Injury to the pancreas
• In penetrating injuries, especially if other organs are injured and the
patient’s condition is unstable, there is a greater need to perform an
urgent surgical exploration.
• If the gland is transected in the body or tail, a distal pancreatectomy
should be performed, with or without splenectomy. If damage is
purely confined to the head of the pancreas, hemostasis and external
drainage are normally effective .
• However, if there is severe injury to the pancreatic head and
duodenum, then a pancreatoduodenectomy may be necessary.
 Acute PANCREATITIS
• Acute pancreatitis is defined as an acute condition presenting with
abdominal pain, a threefold or greater rise in the serum levels of the
pancreatic enzymes amylase or lipase characteristic
findings of pancreatic inflammation on contrast-enhanced CT.
• Acute pancreatitis may be categorized as mild (interstitial edematous
pancreatitis) or severe (necrotizing pancreatitis
• The majority of patients will have a mild attack of pancreatitis, the
mortality from which is around 1%. Severe acute pancreatitis is seen in
5–10% of patients and is characterized by pancreatic necrosis,
• systemic inflammatory response and often multiorgan failure may occur In
those who have a severe attack of pancreatitis, the mortality varies from
20% to 50%
 Acute PANCREATITIS
• Acute pancreatitis: Etiology :The two major causes of acute pancreatitis are biliary calculi,
which occur in 50–70% of patients, and alcohol abuse, which accounts for 25% of cases
Among patients who undergo ERCP, 1–3% develop pancreatitis, probably as a
consequence of duct disruption and enzyme extravasation.
• Hereditary pancreatitis is a rare familial condition associated with mutations of the
cationic trypsinogen gene. The underlying mechanism of injury in pancreatitis is thought
to be premature activation of pancreatic enzymes within the pancreas, leading to a
process of auto digestion
• As inflammatory mediators are released into the circulation, systemic complications can
arise, such as hemodynamic instability, bacteremia (due to translocation of gut flora),
acute respiratory distress syndrome and pleural effusions, gastrointestinal hemorrhage,
renal failure and disseminated intravascular coagulation (DIC).
• About one-third of deaths occur in the early phase of the attack, from multiple organ
failure. The late phase is seen typically in those who suffer a severe attack and can run
from weeks to months
 Assessments of severity
• It is important to identify those patients who will develop severe pancreatitis as they require aggressive early
management and possibly transfer to a specialist unit . Various prognostic scoring systems have been used,
all aimed at predicting persistent organ failure. The Ransom scoring system is a specific for acute pancreatitis,
and a score of 3 or more at 48 hours indicates a severe attack .Regardless of the system used, persisting
organ failure indicates a severe attack. patients with acute pancreatitis can be stratified into three groups:
• Mild acute pancreatitis:
• no organ failure;
• no local or systemic complications.
• Moderately severe acute pancreatitis:
• ● organ failure that resolves within 48 hours (transient organ failure); and/or
• local or systemic complications without persistent organ failure.
• Severe acute pancreatitis:
• persistent organ failure (>48 hours);
• single organ failure;
• ●multiple organ failure.
Ransom score on admission. The disease is considered severe
when three or above of the following criteria are present
• Age above 55
• White blood cells more than 16000
• Blood glucose more than 200mg/dl
• LDH more than 350 units/L
• AST more than 250/L
• Within 48 hours:
• Hematocrit falls of 10% or greater
• Blood urea nitrogen rise more than 5 mg/dl in spite of good fluid intake
• Arterial oxygen saturation less than 60mmHg
• Serum calcium less than 8 mg/dl
• Base deficit more than 4mmol/L
• Fluid sequestration more than 6 L
 imaging

• 1-contrast-enhanced CT is indicated in the following situations: ●

• 2-If there is diagnostic uncertainty.
3-In patients with severe acute pancreatitis to distinguish interstitial from
necrotizing pancreatitis (In the first 72 hours, CT may underestimate the extent of
necrosis). . .
4-When a localized complication is suspected, such as fluid collection, pseudo cyst
or a pseudo aneurysm.
 Early management of severe acute pancreatitis

• 1-Admission to HDU/ICU—analgesia—aggressive fluid rehydration—supplemental

oxygen—invasive monitoring of vital signs(central venous pressure, urine output, blood gases)
• 2-Frequent monitoring
3-biochemical check
4-nasogastric drainage only initially---
5antibiotic cover if cholangitis is suspected
6-CT scan is essential if organ failure, clinical deterioration or signs of sepsis develop
7-ERCP within 72 hours for severe gall stone pancreatitis or signs of cholangitis----
• 8-Supportive therapy for organ failure if develops( inotrops,ventilator support,haemofiltration
etc.)
• 9-If nutritional support is required, consider enteral feeding----
• 10-Surgery has no role during the initial period of resuscitation and stabilization and is reserved
for the patient who deteriorates following successful stabilization
 The treatment of Pancreatic fistula
• ● Determine the anatomy of the fistula ●
Check if the main pancreatic duct is blocked or disrupted . ●
Correct fluid and electrolyte imbalances ●
Protect the skin, ●
Relieve pancreatic duct obstruction if possible (ERCP and stent) ●
Treat underlying cause. Management includes correction of metabolic
state and electrolyte disturbances. ●
 The treatment of Pancreatic fistula
• adequate drainage of the fistulae into a stoma bag with protection of the
skin.
Investigation of the cause of the fistula is required as the underlying cause
must be treated before the fistula will close.
Frequently, the cause is related to obstruction within the pancreatic duct,
which can be overcome by endoscopic insertion of a stent or catheter into
the pancreatic duct
• While waiting for closure of the fistula,
the patient should be given parenteral or nasojejunal nutritional support .
• The use of octreotide will also suppress pancreatic secretion. ●
•
 Complications of acute pancreatitis

• Systemic: cardio-vascular.—shock—Arrhythmia—pulmonary –ARDS(adult respiratory distress

syndrome)—renal failure—hematological—DIC(disseminated intravascular
coagulopathy)—metabolic—hypocalcaemia—hyperglycemia—hyperlipidemia—ileus—
1. Visual disturbance—irritability—confusion—encephalopathy—subcutaneous fat
necrosis—arethralgia.all the above are usually in the first week.
• Local:peripancreatic fluid collection—sterile pancreatic necrosis—infected pancreatic necrosis—
• Pancreatic abscess—pseudocyst—pancreatic ascites—pleural effusion—portal/splenic vein
• Thrombosis—pseudoaneurysm.
Post pancreatitis complications
Acute peripancreatic fluid collection
• Sterile and infected pancreatic necrosis: Infected necrosis is associated with a mortality rate of
up to 50%
• Pancreatic necrosectomy should be considered if sepsis worsens despite conservative measures.
• Closed continuous lavage
Closed drainage
• Open packing.
Closure and relaparotomy.
Patients with peripancreatic sepsis are ill for long periods of time and may require management in
an intensive care unit
•
CT showing severe pancreatitis
Barium meal showing pseudocyst pushing
the stomach
 Outcomes and follow-up of acute pancreatitis
The overall mortality from acute pancreatitis has remained at 10–15%
over the past 20 years.
Complications of acute pancreatitis
• Systemic Local
• (More common in the frst week) (Usually develop after the first week

• Cardiovascular Peripancreatic fluid collection

• Shock Sterile pancreatic necrosis
• Arrhythmias Infected pancreatic necrosis
• Pulmonary Pancreatic abscess
• ARDS Pseudo cyst
• Renal failure Pancreatic ascites
• Hematological Pleural effusion
• DIC Portal/splenic vein thrombosis
• Metabolic Pseudo aneurysm
• Hypocalcaemia
• Hyperglycemia
• Hyperlipidemia
Systemic complications of acute pancreatitis
• Ileus
• Neurological
• Visual disturbances
• Confusion, irritability
• Encephalopathy
• Miscellaneous
• Subcutaneous fat necrosis
• Arthralgia
Treatment of local complications
• A CT scan should be performed if pain persists, signs of sepsis develop, organ dysfunction worsens
or there is a further spike in the serum amylase level. The management is conservative with
surgery only when conservative management has failed.
1)Acute Peripancreatic fluid collection: treatments conservative unless large
•
• .2) sterile & infected pancreatic necrosis: This can be identified by an absence of parenchymal
enhancement on CT with intravenous contrast. Gradually, over a period of over 4 weeks, this may
develop a well-defined inflammatory capsule and evolve into walled-of necrosis. Infected necrosis
is associated with a mortality rate of up to 50%.Aspiration fluid with a fine needle, percutaneously
under CT or ultrasound guidance, can provide the answer. Internal drainage into the stomach
under endoscopic ultrasound guidance should be considered Pancreatic necrosectomy should be
considered if sepsis worsens despite conservative measures. This is a challenging operation that
carries a high morbidity and mortality. A feeding jejunostomy may be a useful adjunct to the
procedure. If gallstones are the precipitating factor of the pancreatitis, a cholecystectomy should
be included
Management of Local complications after
pancreatitis
• 3)Closed continuous lavage. Tube drains are left in and the raw area flushed
• .4)Closed drainage. The incision is closed, but the cavity is packed with gauze-filled, Penrose drains and
closed suction drains. The Penrose drains are brought out through the flank and slowly pulled out and
removed after 7 days
• 5)Open packing. The incision is left open, and the cavity is packed with the intention of returning to the
operating room at regular intervals and repacking until there is a clean granulating cavity. 6)
Closure and relaparotomy. The incision is closed with drains with the intention of performing a series of
planned relaparotomies every 48–72 hours until the raw area granulates
• 6)pseudocyst: Pseudo cysts typically arise following an attack of mild acute pancreatitis, lie outside the
pancreas and represent an APFC(acute pancreatic fluid collection) that has not resolved and matured.
Formation of a pseudo cyst requires 4 weeks or more from the onset of acute pancreatitis More than half
have a communication with the main pancreatic duct. Occasionally, a cystic neoplasm may be confused
with a chronic pseudo cyst. EUS and aspiration of the cyst fluid are very useful in such a situation. The
fluid should be sent for measurement of carcinoembryonic antigen (CEA) levels, amylase levels and
cytology Pseudo cysts usually resolve spontaneously, Therapeutic intervention is advised only if the
pseudo cyst causes symptoms, complications develop or distinction has to be made between a
pseudo cyst and a tumor. There are three possible approaches to draining a pseudo-cyst:
percutaneous, endoscopic and surgical