Pancreatitis and Pancreatic Cancer Dublin PDF

RCSI Royal College of Surgeons in Ireland Col~iste Rioga na M~inle~ in Eirinn # RCSI Title Pa ncreatitis Thomas N Walsh Class Year 2 Course Surgery Year 2024/2025 LEARNING OUTCOME Describe the relevant pancreas anatomy Identify the causes of pancreatitis Discus...

RCSI Royal College of Surgeons in Ireland Col~iste Rioga na M~inle~ in Eirinn # RCSI Title Pa ncreatitis Thomas N Walsh Class Year 2 Course Surgery Year 2024/2025 LEARNING OUTCOME Describe the relevant pancreas anatomy Identify the causes of pancreatitis Discuss the presentation and risk factors for pancreatitis Define the severity stratification and rationale Describe the management options and potential complications Discuss t he present at ion and management of pancreat ic cancer # RCSI ANATOMY Inferior Abdominal aorta Spleen Body of Bile E i d ---- duct pancreas Pancreatic L ducts Duod enal papilla Duodenum 3 of small intestine # RCSI  ACUTE PANCREATITIS Definition: Acute inflammation of the pancreas over a short period of time - Associated release of inflammatory cytokines and pancreatic enzymes. 1/ Common hepatic duct Common bile duct Occurs at any age Minor duodenal p apil l t Overall mortality 10% Gallstone blocking ampulla Accounts for 3% hospital Major duodena l papilla Illustration by Myriam Kirkman-Oh admissions with abdominal pain # RCSI What causes pancreatitis? "I GET SMASHED" Pancreatitis Hi Panceas! l maked these! Idiopathic Gallstones } 80% EtOH (Alcohol) Trauma 020 15 The Awlow ed Yet the wlewd'Yeti.corn ou like dem? Steroids Mumps Autoimmune Scorpion sting theAkard'Yeti.com Hypertriglyceri dae m ia/Hyperca lcaem ia ERCP Drugs {eg Thiazides) # RCSI PATHOGENESIS Autodigestive process 1. Activation of pancreatic enzymes secondary to injury. 2. Pancreatic enzymes (eg lipase, trypsin) act on pancreatic tissue. 3. Release of cytokines - cytokine storm 4. Local and systemic inflammatory response. ACUTE PANCREATITIS SYMPTOMS 1. Epigastric pain Often rapid onset Radiates to back Relieved by sitting forward 2. Nausea and vomiting # RCSI  SIGNS SIGNS DEPEND ON SEVERITY Dehydration Epigastric guarding Tachycardia, tachypnoea, mi Id pyrexia If cholangitis (bile duct inflammation due to gallstones} - Charcot's triad may be present - Jaundice - Pyrexia - RUQ pain ·Cullen's sign (Peri-umbilical bruising} Grey Turner's sign (Flank Bruising) } Seen in haemorrhagic pancreatitis # RCSI RCSI SEVERITY STRATIFICATION Glasgow (IMRIE) Criteria P - Pao2 5 5 N - Neutrophilia (WCC >15x10 9/L) C - Calcium 16mmol/L) E- Enzymes (LOH >600iu/ L, AST > 200iu/ L) A-Albumin (10mmol/L) Score greater than 3 predicts severe disease ➔High dependency/ICU care with hourly monitoring of vital signs # RCSI WORKUP Bedside Investigations Imaging Laboratory Investigations Phyiscal examination CXR: free air under Serum amylase/lipase including vitals diaphragm US abdomen (looking for Urinary amylase gallstones) ECG CT pancreas (after 3 days: FBC, CRP, LFT's, U&E, LDH, to judge Calcium, Album in, severity/complications) Glucose Urine dipstick +/- beta CT Abdomen and Pelvis Coagulation profile hCG earlier if alternative diagnosis is suspected Blood glucose ABG/VBG (lactate) # RCSI  IMAGING - ULTRASOUND Gastroenter ol ogy Department 28/11 16 10:53:51AM AD M 281116-104328AM Pancreatic duct Gallstone LoGIQ E9 Head + PD PD stone seA/ Stones in GB Stone in the pancreatic duct [Needs an expert ultrasonologist] li RCSI CT IMPORTANT - BUT BEST TO DELAY Ed emato us and rammed pan creatic N gist Pay3 # RCSI ACUTE MANAGEMENT Generally does not require surgical intervention Oxygen IV fluids + urine output monitoring Analgesia Monitoring vital signs Glasgow IMRIE score to assess severity (repeat at 48hrs) Manage systemic and local complications Introduce feeding when possible Antithrombotic prophylaxis Be aware of alcohol withdrawal! (chlordiazepoxide + pabrinex) Antibiotics in pancreatic necrosis (eg Meropenem) - B l o o d c " l g RCSI COMPLICATIONS ARDS Pseudocyst formation Pancreatic abscess Necrotising pancreatitis Acute Kidney Injury Pancreatic haemorrhage Chronic pancreatitis Mortality Metabolic (hyperglycaemia, hypocalcaemia) Necrosis of transverse colon # RCSI  NECROTISING PANCREATITIS Two phase disease 1-2 weeks - severe SIRS due to cytokine release 2+ weeks - sepsis-related complications due to infected pancreatic necrosis # RCSI PANCREATIC NECROSECTOMY RCSI SURGICAL MANAGEMENT OF NECROTISING PANCREATITIS severity assessment Glasgow criteria C-reactive protein l dynamic CT APACHE II l pancreatic necrosis l percutaneous needle aspiration infected necr osis l sterile necrosis operation management l ?non-operative #k RCSI Surgical Management of Necrotising Pancreatitis Infected pancreatic necrosis accounts for 80% of acute pancreatitis associated mortality # RCSI PREVENTION OF FURTHER EPISODES. Gallstones - 30% risk second episode (average 3 months) EUS/MRCP/ERCP Cholecystectomy- usually 6 weeks after acute gallstone pancreatitis. Alcohol withdraw/. Psychological. Pharmacological -Seek and treat 1Ca,lipids.10% Pancreatic neoplasms present with Acute Pancreatitis # RCSI CHRONIC PANCREATITIS Common Fibrosis affecting bile duct nerves (pain) Pancreas Pseudocyst Duodenum Fibrosis causing damage to islets and glandular tissue Fibrosis causing CBD obstruction Ductal dilatation Stones in the pancreatic duct Strictures Chronic pancreatrtis d CSI PATHOGENESIS OF CHRONIC PANCREATITIS Protein precipitates form in pancreatic tubules Calcium is deposited in these precipitates Causes obstruction to acini Progressive course Episodic/continuous pain Patchy fibrosis Eventual exocrine and endocrine failure # RCSI CAUSES OF CHRONIC PANCREATITIS Recurrent acute pancreatitis Secondary to pancreatic duct obstruction - Pancreatic head tumors or custs - Pancreatic duct strictures - Congenital anomalies - Cystic fibrosis Autoimmune diseases Idiopathic # RCSI CHRONIC PANCREATITIS Treatment Treat causative agent Stop alc ohol/ ch olecy stec to my / tr eat au toimm un e disea ses Dietary modifications Reduc e fa t Enzyme supplementation Cre on Analges ia Patients who continue to have pain may be considered for: "End osc opic ther ap y Celiac nerve block S ur ge ry "Eg: Whipple's procedure # RCSI CHRONIC PANCREATITIS Intractable pain is the most frequent indication for operation in patients with chronic pancreatitis £N.,835 606 + 3 2/01 :31.39 PM 1 IMA 11 1100.0 8 6.0 O JE CTIO N I # RCSI  RCSI Royal College of Surgeons in Ireland Col~iste Rioga na M~inle~ in Eirinn # RCSI Title Pancreatic Cancer Class Year 2 Course Surgery Year 2023/2024 PANCREATIC CANCER Tumour doubling time for pancreatic cancer is 60 days 85% are unresectable Mean survival of bypassed pat ients is 6 mo nt hs 90% of pat ients wit h pancreat ic adenocarcino ma die within 12 months # RCSI COURVOISIER'S LAW Palpable painless gallbladder in a jaundiced patient is unlikely to be due to gallstone disease # RCSI RISK FACTORS FOR PANCREATIC CANCER Age (80% of cases of pancreatic cancer occur in 6" and 7 decades of life) Smoking Alcoholism Diabetes Chronic pancreatitis # RCSI  CLINICAL FEATURES Progressive jaundice Vomiting (duodenal obstruction) Ascites Back pain Anorexia Weight loss Sister Mary Joseph nodule # RCSI MANAGEMENT Palliation Surgery Biliary stent Whipples procedure (resection of part of stomach, Gastro-jejunostomy duodenum, pancreatic head Coeliac axis block and neck, gallbladder and part of the bile duct along with clearance of draining lymph nodes) # RCSI WHICH OF THE FOLLOWING ARE CAUSES OF PANCREATITIS? A. Alcohol B. Auto-immune disease C. Gastro-oesophageal reflux disease D. Hypocalcaemia E. Gallstones # RCSI Signs of pancreatitis may include which of the following: A. Epigastric tenderness B. Cullens sign C. Courvoisier's Law D. Dehydration E. Murphy's sign # RCSI The following help predict the severity of pancreatitis: A. Glasgow/lMRIE scoring system B. Age> 65 C. Ranson's Criteria D. APACHE Score E. Faecal occult blood # RCSI Acute Pancreatitis & Pancreatic Carcinoma Thank you. Any Questions? # RCSI