🔴Pancreatitis

▪It's Inflammation Of The Pancreatic Tissue Due To Premature Activation Of Pancreatic

Enzymes Within The Pancreas Leading To AutoDigestion Of The Pancreas & Systemic
Inflammatory Response

▪The Pancreas is RetroPeriToneal Organ (Not Covered By Peritoneum) Consist Of Head Lies
Within The Curve Of The Duodenum & Body & Tail

🔰Types Of Pancreatitis
🔶A. Acute Pancreatitis
▪Acute Inflammation Of The Pancreas Characterized By Abdominal Pain With 3x Increase in
Pancreatic Enzymes & Inflammatory Changes Of Pancreas On CT Scan

🔹Causes Of Acute Pancreatitis

1. Gallstones (50-70%) ➡ Smaller Stones With Wide Cystic Duct Have More Risk Of Causing
Pancreatitis

2. Alcohol Abuse (25%)

3. After ERCP (1-3%)

4. Biliary Or Upper Git Or Cardiothoracic Surgeries

5. Abdominal Trauma

6. Tumour At Ampulla Of Vater (Duct Between Doudenum & Pancreas)

7. Drugs (Steroids/Estrogen/Thiazide/Valproic Acid/Azathioprine/Asparaginase/Statins)

8. Hyperparathyroidism & Hypercalcemia (High Ca) & Hypertriglycerides

9. Hereditary Pancreatitis ➡ Mutation Of Cationic Trypsinogen Leads To Episodes Of Acute

Pancreatitis At Young Age (Teen) Then Progress To Chronic Pancreatitis Then Pancreatic
Cancer (40% Risk) At Age Of 70 Years
10. Viral Infections (Mumps/Coxsackie B) & Scorpion Bites

11. Malnutrition/Autoimmune/Congenital (Pancreas Divisum)/Idiopathic

🔹Clinical Features Of Acute Pancreatitis

📍1. Start As Severe Acute Abdominal Pain
▪Reaching Maximum Intensity Within Minutes & Persist For Hours Or Days

▪Start In Epigastrium Then Localized To Upper Quadrant Or Become Diffuse

▪Constant (Not Intermittent) & Radiating To Back

▪Not Respond To Analgesics & Mild Relief By Sitting Or Leaning Forward

▪Associated With Nausea & Repeated Vomiting With Retching & Hiccups

📍Changes
2. Systemic Inflammatory Response ➡ Tachypnea/Tachycardia/Hypotension/Temperature
(<36° Or >38°)/WBCS Changes (<4k Or >12k)

📍3. Mild Obstructive Jaundice (in Gallstone Pancreatitis)

📍4. Swinging Pyrexia (Temperature Raise To High Levels Then Back Due To Cholangitis)
📍5. Bleeding Into The Abdomen Results in
▪Grey Turner's Sign (Blush Discoloration At Flanks) ‫ﻋﻠﻰ اﻟﺠﻮاﻧﺐ‬

▪Cullen's Sign (Blush Discoloration At Umbilicus)

📍6. Small Red Tender Nodules On Skin Of Legs (Subcutaneous Fat Necrosis)
📍7. Abdominal Distension (Due To ileus Or Ascites)
📍9. Epigastric Mass
📍10. Guarding (Voluntary) & Rigidity (Involuntary) Of Upper Abdomen
📍Infection)
11. Pleural Effusion/Pulmonary Edema/Pneumonitis (Lung Tissue Inflammation Without

🔹Dx Of Acute Pancreatitis

📍1. Clinical Features
📍2. Increase Pancreatic Enzymes 3x Above The Normal
▪Amylase ➡ Raise After 2-12h & Return To Normal in One Week (Normal Level 24-151 IU/L)

▪Lipase (More Sensitive & Specific) ➡ Raise After 4-8h & Return To Normal in One-Two Weeks
(Normal Level 10-181 IU/L)

📍Enhancement
3. Contrast CT Scan (Confirm Dx) ➡ Focal Or Diffuse Enlargement With Heterogeneous
& Irregular Contour & Blurring Of Surrounding Fat & Fluid Collection

🔹Severity Of Acute Pancreatitis

📍1. Mild (Interstitial Edematous Pancreatitis)
▪Interstitial Edema Of Gland With
Minimal Or No Organ Dysfunction & No Complications

▪1% Mortality Rate

📍Without
2. Moderate ➡ Organ Failure Resolve Within 48h (Transient) Or Complications Develop But
Organ Failure

📍3. Severe (Necrotizing Pancreatitis Affect Only 5-10% Of Patients)

▪Persistent Organ Failure (>48h) & Severe Systemic Inflammatory Response
▪20-50% Mortality Rate

🔹Complications Of Acute Pancreatitis

🔶A. Systemic Complications (1st Week)
1. Shock/Arrhythmia/ARDS/Renal Failure/DIC

2. Hypocalcemia/Hyperglycemia/Hyperlipidemia ‫ﻳﻨﺰل اﻟﻜﺎﻟﺴﻴﻮم‬

3. Bowel Obstruction (Ileus)

4. Encephalopathy With Confusion & Irritability

5. Subcutaneous Fat Necrosis & Arthralgia

6. Death From Multiple Organ Failure

🔶B. Local Complications (2nd Week)

1. Sterile Fluid Collection Around The Pancreas

2. Pancreatic Necrosis (Sterile Or Infected Pancreatic Tissue Death)

3. Pancratic Abscess ➡ Intraabdominal Pus Collection Near The Pancreas

4. Pancreatic Ascites ➡ Fluid Collection Inside The Abdomen Rich in Pancratic Enzymes

5. Pleural Effusion ➡ Fluid Collection in Pleural Cavity

6. Bleeding Inside The Abdomen

7. Portal Or Splenic Vein Thrombosis ➡ Associated With Thrombocytosis (Increase Platelets)

8. PseudoAneurysm (Erosion Of Surrounding Vessels)

9. Pancreatic Pseudocyst
▪Fluid Collection Inside A Cyst Outside The Pancreas & Rich in Pancreatic Enzymes

▪Develop 4 Weeks After Attack Of Mild Pancreatitis & Mostly Resolve Spontaneously

▪DDX ➡ Cystic Neoplasms (High Level Of CEA & Low Amylase)

🔹Mx Of Acute Pancreatitis

🔸A. Mild Attack
📍1. Nill By Mouth
📍2. IV Fluids & Analgesics
📍3. Brief Fasting
🔸B. Severe Attack
📍1. ICU Admission
📍2. Oxygen
📍3. Nill By Mouth
📍4. Aggressive Fluids Administration (Ringer)
📍5. Analgesics (Paracetamol Or Bethidine)
*Don't Give Morphine (Biliary Spasm)

📍Days6. Prophylactic Antibiotics (IV Cefuroxime/Imipenem/Ciprofloxacin/Metronidazole) For 14

➡ To Prevent Sepsis

📍7. Urgent ERCP Within 72h If :

▪Gallstones Are The Cause Of Pancreatitis

▪Patient Develop Jaundice Or Cholangitis (Bile Ducts Inflammation)

▪Dilated Common Bile Duct

📍8. Fluid Or Abscess Drainage (Aspiration)

🔶B. Chronic Pancreatitis

▪Continuous Inflammation Of The Pancreas Results in Progressive & Irreversible Destruction
Of Pancreatic Tissue & Loss Of Function

▪More in Men At 40 Years Age

▪Risk Of Pancreatic Cancer (If Disease Present For 20 Years)

🔹Causes Of Chronic Pancreatitis

1. Chronic High Alcohol Consumption (60-70%)

2. Pancreatic Duct Obstruction (By Strictures Or Pancreatic Cancer Or Acute Pancreatitis)

3. Congenital Anomalies (Pancreas Divisum & Annular Pancreas)

4. Cystic Fibrosis

5. Hyperlipidemia & Hypercalcemia

6. Malnutrition/Hereditary/Autoimmune /Idiopathic

🔹Clinical Features Of Chronic Pancreatitis

📍1. Chronic Mild To Moderate Dull Abdominal Pain
▪More At Epigastrium & Radiate To Shoulder Or Back

▪Intermittent Attacks (Comes & Go)

▪Nausea & Vomiting During The Attack

▪Risk Of Severe Flare Ups

📍2. Anorexia & Weight Loss

📍3. Decrease Sleep
📍4. Analgesic Abuse & Dependent
📍5. Steatorrhea (Loss Exocrine Function)
📍6. Diabetes (Loss EndoCrine Function)
📍7. Infections

🔹Dx Of Chronic Pancreatitis

📍1. US Of Pancreas (≥4 Features Highly Suggestive Of Chronic Pancreatitis)
▪Stones Present

▪Branches & Cysts & Lobularity & Strands

▪Irregularities & Dilatation Of Main Pancreatic Duct With Hyperechoic Margins

▪Hyperechoic Foci in Pancreas

📍2. Abdominal Xray Or CT ➡ Pancreatic Calcification

📍3. MRCP ➡ Biliary Obstructions & Strictures
📍4. ERCP ➡ Most Accurate For Dx & Mx

🔹Mx Of Chronic Pancreatitis

📍1. Stop Alcohol & Smoking
📍2. Relive Obstruction Using ERCP
📍3. Gradual increase in Analgesics Dose
📍4. Nerve Block For Pain Relief (Coeliac Axis Block)
📍5. Diet Low in Fat & High In Proteins & Carbs
📍6. Pancreatic Enzymes Replacement & Diabetes Mx
📍7. Correct Malabsorption (Give B12/C/E/Selenium/Methionine/Medium-Chain Triglycerides)
📍8. Reduce Gastric Secretions (PPi)
🔴Pancreatic Cancer
▪6th Most Common Cause Of Cancer Death in UK & 4th in USA With Late Presentation & Very
Poor Prognosis

🔹Pathological Types Of Pancreatic Cancer

📍1. Pancreatic Ductal Adenocarcinoma
▪Most Common (85%)

▪Solid Tumour Arise From Ductal Tissue Of The Pancreas

▪Mostly Arise in Head Of Pancreas

▪Spread Locally Along The Nerve Sheaths & Lymphatics & Blood Vessels

▪Mostly Present With Metastasis (Bad Prognosis)

📍Duct2. Pancreatic IntraEpithelial Neoplasia (PanIN) ➡ Proliferative Lesions in The Pancreatic

That Proceed The Ductal Adenocarcinoma

📍3. Serous CystAdenoma

▪Benign Large Aggregations Of Multiple Small Cysts

▪More in Old Women

▪Present As Incidental Finding Or Causing Pressure Symptoms Or Palpable Mass

📍4. Mucinous Tumours

▪Risk Of Malignant Transformation

▪DDX ➡ Pancratic PseudoCyst

▪Types Of Mucinous Tumours 👇
•Mucinous Cystic Neoplasms (MCNs) ➡ Present As Multi-Locular Thick-Wall Cyst in The Body
Or Tail Of The Pancreas in PeriMenoPausal Women (Near The Menopause)

•IntraDuctal Papillary Mucinous Neoplasms (IPMNs) ➡ Present As A Cyst in The Head Of

Pancreas in Old Men With Thick Mucus Production

📍5. Ampullary Tumours

▪Arise From The Ampulla Of Vater (Union Of Pancreatic & CBD)

▪Present As Mass in The Head Of The Pancreas

▪Early Presentation (Due To CBD Obstruction & Jaundice) & Better Prognosis

📍6. Solid PsuedoPapillary Tumours

▪Present As Slowly Progressive Pancreatic Tumors in Young Females With Better Prognosis

▪Consist Of Large Solid & Cystic Parts

🔹Risk Factors For Pancreatic Cancer

1. Old Age (65-75) Black Male

2. Chronic & Hereditary Pancreatitis

3. Diabetes Mellitus

4. Smoking & Alcohol

5. Lynch (HNPCC) & FAP & Peutz Jeghers Syndromes

6. Ataxia Telangiectasia

7. Breast-Ovarian Cancer Syndrome & Multiple Mole Melanoma

8. +Ve Family Hx (Of Pancreatic Cancer Or BRCA2 Mutation)

9. High Fat Diet

10. Exposure To Benzidine & Naphthypene

🔹Clinical Features Of Pancreatic Cancer

📍1. Pancreatic Head & Ampullary Tumours
▪Obstructive Painless Progressive Jaundice (Due To Distal CBD Obstruction) ➡ Results in
Early Presentation & Less Advanced Cancer

▪Pruritus/Pale Stool/Dark Urine/Steatorrhea

▪Anorexia & Weight Loss

▪Palpable Non Tender Gallbladder (Courvoisier Sign)

📍2. Pancreatic Body & Tail Tumours

▪Silent (Asymptomatic) ➡ Results in Late Presentation & More Advanced Cancer

▪Back Pain (RetroPeriToneal Invasion)

▪Anorexia & Weight Loss

📍3. Unexplained Recurrent Attacks Of Pancreatitis

📍4. New Onset DM in Old Age (50 Years) With No Family Hx Of DM & No Obesity
📍5. Liver Enlargement
📍6. Thrombophlebitis (Trousseau's Sign) & DVT

🔹Dx Of Pancreatic Cancer

1. Bilirubin & LFT & Abdominal US ➡ Confirm Obstructive Jaundice With Dilated CBD &
Exclude Gallstones

2. Contrast CT ➡ Confirm Pancreatic Cancer & Determine Operability (is The Tumour
Resectable Or Not)

3. ERCP & Biliary Stenting ➡ For Dx & Relive Obstructive Jaundice & Cholangitis

4. TransGastric Or TransDuodenal FNA Or Trucut Biopsy ➡ Confirm Dx Of Malignancy

5. Endoscopic US (EUS) Alternative To CT

6. Diagnostic Laparoscopy ➡ Detect Small Peritoneal & Liver Metastases

7. CA19-9 Tumour Marker ➡ Follow Up Of Recurrence

🔹Mx Of Pancreatic Cancer

🔶A. Palliative Tx
📍1. Relive Jaundice & Biliary Obstruction
▪ERCP & Biliary Stenting

▪Percutaneous TransHepatic Biliary Stenting (PTC)

▪Surgical Biliary Bypass (CholeCystoJejunoStomy Or CholedocoJejunoStomy)

📍2. Relief Duodenal Obstruction

▪Endoscopic Duodenal Stenting
▪Surgical GastroJejunoStomy

📍3. Pain Relief

▪Increase Dose Of Analgesics
▪Coleliac Plexus Block
▪TransThoracic SplanchnicEctomy

📍4. Enzymes Replacement For Steatorrhea

📍5. Mx Of DM
📍6. Palliative Chemotherapy

🔶B. Curative Tx
📍Whipple
1. Head & Ampullary Tumours ➡ Pylorus Preserving PancreatoDuodenEctomy (PPPD Or
Procedure)

📍2. Body & Tail Tumours ➡ Distal PancreatEctomy & SplenEctomy

📍3. Postoperative Chemotherapy (Adjuvant)

🔹Prognosis Of Pancreatic Cancer

▪85% Of Pancreatic Cancer Are Unresectable At The Time Of Dx (Late Presentation)

▪5-Year Survival Only 12%

▪Locally Advanced Cancer ➡ 6-10m Survival Rate

▪Metastatic Cancer ➡ 2-6m Survival Rate