ACUTE PANCREATITIS PANCREATIC DISEASE The pancreas secretes 1.5 liters of enzyme-rich fluid every day for the digestion of fats, starch, and protein. Normal pancreatic juice is clear, colorless, isotonic, and alkaline. A large volume of alkaline, enzyme-rich fluid enters the duodenum to neutralize gastric chyme for optimal digestion.

Facts of Exocrine Pancreas 1.5 liters of enzyme-rich fluid every day: digests of fats, starch, and protein. Normal pancreatic juice is clear, colorless, isotonic, and alkaline. Neutralizes acidic gastric contents in duodenum 11/9/2018

ACUTE PANCREATITIS ESSENTIALS Abrupt onset of deep epigastric pain Often with radiation to the back. History of previous episodes, often related to alcohol intake. Nausea, vomiting, sweating, weakness. Abdominal tenderness and distention and fever. Leukocytosis Elevated serum amylase Elevated serum lipase. 11/9/2018

Etiology Reflux of bile into pancreatic duct Injury to pancreatic gland cells Hypercalcemia Hyperlipidemias Drugs- Chemo/ HIV Infections- Mumps/ CMV Cystic fibrosis 11/9/2018

Pain characteristics: Abrupt epigastric/ upper abdo. pain (dull and boring) Radiates to the back Worse on recline & walking Better when sitting and leaning forward Weakness, sweating, and anxiety present Preceded by alcohol intake 11/9/2018

Symptoms and Signs Tender distended upper abdomen Bowel sounds absent (ileus) Fever (38-39◦C) Tachycardia/ Shock/ Pallor 11/9/2018

Severe Pancreatitis >55 yrs WBC >16,000 Blood glucose >200 mg/dL Serum LDH >350 u/L AST >250 u/L 11/9/2018

Lab Workup Serum amylase and lipase > 3 x normal Urine- protein +, casts +, glycosuria + AXR 11/9/2018

CT: Acute Pancreatitis 11/9/2018

CT: Pseudocyst 11/9/2018

Pancreatic Pseudocyst: Draining into Stomach 11/9/2018

Therapy ICU Pain relief Fluid Volume control Prevent complications Fatal- 5-20% 11/9/2018

PANCREATIC DISEASE CHRONIC PANCREATITIS

Essentials Chronic or intermittent epigastric pain Steatorrhea Weight loss Abnormal pancreatic imaging. 11/9/2018

Predisposing Factors Toxic-metabolic- Alcoholic (80%)/ Tobacco Idiopathic (20%) Genetic- chr.7 Autoimmune Recurrent and severe acute pancreatitis or Obstructive 11/9/2018

Steatorrhea: bulky, foul, fatty stools 11/9/2018

Signs & Symptoms Episodic epigastric and left upper quadrant pain radiating to the upper left lumbar region are typical Anorexia Nausea, vomiting, constipation, flatulence, and Weight loss 11/9/2018

Lab Workup Serum amylase and lipase + / - ALP and Bili may be elevated Excess fecal fat – pancreatic insufficiency AXR- calcification ERCP 11/9/2018

ERCP 11/9/2018

Therapy Correct strictures Low fat diet Forbid alcohol Avoid narcotics Pancreatic enzyme supplements Raniitidine, Omeprazole suppress acid- help pancreatic enzymes 11/9/2018

Coated Uncoated Enteric-coated microspheres 5,000 10,000 20,000 Commonly Available Pancreatic Enzyme Preparations Preparation Form Enzyme Content (USP Units) Lipase Protease Amylase Uncoated Cotazym Capsule 8,000 30,000 Pancreatin Tablet 12,000 60,000 Viokase Coated Creon 5/10/20 Enteric-coated microspheres 5,000 10,000 20,000 18,750 37,500 75,000 16,600 33,200 66,400 Pancrease MT 4/10/16/20 Enteric-coated microtablets 4,000 10,000 16,000 20,000 12,000 30,000 48,000 44,000 12,000 30,000 48,000 56,000 Ultrase MT 6/12/16/20 6,000 12,000 18,000 20,000 19,500 39,000 58,500 65,000 11/9/2018

COMPLICATIONS Opioid addiction DM Pseudocyst / Abscess Steatorrhea / Malnutrition Pancreatic cancer (4% after 20 yrs) 11/9/2018

Treatment of Steatorrhea 11/9/2018

Prognosis Leads to chronic disability 11/9/2018

PANCREATIC DISEASE CANCER PANCREAS

Essentials Obstructive jaundice (may be painless). Enlarged gallbladder (may be painful). Late Manifestations: Upper abdominal pain with radiation to back Weight loss and Thrombophlebitis 11/9/2018

Cancer Pancreas Location: 75% in the head of pancreas 25% in the body & tail Ampulla of Vater / CBD / Head of Pancreas have similar presentation 90% of these are due to Cancer head of Pancreas 11/9/2018

Risk Factors Age Obesity Tobacco use Chronic pancreatitis Prior abdominal radiation and Family history ‘New Diabetic’ after 50 yrs of age (suspect) 11/9/2018

Symptoms and Signs Vague, diffuse epigastric / LUQ pain (70%) Pain indicates tumor spread beyond pancreas Maldigestion / diarrhea are early signs Weight loss a late sign Painless jaundice obstructive Sister Joseph's (Umbilical nodule) 11/9/2018

Diagnostic Test Multiphase thin-cut spiral CT scanning (80%) FNAC PET scanning Endoscopic US scanning 11/9/2018

Therapy Explorative surgery (30%) / Laparoscopy If localized - Radical pancreaticoduodenal (Whipple) resection Adjuvant chemo: Gemcitabine (Gemzar®) Fluorouracil, 5-FU (Adrucil®) Stenting of the duct 11/9/2018

Prognosis Body & Tail – poor (<2-5% 5 year survival) Ampulla better (20-40%) Jaundice and lymph node involvement –poor Palliative care are essential 11/9/2018