chronic pancreatitis

• Chronic pancreatitis

• It is a chronic inflammatory disease due to repeated bouts of pancreatitis in which there is irreversible destruction of pancreatic tissue and pancreatic function.
• It is characterized by progressive fibrosis and calcification of the pancreas.
• Later the pancreas enlarges and become hard.
• The duct become distorted, either strictured or dilated containing plugs or stones.

ERCP

Calcification

Etiology:

• Alcoholic abuse: 60-70%
• Idiopathic 20-30%
• Less common causes 10%
• Pancreatic duct obstruction
• Pancreas divisum
• Trauma
• Hypercalcemia
• Hypertriglyceridemia
• hyperparathyroidism


Clinical features
• 1. Pain: is the outstanding symptoms in the majority of patients, it is dull and gnawing.
• The site depends on the actual focus of the disease, it may radiate to the shoulder and back.
• Nausea and vomiting are common.
• The number of hospital admission and analgesic abuse, give an indicator to the severity of the disease.
• All the complications of acute pancreatitis can occur, jaundice in 15%
• 2. Classic triad
• Weight loss, steatorrhea, diabetes

• Investigations

• Serum amylase will rise in the early stages of the disease
• Plain X-ray show calcification or stones
• MRI, CT scan: will show the outline and the area of damage. Calcifications seen on CT but not on MRI.
• MRCP: will identify the presence of biliary obstruction and the state of the pancreatic duct.
• ERCP : The most accurate test to determine the anatomy of the pancreatic duct.
• Pure pancreatic juice can be obtained for cytology.
• Therapeutic endoscopic papillotomy.

• Conservative treatment

• Control of pain
• Correction of the malabsorption
• treatment of diabetes
• Avoid alcohol intake
• Nutritional and digestive measures
• Surgical treatment : indications
• 1. Persistent uncontrollable pain
• 2. Relief of biliary or pancr. duct obstruction.


Carcinoma of the Pancreas
• Incidence and Aetiology:
• It is the sixth most common cancer causing death.
• It affects males more than females.
• Peak incidence between 65-75 years.
• Prognosis is poor. 5 year survival < 5%.
• Cigarette smoking.
• Family history.
• Chronic pancreatitis
• Hereditary pancreatitis

Pathology:

Adenocarcinoma accounts for 85% of cases, they are solid scirrhous tumors
(1) Cancer of the head (70%)
head proper 2/3
periampullary 1/3
(2) Cancer body and tail (30%)
• The growth is infiltrating, hard, and irregular.
• Spread
• Direct: duodenum
• Lymphatic:
• Blood:
• Peritoneal implantation

Ca Pancreas

• Clinical picture

• (a) Cancer head : Symptoms:
1. Obstructive jaundice : painless progressive in 75%
2. pain: steady, dull, epigastric, radiated to the back.
3. Loss of weight, weakness, and anorexia.
4. Steatorrhea, diabetes, malignant ascites, acute pancreatitis, gastric outlet obstruction.
Signs:
Enlarged liver due to multiple metastasis.
Palpable non tender gall bladder in 60%
Palpable hard epigastric mass
Ascites, secondaries, thrombophlebitis (trousseau’s sign) , and Virchow’s glands.

ERCP: irregular stricture Ca pancreas

CT scan Ca pancreas

• (b) Carcinoma of the body and tail:

• Intractable pain. The pain is relieved by leaning forward, it is not related to food.
• Loss of weight, weakness, anorexia.
• Jaundice in 10% may occur due to LN in porta hepatis.
• Sudden onset of diabetes in 25%
• Differential diagnosis:
• Calcular obstructive jaundice
• Chronic pancreatitis

Complications:

• 1. Pancreatic asthenia and cachexia due to
• a. steatorrhea
• b. exhaustion from insomnia due to pain and pruritus.
• 2. Malignant obstructive jaundice.
• 3. Duodenal or pyloric obstruction
• 4. Ascites: from metastasis, portal v. pressure.
• 5. Edema of the lower limbs
• 6. Splenic V. thrombosis in 10%


• Investigation
• Laboratory:
• Liver function test
• Serum bilirubin level
• alkaline phosphatase level
• Low prothrombin concentration.
• Carcinoembryonic antigen (CEA) and CA19-9 antigen
• Imaging:
• Ultrasound: is the first examination to be ordered in obstructive jaundice.

• EUS is more useful in the diagnosis and follow up.

• CT scan: the preferred test is contrast enhanced CT scan:
• It guides for percutaneous FNAC. If the tumor is small (less than 4 cm) and confined to the head without evidence of distant metastasis or vascular invasion should undergo surgery.
• MRI:
• ERCP:
• Barium meal: “ pad sign” which is widening of the C-shaped duodenal loop.
• The reversed 3 sign due to filling defect of the periampullary mass.
• Angiography.
• laparoscopy

Treatment

At the time of presentation 85% of patients are unsuitable for resection because the disease is advanced.
_ potentially curable and fit for surgery : surgery is the best treatment. PPPD operation.
_ late and unfit patient: drainage procedures by endoscopic stenting or surgical anastomosis.
Adjuvant therapy: 5-FU, or gemcitabine

INSULINOMA:

 The commonest islet cell tumor. In males less than 40 years old usually overweight. Usually benign.
Clinical features:
Hypoglycemia less than 45mg/dl
• Relieved by glucose
• Investigations
• Measurement of bd. sugar
• Preoperative localization
• Treatment:
• surgery