Pancreatitis

Inflammation of the pancreas may be acute or chronic.

Acute Pancreatitis

May effect any age group Mortality about 10%

5 -100 new cases per million per year Increasing in incidence in the UK

Pathophysiology

Severity may vary from mild oedema to very severe with necrosis and haemorrhage

Reflux of duodenal juice and bile into the pancreatic system and/or spasm/blockage of the sphincter of Oddi

Premature activation of pancreatic enzymes which rupture the duct system leading to autodigestion

Autodigestion ----- cell necrosis ------- further enzyme release

Trypsinogen, chymotrypsinogen, lipase are activated and start a chain reaction of cell necrosis

Retroperitoneal and peritoneal exudation ------ Fluid, electrolyte and protein loss from circulation

Enzymes and vasoactive substances leak into the blood stream

Both of the above contribute to shock

Complications include renal failure, shock lung, ECG changes suggesting ischaemia, abscess and cyst formation, hypocalcaemia, diabetes

Aetiology

50% Biliary tract disease usually gall stones 20% Alcohol

20% Idiopathic 5% Traumatic e.g. blunt trauma

All the above are UK figures - populations who drink more alcohol have more alcohol associated disease.

Proportion of disease associated alcohol varies around the world

E.g. France its 50 - 90 % of cases, Scotland its 30%

Gall stones

These block of the common channel of the pancreatic duct and the bile duct causing bile to flow the wrong way up the pancreatic duct.

Stones (usually 1 - 12 mm) often found in faeces a few days after the onset of the pancreatitis

Transient impaction of the sphincter of Oddi

Alcohol

Mechanism is uncertain - may be a specific toxic effect, pancreatic hypersecterion with plug formation, spasm of Oddi, or duodenitis

Minor correlates include

Pancreatic cancers Steroids Hyperlipidaemia Some viral infections

Clinical features

May be delayed for 24 hours after drinking alcohol

Agonising pain in the epigastrium or right hypochondrium often with radiation through to the back.

Nausea, vomiting, retching

Accompanied by shock if severe

Little muscle guarding or rigidity, only slight tenderness

Bruising around the umbilicus and loin are late signs

Diagnosis

Clinical picture Patient history

Serum amylase - normal = 100 - 300 iu/l > 1000 strongly supports diagnosis

Amylase in urine

Management

No specific treatment

Treat underlying condition - Treat gall store/bladder disease, stop drinking alcohol

Pain relief

Treatment of shock - crystalloid and colloids

Oxygen therapy essential if shocked

Suspend pancreatic function

No food or drink

Nasogastric aspiration

TPN

Anticholinergics inhibit vagal activity and relax the sphincter of Oddi but do not seem to help

Surgery carries about 50% mortality

Chronic Pancreatitis

Aetiology

Alcohol most common, bile stones second

Caused by malnutrition in third world

Pathophysiology

Chronic inflammation leads to progressive fibrosis of gland

Progressive fibrosis of all pancreatic tissue

Multiple strictures lead to further obstruction and inflammation

Clinical features

Weight loss

Malabsorption and steatorrhoea

Stools - pale, bulky, offensive, float

Pain - may be made worse by eating

Epigastric pain - may radiate to back - sometimes relieved by leaning forward

Some jaundice possible

Diabetes mellitus develops

Diagnosis and investigations

Tests to evaluate exocrine function - from duodenal secretions

Faecal fat estimations - should be about 5%

X ray reveals a speckled calcification

Ultrasound and CT

Management

Deal with cause then deal with functional deficiency

Analgesics

Functional management

Treat diabetes

Give deficient exocrine enzymes - H2 antagonist will help oral enzymes to work better

Carcinoma - pancreas

Pathophysiology

Benign pancreatic neoplasm is rare and usually asmptomatic

Almost always adenocarcinoma

Exocrine tissue most commonly effected

Most commonly effects head of pancreas ------ obstruction

Local spread and local lymphatic spread

Metastatic spread - often liver first

Usually spread is too extensive at time of diagnosis -------- 5 year survival uncommon

Aetiology

Don’t know

Fourth most common cause of cancer deaths in men and sixth in women

Men effected more than women

Possible factors - alcohol, smoking, high fat and/or protein diet

Clinical features

Most commonly seen between 55 - 70 years

Epigastric or ill defined upper abdominal pain radiated through to the back - often worse lying down, helped by leaning forward

Weigh loss often first feature

Nausea, anorexia

Obstructive jaundice - usually progressive as opposed to fluctuating

Palpable gall bladder

Possible diabetes and steatorrhoea

Diagnosis and investigations

Confirm obstructive nature of jaundice Ultrasound - dilation of biliary tree

ERCP CT

Percutaneous fine needle aspiration

Management

Surgical resection the only prospect of cure

Whipple`s procedure - pancreaticoduodenectomy

Relief of obstruction Stents Pain relief Chemotherapy not very useful

Endocrine tumours

Uncommon

May be functional

Insulinoma most common 90% of which are benign

Glucagonoma may also rarely occur