Pancreatic Pancreatic diseasesdiseases

WU JIAN WU JIAN Department of hepatobiliary Surgery Department of hepatobiliary Surgery

First Affiliated HospitalFirst Affiliated HospitalZhejiang University School of MedicineZhejiang University School of Medicine

Pancreas: Anatomy and Pancreas: Anatomy and PhysiologyPhysiology

Retroperitoneal organRetroperitoneal organ 15-20cm in length15-20cm in length Head, neck, body and tailHead, neck, body and tail Uncinate process: curves behind the superior mesenteUncinate process: curves behind the superior mesente

ric vessels ric vessels

PosteriorPosterior L1-2 vertebral cL1-2 vertebral c

olumnolumn AnteriorAnterior stomach, omenstomach, omen

tumtum RightRight DuodenumDuodenum LeftLeft Splenic hilumSplenic hilum

Neighborhood of the Neighborhood of the pancreaspancreas

Main duct : Wirsung ( 1642)Main duct : Wirsung ( 1642) Ampula: Vater (1720)Ampula: Vater (1720) Accessory duct : Santorini( 173Accessory duct : Santorini( 173

4)4)

Pancreas: blood Pancreas: blood supplysupply

HEADHEAD ：： Superior pancreatoduodSuperior pancreatoduod

enal A. (from gastroduodenal A. (from gastroduodenal A.)enal A.)

Inferior pancreatoduodeInferior pancreatoduodenal A. (from SMA)nal A. (from SMA)

BODY AND TAILBODY AND TAIL ：： superior pancreatic A.superior pancreatic A. pancreatic magna A.pancreatic magna A. transverse pancreatic A.transverse pancreatic A. VEINVEIN ：： to splenic vein ,SMV and to splenic vein ,SMV and

portal veinportal vein

Lymphatic drainage of Lymphatic drainage of pancreaspancreas

Common Common

pathwaypathway

PhysiologyPhysiology

ExocrineExocrine ：： pancreatic juicepancreatic juice 。。 HCOHCO33

-- and digestive enzyme and digestive enzyme

EndocrineEndocrine ：： A cellA cell ：： glycagonglycagon B cellB cell ：： insulininsulin D cell D cell ：： somatostatinsomatostatin G cell G cell ：： gastringastrin

Acute PancreatitisAcute Pancreatitis Chronic PancreatitisChronic Pancreatitis Pancreatic cancerPancreatic cancer Periampullary cancePeriampullary cance

rr Endocrinal tumor Endocrinal tumor

AcuteAcute PancreatitisPancreatitis

Common acute abdomenCommon acute abdomen Local inflammatory change in Local inflammatory change in

pancreaspancreas Systemic changeSystemic change Life-threatening inflammatory Life-threatening inflammatory

disorder of the pancreasdisorder of the pancreas Abrupt onset and Abrupt onset and

unpredictable courseunpredictable course Variable severity and durationVariable severity and duration Self-limited but remarkable Self-limited but remarkable

morbidity and mortalitymorbidity and mortality

EtiologyEtiology Biliary tract diseaseBiliary tract disease Abuse of ethanolAbuse of ethanol Endoscopic retrograde cholangioEndoscopic retrograde cholangio

pancreatographypancreatography Trauma and operation Trauma and operation Ischemia of pancreasIschemia of pancreas DrugsDrugs Idiopathic pancreatitisIdiopathic pancreatitis Hypercalcemia Hypercalcemia Hyperlipidemia Hyperlipidemia Infections and Parasites Infections and Parasites Scorpion sting Scorpion sting

PATHOGENESISPATHOGENESIS

““Self digestion”Self digestion”

Reflux of bile or duodenal juiceReflux of bile or duodenal juice

Trypsinogen was activatedTrypsinogen was activated

Trypsin can activate the other zymogensTrypsin can activate the other zymogens

Intraparenchymal enzyme activation, tissue dIntraparenchymal enzyme activation, tissue d

estruction, and ischaemic necrosis.estruction, and ischaemic necrosis.

Pathological and Pathological and clinical typeclinical type

Pathological type Pathological type Acute edematic pancreatitisAcute edematic pancreatitis Acute hemorrhgic and necrotic pancreatitis Acute hemorrhgic and necrotic pancreatitis

(AHNP)(AHNP)

Clinical typeClinical type Mild Acute pancreatitis (MAP)Mild Acute pancreatitis (MAP) Severe Acute pancreatitis (SAP)Severe Acute pancreatitis (SAP) Fulminant Acute pancreatitis (FAP)Fulminant Acute pancreatitis (FAP)

Clinical manifestationsClinical manifestations

Abdominal painAbdominal pain Nausea, vomitingNausea, vomiting Distension Tenderness, rebound tenderness, muscular regTenderness, rebound tenderness, muscular reg

ardard FeverFever ，， jaundicejaundice ， ， Gray-Turner sign: flank ecchymoses Gray-Turner sign: flank ecchymoses Cullen sign: periumbilical ecchymoses Cullen sign: periumbilical ecchymoses MODSMODS

laboratory testlaboratory test

Amylase level in serum and in urineAmylase level in serum and in urine

Lipase assaysLipase assays

Blood Rt, liver function, FBS, PaCO2 Blood Rt, liver function, FBS, PaCO2 ,serum calcium, DIC,serum calcium, DIC

Diagnostic paracentesisDiagnostic paracentesis

Image findingsImage findings

BUSBUS CT CT ERCPERCP MRCPMRCP Abdomen plain Abdomen plain

filmfilm

Pancreatic necrosisPancreatic necrosis Infective pancreatic necrosisInfective pancreatic necrosis

Sterile pancreatic necrosisSterile pancreatic necrosis

Pancreatic abscessPancreatic abscess

Pancreatic pseudocystPancreatic pseudocyst

Local complicationLocal complication

Acute pancreatic pseudocystAcute pancreatic pseudocyst

Peripancreatic fluid collections occur in 1Peripancreatic fluid collections occur in 10-20 % of patients0-20 % of patients

Those persisting beyond the phase of acute Those persisting beyond the phase of acute inflammation become pancreatic pseudocyinflammation become pancreatic pseudocystssts

Collection surrounded by fibrous tissue or Collection surrounded by fibrous tissue or granula tissuegranula tissue

Diagnosed by PE or image test Diagnosed by PE or image test Round or ellipseRound or ellipse Clear cyst wallClear cyst wall

Severe Acute PancreatitisSevere Acute Pancreatitis

Severe Acute pancreatitis (SAP)Severe Acute pancreatitis (SAP) Complicated with MODSComplicated with MODS

Necrosis, abscess, pseudocystNecrosis, abscess, pseudocyst

Or bothOr both

ClassificationClassification systemsystem

General evaluationGeneral evaluation John Ranson score (1974):5 (on admission) +6 (48hr)John Ranson score (1974):5 (on admission) +6 (48hr) Imrie score:8 (WBC,Ca,sugar,PO2,LF) Imrie score:8 (WBC,Ca,sugar,PO2,LF) APACHE II score (1985):12+ageAPACHE II score (1985):12+age ＋＋ Chronic health+coma Chronic health+coma

Atlanta classification system(1992)Atlanta classification system(1992) Local evaluation Local evaluation

Beger’ criteria (1985) Beger’ criteria (1985) Balthazar CT classification system (1990):I, II, III GRADBalthazar CT classification system (1990):I, II, III GRAD

EE MODS evaluationMODS evaluation

Marshall MODS score system(1995):6 systems/organs inMarshall MODS score system(1995):6 systems/organs involved volved

Clinical manifestation of SAPClinical manifestation of SAP

Abdominal sign: obvious tenderness, rebound tendAbdominal sign: obvious tenderness, rebound tenderness, muscular regard, distension, lose of bowl serness, muscular regard, distension, lose of bowl soundound

Mass in abdomen, GreyMass in abdomen, Grey －－ Turner, CullenTurner, Cullen MODSMODS Irreversible shockIrreversible shock CT: swellingCT: swelling ，， uneven density, invade to outside of uneven density, invade to outside of

pancreas(Balthazar CTpancreas(Balthazar CT>>II)II) APACHE valueAPACHE value>>88

MODSMODS

Cardiac functionCardiac function ：： quick pulsequick pulse 、、 shockshock Pulmonary function Pulmonary function ：： PaO2<60mmHgPaO2<60mmHg ，， AA

RDSRDS Liver functionLiver function ：： jaundicejaundice ， ， elevated ALTelevated ALT Renal functionRenal function ：： elevated BUN and Creatinielevated BUN and Creatini

nene Digestive functionDigestive function ：： GI bleedingGI bleeding Endocrinal function Endocrinal function ：： glucose>11.1mmol/Lglucose>11.1mmol/L Coagulation systemCoagulation system ：： DICDIC Nerve systemNerve system ：： unclear consciousnessunclear consciousness 、、 papa

ncreatic brain disease ncreatic brain disease

Stage of SAPStage of SAP

Acute response stage ： within 2 weeks

complicated with shock,ARDS,renal failure

Systemic infection stage ： 2 weeks to 2 months

Bacteria or fungus infection

Post-infection stage ： after 2 3 months

Abscess, fistula,

TREATMENTREATMENTT

I.I. Non-operative Non-operative therapytherapy

Acute Response StageAcute Response Stage

ICU ICU ：： to prevent MODSto prevent MODS fasting the patient, fasting the patient, nasogastric suctionnasogastric suction Minimizing pancreatic secretionMinimizing pancreatic secretion

antacidsantacids 5-FU5-FU somatostatin analoguessomatostatin analogues antiproteaseantiprotease

Fluid replacementFluid replacement and Nutritional support and Nutritional support maintenance of adequate hydrationmaintenance of adequate hydration TPNTPN ，， glucose ,lipid, amino acid, proteinglucose ,lipid, amino acid, protein

AnalgesiaAnalgesia AntibioticsAntibiotics Traditional Chinese MedicineTraditional Chinese Medicine Abdominal lavageAbdominal lavage

II. OperationII. Operation

Indication of OperationIndication of Operation

Biliary obstructionBiliary obstruction Secondary pancreatic infectionSecondary pancreatic infection Shock cannot be reversed,Shock cannot be reversed, multiple ogan deterioratemultiple ogan deteriorate Undetermined diagnosis, need Undetermined diagnosis, need

to laparotomyto laparotomy

Principle for treatment of Principle for treatment of pancreatitispancreatitis

MAPMAP SAPSAP

BiliaryBiliary Non-biliaryNon-biliary

ObstuctiveObstuctive Non-obstructiveNon-obstructive InfectionInfection No No infectioninfection

Conservative Conservative therapytherapy

Urgent operationUrgent operationOr ERCPOr ERCP Conservative Conservative

therapytherapyElective operationElective operation

Elective operationElective operation

Conservative Conservative therapytherapy

Chronic pancreatitisChronic pancreatitis

Recurrent upper abdominal painRecurrent upper abdominal pain

With dysfunction of endocrine and With dysfunction of endocrine and

exocrine of pancreasexocrine of pancreas

Clinical manifestitionClinical manifestition

Four main symptomsFour main symptoms

Abdominal painAbdominal pain

Body weight lossBody weight loss

DiabetesDiabetes

Lipid diarrheaLipid diarrhea

Therapy of chronic Therapy of chronic pancreatitispancreatitis

Relieve painRelieve pain

Drainage of the pancreatic juiceDrainage of the pancreatic juice

Prevent acute attackPrevent acute attack

Ameliorate the nutritionAmeliorate the nutrition

Improve pancreatic functionImprove pancreatic function

Non-operation or operationNon-operation or operation

Pancreatic Cyst Pancreatic Cyst

Pancreatic pseudocystPancreatic pseudocyst

Congenital pancreatic cystCongenital pancreatic cyst

Retention pancreatic cystRetention pancreatic cyst

Neoplastic pancreatic cystNeoplastic pancreatic cyst

Pancreatic cystadenomaPancreatic cystadenoma

Pancreatic cystadenocarcinomaPancreatic cystadenocarcinoma

Pancreatic pseudocystPancreatic pseudocyst

Indication for operationIndication for operation Associated with ongoing painAssociated with ongoing pain More than 6 cm in diameter which persist for 6 More than 6 cm in diameter which persist for 6

weeks weeks Cyst with haemorrhage and sepsisCyst with haemorrhage and sepsis

MethodsMethods Percutaneous drainagePercutaneous drainage Operative drainageOperative drainage Cystgastrostomy, cystjejunostomyCystgastrostomy, cystjejunostomy Resection of pancreatic body and tailResection of pancreatic body and tail

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