C1: Patients with endocrine function impairment; C2: Patients with exocrine function impairment; C3: Patients with exocrine/endocrine function impairment and/or complications.
A low-fat diet and pancreatic enteric coated tablets during meals, along with treatment of the underlying cause.
Whipple’s operation (Pancreaticoduodenectomy) involves removing the tumor along with the head and neck of the pancreas, C loop of duodenum, 40% distal stomach, 10 cm proximal jejunum, lower end of the common bile duct, gallbladder, and various lymph nodes.
The treatment is partial gastrectomy with removal of the 'G' cell area.
Approximately 20%
A liquid test meal containing protein, fat, and carbohydrate (300 ml) is given orally, and duodenal fluid is collected for 2 hours.
Abrupt block of pancreatic duct with irregular stricture, pancreatic duct encasement, double duct sign, parenchymal filling with scrambled egg appearance.
Atrophy of acini, hyperplasia of duct epithelium, interlobular fibrosis, calcifications, ductal dilatation, strictures in the duct, focal necrosis.
A — Hyperechoic foci with shadowing and calculi in the main pancreatic duct; B — Lobularity with honeycombing.
Gastrinoma.
The mortality rate in Whipple’s operation is between 2% and 8%.
50%.
Neoadjuvant chemoradiotherapy is becoming popular to improve resectability and survival, especially since only 20% of pancreatic carcinomas are amenable to surgical resection.
Pancreatoblastoma
3D/spiral CT scan, EUS, Laparoscopy, ERCP.
The most difficult situation is in patients with underlying chronic pancreatitis.
Tumor size less than 3 cm, periampullary tumors, and growth not adherent to the portal system.
Persistent pseudocyst, splenic vein thrombosis, fistula (pancreatico-enteric, pancreaticopleural fistula).
Distal pancreatectomy is the treatment of choice, and Prednisolone can help control diarrhea.
Mortality rates for pancreatic resection can range from 8% to 21%, which is considered very high.
Serum trypsinogen and trypsin level estimation, faecal fat estimation after collecting 72 hours of faecal fat, Pancreolauryl test, and Triolin breath test.
Pancreatic carcinoma is higher in men, particularly common in African American males and those of Jewish heritage and native Hawaiians.
Complications include delayed gastric emptying (19%), pancreatic fistula (14%), infections (intra-abdominal abscess, wound infection, cholangitis, pancreatitis, pneumonia), and bile leak.
Gastrinoma triangle (Passaro's triangle) - junction between the head and neck of the pancreas, junction of cystic duct with CBD, and junction between the 2nd and 3rd parts of the duodenum.
Analgesics, splanchnic nerve or coeliac plexus block, antioxidants, amitriptyline, fluoxetine, and octreotide.
Steatorrhoea can be controlled by proton pump inhibitors with 150,000 units of oral lipase and a low-fat diet, as PPIs inhibit acid in the stomach to prevent lipase inactivation.
The incidence of pancreatic divisum is 10%.
They can be solid (75%) or cystic, with infiltrating ductal adenocarcinoma being common.
Essential investigations include ultrasound, very high amylase and protein levels in ascitic fluid, ERCP to identify leaks, and CT scans.
Cysts; Dilated ducts ≥3.5 mm; Irregular PD contour; Dilated side branches ≥1 mm; Hyperechoic duct wall, strands; non-shadowing hyperechoic foci; Lobularity with non-contiguous lobules.
Ampullary tumors mainly present with jaundice and weight loss.
Injection vitamin K 10 mg IM for 5 days.
Increased serum bilirubin, decreased serum albumin, widened prothrombin time, and increased serum alkaline phosphatase are indicative.
Trousseau’s sign, which occurs in about 10% of cases, is characterized by migratory superficial thrombophlebitis due to the release of platelet aggregating factors from the tumor or its necrotic material.
Mean survival rate of 6 – 9 months.
CT scan, ERCP, fistulogram, amylase estimation of the discharge.
To evaluate pancreatic function by administering an initial test dose of secretin followed by a full dose, with fluid collected continuously in segregations.
Only 10-15% of pancreatic carcinomas (head) are operable.
Ductal adenocarcinoma (90%)
Non-modifiable risk factors include family history of chronic pancreatitis, advancing age, male sex, chronic pancreatitis, diabetes mellitus, and previous cholecystectomy.
Roux-en-Y choledochojejunostomy is an ideal palliative procedure used along with gastrojejunostomy after performing cholecystectomy.
Normal level <200 pg/ml.
Plain X-ray abdomen shows a double-bubble appearance, and barium meal shows obstruction at the 2nd part of the duodenum.
Major pancreatic secretion draining through the minor papilla can cause partial obstruction, leading to pancreatitis.
Post-operative care includes nutrition management (TPN/jejunostomy feed), fluid and electrolyte management, prevention/control of sepsis, and proper monitoring.
Correction of anemia, protein and amino acid deficiency, distal pancreatectomy, and occasionally Whipple’s/total pancreatectomy.
Secretin cholecystokinin test.
Causes include Whipple’s operation, pancreaticojejunostomy, splenectomy, colonic surgeries, trauma, and drainage of infected pseudocysts.
Triphasic Spiral CT/3D CT is ideal for detecting operability, portal vein invasion, size, extent, and nodal status.
Insulinoma.
Insulinomas are commonly benign; 15% are malignant.
An attack of hypoglycemia in fasting state, blood sugar below 45 mg%, and symptoms relieved by glucose.
Sterile necrosis (60% of total necrosis, 10% mortality) and infected necrosis (40% of total necrosis, 30-40% mortality).
Antibiotics (imipenem, cefuroxime, ofloxacin, meropenem), percutaneous drainage, laparotomy, necrosectomy, debridement, saline wash closure with tube irrigations/lavage.
Maldigestion of fat and proteins causing steatorrhoea and weight loss, metabolic bone disease, impaired night vision, and fat-soluble vitamin deficiencies. Vitamin B12 deficiency can occur due to decreased intestinal pH preventing transfer to intrinsic factor.
Adequate hydration, replenishing glycogen reserves, administering mannitol, vitamin K injection, and considering ERCP stenting if necessary.
ERCP (Endoscopic Retrograde Cholangiopancreatography).
Type I is characterized by 'G' cell hyperplasia with hypergastrinemia and chronic peptic ulceration.
Body and tail of the pancreas
The Whipple procedure (pancreaticoduodenectomy) involves en-bloc removal of the distal segment of the stomach, duodenum, proximal 15 cm of jejunum, head of pancreas, common bile duct, and gallbladder.
The ideal treatment is duodenoduodenostomy.
Persisting pain when endotherapy has failed, severe malabsorption, suspicion of malignant transformation, multiple relapses, complications like pseudocyst, segmental portal hypertension, biliary obstruction, pancreatic ductal dilatation >7 mm, pancreatic ascites/fistula, and pancreatic ductal stenosis.
Patients will experience high mortality and severe exocrine and endocrine deficiency, requiring permanent insulin and oral pancreatic enzyme therapy.
Serous cystic neoplasms
Nodal spread usually occurs to perihepatic nodes around the duodenum and CBD, subpyloric, and celiac nodes. Hard dark greenish nodes are typical, although nodal enlargement may often be due to reactive hyperplasia.
Metastatic symptoms include ascites, bone pain, CNS symptoms, and dyspnoea.
MRCP is non-invasive and visualizes the entire biliary tree, especially when there are no therapeutic indications for ERCP.
Trucut biopsies may cause bleeding, infection, leaks, and a negative biopsy will not rule out malignancy.
Treatment aimed at underlying aetiology, symptoms, and complications.
MEN syndrome (Type I, Wermer’s syndrome).
Poor prognosis.
Vipoma arises from D2 cells of the pancreas and is usually malignant.
Modifiable risk factors include smoking, obesity, a high-fat diet, a high-meat diet, and a diet low in vegetables and folate.
Complications can include pancreatic leak/fistula (10%), infection, bleeding, recurrence, and brittle diabetes.
Diagnosis includes DNA study, sweat test for sodium and chloride, and pulmonary function tests.
Depends on location; options include Whipple’s operation, distal pancreatectomy, or median pancreatectomy.
60% are curable; options include enucleation of tumors, distal pancreatectomy, pancreaticoduodenectomy, subtotal pancreatectomy, and often total gastrectomy.
Courvoisier’s sign refers to painless obstructive jaundice with a palpable gallbladder, indicating biliary obstruction.
EUS is used to assess the size of the primary tumor and to perform endosonographic FNAC, especially in periampullary carcinoma.
Symptoms include steatorrhoea and malabsorption.
ERCP may contaminate the biliary tree, leading to difficult dissection and postoperative sepsis.
Cystadenocarcinoma is common in the body and tail of the pancreas, presenting with epigastric pain radiating to the back and a non-mobile mass in the epigastrium.
Often ventilator is needed for 24 hours.
Gastrinoma, glucagonoma, VIPoma, pancreatic polypeptidoma.
Abdominal discomfort, trembling, sweating, hunger, dizziness, diplopia, hallucinations, later epilepsy and unconsciousness.
Associated problems like pancreatitis, diabetes mellitus.
Total parenteral nutrition, zinc oxide cream for skin excoriation, correction of electrolyte imbalance, antibiotics, octreotide.
The prognosis is very poor, with most patients having incurable disease at the time of diagnosis and an overall 5-year survival rate of about 5%.
A pancreatic duct diameter greater than 7 mm is an indication for surgery, specifically pancreaticojejunostomy.
Symptoms include severe exocrine dysfunction, chronic pulmonary disease, steatorrhea, and poor growth due to malabsorption.
Cystic neoplasms have high viscosity and high CEA, while pseudocysts have low viscosity and low CEA.
Therapeutic ERCP is useful for the removal of stones in a dilated duct.
Endoscopic therapy is less invasive, can be repeated, has less severe complications, and can be used as bridge therapy prior to surgery.
Fasting glucagon level more than 50 pmol/litre.
Drainage or pancreatic duct decompression is preferred in patients with dilated ducts.
Distant spread commonly occurs to the liver as multiple secondaries in both lobes, and occasionally to the lungs, adrenals, brain, and bone.
Observation for bleeding and its control by transfusion of blood, fresh frozen plasma (FFP), and prevention of DIC.
The barium meal shows a widened duodenal 'C' loop, known as the pad sign, and the reverse 3 sign.
CA 19-9 is a carbohydrate antigen that is not a screening test but can act as a prognostic marker and indicate tumor recurrence.
Avoid alcohol; low fat, high protein, high carbohydrate diet; small and more frequent meals.
100 – 150 pg/ml; levels above 200 pg/ml are considered high.
It is a diffuse or focal area of non-viable parenchyma of the pancreas that occurs during an attack of severe pancreatitis, associated with peripancreatic fat necrosis.
CT scan abdomen and CT-guided FNA for Gram’s staining and culture, CRP value >120 mg/litre, interleukin level, elastase level, urinary TAP assessment.
Mutational activation of KRAS oncogene
PERT is used to relieve pain based on the negative feedback mechanism of pain, where the protease content is responsible for pain relief. It may be beneficial only in females with idiopathic pancreatitis, small duct disease, and pancreas divisum.
First-degree relatives have a 9X increased risk of pancreatic cancer over the general population, which increases to 32X with three or more first-degree relatives affected.
The ventral pancreatic bud forms the main pancreatic duct of Wirsung, while the dorsal bud forms the accessory pancreatic duct of Santorini.
Steatorrhoea is treated with enzyme replacement therapy.
Pancreatic ascites can occur in chronic pancreatitis or as a complication of acute pancreatitis, with an incidence of 1%.
Local spread occurs to adjacent structures like the duodenum, portal vein, superior mesenteric vein, and retroperitoneum. It is more likely in carcinoma of the head of the pancreas than in periampullary carcinoma, especially when the carcinoma head exceeds 3 cm in size.
If there is no improvement, ERCP stenting of the pancreatic duct is done initially, followed by resection or drainage surgery.
Volume is normal (>2 ml/kg) but bicarbonate content is less than 80 mEq/L.
Cystadenocarcinoma presents with pain, weight loss, and a mass, with obstructive jaundice associated with pruritus.
Abdominal X-Ray, CT/MRI, and MRCP.
To suppress pancreatic secretion so as to prevent leak.
Growth more than 3 cm.
Non-beta cells (G cells) of the pancreas.
Roux-en-Y anastomosis, resection of fistula with pancreas, endoscopic stenting of the pancreatic duct.
65% are polymicrobial; commonest is E. coli, along with Proteus, Pseudomonas, Klebsiella, staphylococci, Streptococcus faecalis, enterococci, anaerobes, Clostridium welchii.
MEN I syndrome.
Genetic syndromes include Peutz-Jegher syndrome, HNPCC, ataxia telangiectasia, hereditary breast and ovarian cancers, and familial adenomatous polyposis (FAP).
Pancreatic divisum is the failure of fusion of ventral and dorsal pancreatic ducts, resulting in the dorsal pancreas draining through the duct of Santorini and the ventral one draining through the duct of Wirsung.
MRI, CT scan, Endosonography, and Angiogram.
Common in females (90%) and often seen in the early age group.
The phases involved are arterial, venous, and portal venous.
Diabetes mellitus is significant, with 25% of patients having it at diagnosis, and new onset DM within the year prior to diagnosis found in 15% of patients.
A biopsy specimen is not needed when the suspicion of cancer is high, as ERCP can be used to take biopsy/brush cytology.
Trousseau’s Sign refers to migratory thrombophlebitis, occurring in 6% of patients due to tumor-elaborated procoagulants.
It is a simple and cheap test for assessing pancreatic function to determine if the patient has significant steatorrhea.
Symptoms include diarrhea, steatorrhea, acholic stools, and tea-colored urine.
Early features include persistent and progressive jaundice, with occult blood in stool and growth not visible on endoscopic examination.
Nodal involvement.
Septicaemia, ARDS, renal failure, MODS, pancreatic fistula after surgery, intra-abdominal abscess, abdominal dehiscence, incisional hernia after surgery.
The principle is that the pancreas and duodenum share the same arterial blood supply (gastroduodenal artery), so both must be removed.
Adjuvant chemotherapy may include gemcitabine, 5-fluorouracil, mitomycin, vincristine, cisplatin, docetaxel, leucoverin, and abraxane (paclitaxel protein bound, oxaliplatin).
Necrolytic migratory erythema (65%).
The role of somatostatin and its analogues is not clear in the management of chronic pancreatitis.
Conservative therapies include repeated ascitic tap, pleural tap, TPN, and somatostatin or octreotide to reduce pancreatic secretion.
Maintenance of proper fluid and electrolyte balance.
Carcinoma of the head and neck region presents with weight loss and jaundice.
Ideally post-operative ICU care is better.
Mannitol should be continued.
CT-guided 50% of 20 ml ethanol injection into coeliac ganglion.
Insulin radioimmunoassay, MRI, angiogram, hormone assay, endosonography, blood sugar estimation.
25% in one week, 35% at the end of the 2nd week, and 70% at the end of the 3rd week.
Persisting pain is the main indication when endotherapy has failed.
Common symptoms include nausea and vomiting.
Tissue diagnosis is crucial to rule out benign disorders such as autoimmune pancreatitis.
Pancreatic fistula can be classified into external and internal types, with low output fistulae being <200 ml and high output fistulae being >200 ml.
Abnormal test results in 14-65% of cases.
Pain can occur in the right hypochondrium, epigastrium, or left hypochondrium depending on the tumor's location. Back pain may arise from retropancreatic nerve involvement or pancreatic duct obstruction.
CEA is often done in suspected cystadenocarcinoma.
Late features include intermittent jaundice, silvery stools, visible growth on endoscopic examination, and a generally poor prognosis.
Enucleation, distal pancreatectomy, Diazoxide, beta blockers, phenytoin, verapamil, steroids, growth hormone, octreotide, calcium channel blockers, and streptozotocin.
Communicating pseudocyst, pancreatic ascites, pancreatic pleural effusion, pancreatic-enteric fistulae.
Haematogenous, reflux through ampulla, mucosal translocation of bacteria, from the biliary tree, lymphatic route, transperitoneal spread.
