Pancreas

Pancreas-

-Acute/Chronic Pancreatitis-

-characterized by inflammation of the pancreas.  Can be acute or chronic
-causes auto digestion of pancreatic and peri-pancreatic tissues from the continuing release of digestive enzymes and vasoconstrictive substances

-most common etiologies gallbladder disease and alcohol (85-90%) of cases
-other etiologies include trauma, viral infections (mumps, cocksackie), hypercalcemia, hypertriglyceridemia, DKA, azathioprine, estrogen, thiazides, valproate, tetracycline, scorpion stings, methanol ingestion, SLE, periarteritis nodosa, and idiopathic

-signs and symptoms:  abdominal pain, nausea, vomiting, low grade fever, tachycardia, abdominal distention, and crackle in the bases
-Cullen's Sign-echymotic discoloration in the periumbilical region with severe pancreatitis
-Grey Turner's Sign-ecyhmotic discoloration in the flank with severe pancreatitis

-Labs reveal elevated lipase (more sensitive) and amylase (60-80% sensitive)
-Amylase and lipase considered specific if three times normal value
-May have mildly elevated WBC's, hypocalcemia, mild increase in bilirubin, decreased albumin, increased BUN, decreased HCO3

-Radiographs may find pancreatic calcifications in chronic disease, localized ileus, left pleural effusion/atelectasis

-Treatment is IV hydration, NPO, anti emetics, and analgesics
-Need to rest the pancreas

-Complications include: necrotizing pancreatitis, pancreatic pseudocyst, pancreatic abscess, exocrine insufficiency, and diabetes from endocrine insufficiency


-Ranson Criteria-
-Initial Criteria
Age >55
WBC > 16,000
Glucose >200
LDH > 350
AST > 250

-Criteria after 48 hours
Decrease in Hct >10%
Increase in BUN > 5
Calcium < 8.0
PaO2 < 60
BE > 4
Fluid Sequestration > 6 Liters

-Number of Criteria Present=
0-2=1% mortality
3-4=16% mortality
5-6=40% mortality
>7=100% mortality

-Chronic Pancreatitis presents as chronic unrelenting pain with flares over many years.
-Chronic Pancreatitis "burns out" over time and endocrine and exocrine dysfunction can develop
-Recommended cessation of alcohol intake, small meals, good hydration, and cessation of smoking
-Pancreatic enzyme supplements suppress exocrine secretion and relieve some pain in some patients
-Patients may need pseudocyst drainage if symptomatic


-Neoplasms-

-Pancreatic cancer is the forth in the cancers causing death in the US

-Pancreatic Ductal Adenocarcinoma- makes up about 85 percent of pancreatic cancers
-Diagnosis requires biopsy or surgical resection.  Has high mortality rate
-usually spreads to adjacent structures such as the duodenum, portal vein, and mesenteric vessels

-Pancreatic Intraepithelial Neoplasia (PanIN) is a small intraductal non invasive lesion that is formed by metaplasia and increased proliferation of the epithelium
-most pancreatic adenocarcinomas arise from PanIN
-considered to by a precursor to invasive ductal adenocarcinoma

-Intraductal Papillary Mucinous Neoplasms (IPMN) are cystic neoplasms derived from the pancreatic ducts
-Patients with IPMN can present with current episodes of pancreatitis
-Diagnosis is suspected when the papilla of Vater has thick mucus extruding from it
-Malignant potential is determined by the histology rather than its location

-Mucinous Cystic Neoplasms (MCN) are sharply demarcated cystic masses with a thick fibrous wall that occur in the body or tail of the pancreas

-Serous Cystadenomas are benign neoplasms

-Solid Pseudopapillary Neoplasms- begin as solid neoplasm that become cystic as they grow large and the cells become so far removed their blood supply and undergo apoptosis or necrosis
-Most of the time these lesions are cleared by resection but metastasis has been reported in a small percentage

-Acinar Cell Carcinoma-rare malignant neoplasms that are solid but sometimes cystic.  Prognosis is better than ductal adenocarcinomas

-Pancreatoblastomas-malignant lesions presumed to be of stem cell origin.  There is less of mortality rate for these lesions than with ductal adenocarcinomas