Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pancreatic disorders Sampath Poreddy Assistant Professor

Similar presentations


Presentation on theme: "Pancreatic disorders Sampath Poreddy Assistant Professor"— Presentation transcript:

1 Pancreatic disorders Sampath Poreddy Assistant Professor
Gastroenterology/Advanced endoscopy University of Cincinnati

2 52yoM cc acute severe epigastric pain x 1 day. VS NML
52yoM cc acute severe epigastric pain x 1 day. VS NML. His abdominal exam showed epigastric tenderness. BS absent. Other systems NML. His labs showed lipase level of 3000 units, Total bili: 4.5, Alk phos: 350, ALT: 120, AST: All of the following measures are true regarding his initial management except for: Start ringers lactate at mL/hr CT scan with contrast ERCP Check ultrasound of abdomen B – CT abdomen w/ contrast

3 Acute Pancreatitis 2/3 of the following criteria
Epigastric pain consistent w/ pancreatitis Serum amylase/ lipase level >3x ULN Radiologic imaging consistent w/ pancreatitis, usually on CT or MRI

4 Approach to Pancreatic Disorders
Lipase: best single enzyme to measure to dx AP No single blood test is reliable for the dx of AP in pts w/ renal failure NML amylase/ lipase may be seen in: delay (of 2–5 days) in blood draw chronic pancreatitis rather than acute pancreatitis hypertriglyceridemia AP = acute pancreatitis

5 Hyperamylasemia Elevated Renal insufficiency Macroamylasemia
Salivary gland lesions Burns Mumps Diabetic ketoacidosis Calculus Pregnancy Irradiation sialadenitis Renal transplantation Maxillofacial surgery Cerebral trauma “Tumor” hyperamylasemia Drugs: opiates lung, esophagus, breast, ovary

6 Hyperamylasemia Other intra-abdominal disorders Biliary tract dz:
cholecystitis, choledocholithiasis Intra-abdominal dz Perforated or penetrating peptic ulcer Intestinal obstruction or inflammation Ruptured ectopic pregnancy Peritonitis Aortic aneurysm Postoperative hyperamylasemia

7 Ascitic Fluid Amylase Disruption of pancreatic duct Leaking pseudocyst
Abdominal disorders that simulate pancreatitis (e.g., intestinal obstruction, intestinal infarction, or perforated peptic ulcer) Elevation of pleural fluid amylase acute pancreatitis chronic pancreatitis carcinoma of the lung esophageal perforation

8 Severity of Acute Pancreatitis

9 BISAP Score B UN >25 mg/dL i mpaired mental status S IRS
a ge >60yo p leural effusion A BISAP score of 4 or 5 is associated w/ 7-12x inc’d risk of developing organ failure

10 Severity of Acute Pancreatitis
Other acceptable markers of severe pancreatitis: 3+ of Ranson's 11 criteria for non-gallstone pancreatitis Acute Physiology and Chronic Health Evaluation (APACHE-II) score >8

11 Etiology of acute pancreatitis
Gall stones – ~40% Ethyl EtOH – ~30% Drugs: 6-mp, azathioprine, l-asparginage, HCTZ, lasix, sulpha, sulfasalazine, mesalamine, estrogens, valproate Infx: mumps, coxsackie virus AIDS: CMV, pentamidine, diadanosine

12 Etiology of acute pancreatitis
Tumors: IPMN Metabolic factors: high TG and calcium (lipoprotein lipase deficiency and apoprotein-CII (APO-CII) deficiency) Trauma Post ERCP Scorpion venom, Organophosphorous poisoning Hereditary/familial/genetic

13 Mgmt of acute pancreatitis

14 Mgmt of acute pancreatitis

15 Mgmt of acute pancreatitis

16 Mgmt of acute pancreatitis

17 Chronic Pancreatitis Characterized by a constellation of features including: exposure to known risk factors genetic background symptoms: pain derangements in pancreatic exocrine or endocrine fx structural changes, +/- visible on imaging, calcifications histology

18 Risk Factors EtOH, smoking, Hypercalcemia, Hypertriglyceridemia, CKD
Idiopathic Tropical calcific pancreatitis Fibrocalculous pancreatic diabetes Genetic Autosomal dominant Hereditary pancreatitis (PRSS1 mutations) Autosomal recessive or modifier genes Mutations of CFTR, SPINK1, Chymotrypsin C mutation, Claudin mutation, Calcium-sensing receptor gene mutations

19 Risk Factors Autoimmune Pancreatitis – IGg4
Postnecrotic (after severe necrotizing pancreatitis) Vascular dz/ischemia Obstructive Benign pancreatic duct obstruction Traumatic stricture Stricture after severe acute pancreatitis Ampullary obstruction Sphincter of Oddi stenosis or SOD Celiac dz Malignant pancreatic duct obstruction Ampullary carcinoma Duodenal carcinoma Pancreatic ductal adenocarcinoma Intraductal papillary mucinous neoplasm

20 Chronic Pancreatits Tx
Chronic Pain: Tramadol, TCA, viokase, neurontin, narcotics, CPB etc. Endoscopic therapy: stone removal, rx for stricture Surgical therapy: lateral pancreaticojejunostomy Exocrine insufficiency: weight loss, steatorrhea pancreatic enzyme replacement, vitamin ADEK Endocrine insufficiency: Insulin

21 Pancreatic Adenocarcinoma
Clinical Presentation Obstructive jaundice abdominal discomfort/pain, pruritus, lethargy, and weight loss Physical Signs Courvoisier’s sign – palpable gallbladder left supraclavicular lymphadenopathy - Virchow’s node periumbilical nodules - Sister Mary Joseph’s nodes Mgmt CT pancreas protocol/MRI Surgery – resectable tumors +/-neoadjuvant/adjuvant chemo Chemo – unresectable tumors Celiac plexus neurolysis Biliary decompression

22 Pancreatic Adenocarcinoma Tumor Markers
CA19-9 is elevated in about 70–80% Not recommended as a routine dx’c or screening test Preoperative CA19-9 levels Correlate with tumor stage Post resection CA19-9 level prognostic value indicator of asymptomatic recurrence

23 Start high dose PPI therapy Secretin stimulation study
28yoF cc postprandial epigastric pain > 1yr. Abdominal exam showed epigastric tenderness. Denies h/o NSAID usage. Her EGD exam showed multiple gastric and duodenal ulcers. Gastric rugal folds are enlarged. Gastric biopsies were negative for H pylori but showed parietal cell hyperplasia. Serum fasting gastrin level was 1500 pg/ml. Gastric PH was All of the following options regarding her mgmt are true except Start high dose PPI therapy Secretin stimulation study CT scan of the abdomen PTH level Surgical consult B – secretin stimulation study

24 Gastrinomas (Zollinger-Ellison syndrome)
Hypergastrinemia and gastric acid output Presentation: abdominal pain – PUD, Diarrhea GERD, diarrhea only Fasting gastrin >1000 pg/mL + gastric pH ≤2.0 (if no retained antrum syndrome) Fasting gastrin <1000 pg/mL (<10x inc’d) and gastric pH ≤2.0 determination of basal acid output secretin provocative test

25 Zollinger-Ellison Syndrome Tx
PPI or frequent H2A Hyperparathyroidism Long-term PPIs (>15 years) are safe and effective Long term PPI use: vitamin B12 deficiency Gastrinomas w/o MEN 1 should undergo surgery

26 Insulinoma Neuroglycemic symptoms Symptoms of catecholamine excess
Symptoms associated with fasting Elevated plasma insulin level at the time of hypoglycemia Most reliable test: fast up to 72 h Terminate test if: symptomatic or glucose levels are persistently < 40 mg/dL 70–80% of pts will develop hypoglycemia during the first 24h, and 98% by 48h

27 Glucagonoma Syndrome: dermatitis, glucose intolerance or DM and weight loss migratory necrolytic erythema starts as an annular erythema at intertriginous and periorificial sites raised, bullae form and eroded areas lesions can wax and wane

28 VIPomas Large-volume diarrhea, hypokalemia, and dehydration
Verner-Morrison syndrome, pancreatic cholera WDHA syndrome: watery diarrhea, hypokalemia, and achlorhydria Children: caused by ganglioneuroma or ganglioneuroblastoma Elevated VIP and large-volume diarrhea Surgery is treatment


Download ppt "Pancreatic disorders Sampath Poreddy Assistant Professor"

Similar presentations


Ads by Google