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