The pancreasDr. Saad M Attash
المرحلة الرابعةجراحة
د.سعد
العدد5
3\4\2018
تسلسل 21
INVESTIGATIONS OF PANCREAS SERUM ENZYME LEVELS: Amylase..Lipase..Trypsin PANCREATIC FUNCTION TESTS MORPHOLOGY ULTRASOUND SCAN COMPUTERISED TOMOGRAPHY MAGNETIC RESONANCE IMAGING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ENDOSCOPIC ULTRASOUND PLAIN RADIOGRAPHY CHEST UPPER ABDOMEN
INJURIES TO THE PANCREAS THE PANCREAS, THANKS TO ITS SOMEWHAT PROTECTED LOCATION IN THE RETROPERITONEUM, IS NOT FREQUENTLY DAMAGED
ACUTE PANCREATITIS ACUTE INFLAMMATION OF PANCREAS IS ONE OF CAUSES OF ACUTE ABD.PAIN. IT’S A SERIOUS CONDITION THAT LEADS TO DEATH IN 10-15% OF CASES. AETIOLOGY GALLSTONES. 50-70% EXCESS ALCOHOL INTAKE. 20% TRAUMA . 5% ACCIDENTAL,OPERATIVE,ERCP. RARE CAUSES :VIRAL,HYPERPARATHYROIDISM, HYPERCALCEMIA,AUTOIMMUNE, MALNUTRITION, SCORPION BITE, DRUGS: CORTICOSTEROID. IDIOPATHIC.
CLINICAL FEATURES SYMPTOMS 1.SEVERE AGONIZING UPPER ABDOMINAL PAIN RADIATED TO BACK. 2.NAUSEA, VOMTING &RETCHING. SIGNS PATIENT LOOKING ILL, TOXIC MAY SHOW HYPOVOL. SHOCK,TINGE OF JAUNDICE,CYANOSIS. PATIENT SITS LEANING FORWARD. TENDERNESS &RIGIDITIY, BRUISING AROUND UMBLICUS(CULLEN SIGN),& IN THE LOIN(GREY TURNER SIGN) ARE RARE LATE FEATURE. UPPER ABD. SWELLING AFTER 2-3 WK (PANCREATIC PSEUDOCYST).
DIFFERENTIAL DIAGNOSIS 1.PERFORATED PEPTIC ULCER 2.ACUTE CHOLECYSTITIS & BILIARY COLIC 3. ACUTE MESENTERIC VASCULAR OCCLUSION 4.LEAKING AORTIC ANEURYSM 5. ACUTE M.I
INVESTIGATIONS 1.SERUM AMYLASE ELEVATE WITHIN FEW HOURS>1000 IU/DL. NR 100-300 2.ARTERIAL BLOOD GASES 3.BIOCHEMICAL .BILIRUBIN ELEVETED.HYPOCAL.HYPOPROT.ELEVETED B.UREA.HYPERGL. 4.BLOOD PICTURE .LEACOCYTOSIS.ELEVATED HAEMATOCRIT 5.U/S GALL STONES, SWOLLEN EDEMATOUS PANCREAS 6.PLAIN X-RAY OF ABDOMEN SHOWS DILATED SHORT SEGMENT OF SMALL INTESTINE(SENTINEL LOOP).COLON CUT-OFF SIGN, RENAL HALO SIGN7.CT VERY HELPFUL SHOWS ENLARGEMENT OF PANCREAS,OEDEMA ,NECROSIS. 8.ECG &CARDIAC ENZYME TO EXCLUDE M.I
RANSON CRITERIAAt admission: 1-age > 55 years. 2- WBC > 16000 cells/mm. 3- blood glucose > 10 mmol/L (>200 mg/dL ) 4- serum AST > 250 IU/L. 5- serum LDH >700 U/L.
Within 48 hours: 1- serum calcium < 2 mmol/L ( <8 mg/dL ). 2- hematocrit fall > 10%. 3- PaO2 <60% mmHg. 4- BUN increased by 1.8 or more mmol/L( 5 or more mg/dL ) after IV fluid hydration. 5- base deficit > 4 mmol/L. 6- sequestration of fluid > 6 L.If score > or = 3 severe pancreatitis. If score < 3 severe pancreatitis is unlikely.
TREATMENT CONSERVATIVE SEVERE CASES ADMITTED TO ICU.TREATMENT IS SUPPORTIVE 1.RELIEF OF PAIN BY STRONG ANALGESIA 2.AGGRESSIVE FLUID REPLACEMENT AND MONITORING 3.RESPIRATORY SUPPORT BY OXYGEN MASK,OR MECHANICAL VENTILATION AND SERIAL ABG ANALYSIS 4.REST OF PANCREAS &BOWEL BY NPO, NG SUCTION.SOMATOSTATIN ENTERAL FEEDING, TPN 5. PROPHYLACTIC ANTIBIOTICS 6.THERAPUTIC ERCP WITHIN 72 HOURS IN SEVERE GS PANCREATITIS OR CHOLANGITIS SURGICAL 1.DOUBTFUL DIAGNOSIS EXPLORATORY LAPAROTOMY 2.DRAINGE OF PANCREATIC ABSCESS ,OR PERSISTENT PSEUDOCYST 3.EXCISION OF NECROTIC TISSUE IN SEVERE NECROTIZING PANCREATITIS
PANCREATIC PSEUDOCYST COLLECTION OF PANCREATIC SECRETION &INFLAMMATORY EXUDATE WITHIN A LINING OF INFLAMMATORY TISSUE AETIOLOGY DEVELOPS IN 10% OF CASES OF ACUTE PANCREATITIS AFTER 4 WEEKS.NEXT CAUSE PANCREATIC TRAUMA SITE LESSER SAC COMPLICATIONS INFECTION ,HAEMORRHAGE,RUPTURE CLINICAL FEATURES -SMALL PAINLESS DISCOVERED BY U/S -LARGE CAUSE DISCOMFORT ,UPPER ABD. SWELLING INVESTIGATIONS -BA-MEAL FORWARD DISPLACEMENT OF STOMACH -U/S&CT
TREATMENT 1.MOST OF CYSTS RESOLVE SPONT. 2.PERSISTANT CYST, THICK WALL, LARGER THAN 6CM .DRAINED AFTER 12WK PERCUTANEOUS, ENDOSCOPIC, SURGICAL
CHRONIC PANCREATITIS
CHRONIC DULL PAIN AND LATER ON EXOCRINE AND ENDOCRINE PANCREATIC INSUFFICIENCY, WEIGHT LOSS, STEATORRHOEAAETIOLOGY:
ALCOHOL 60-70%
OTHER: TRAUMA, CONGENITAL MALFORMATIONS, AUTOIMMUNE, IDIOPATHIC
INVESTIGATIONS: SAME (CALCIFICATIONS)
TREATMENT:
CONSERVATIVE
STOP ALCOHOL
ANALGESIA
NUTRITIONAL SUPPORT
PANC ENZ SUPPLIMENTATION
STEROIDS
TREATMENT OF DM
PANCREATIC CARCINOMAMALE>FEMLE.AGE 55-70.PROGNOSIS POOR AETIOLOGY UNKOWN.SMOKING,CHR PANCREATITIS, HIGH PROTEIN,HIGH FAT FOOD SPREAD DIRECT CBD,LYMPH,BLOOD LIVERLUNG,TRANSPERITONEALCLINICAL FEATURES 1.CA OF HEAD PAINLESS OBST. JAUNDICE,HEPATOMEGALLY,PALPABLE GB,ANOREXIA &WT LOSS 2.CA OF BODY &TAIL EPIGASTRIC PAIN HEPATOMEGALLY,ANOREXIA &WT LOSS INVESTIGATONS 1.TUMOUR MARKER CEA, CA19-9 ,LFT ELEVATED DIRECT BIL.&ALK.PH.LOW PROTHOMBIN 2.U/S DILATED INTRA &EXTRA HEPATIC DUCT,METASTASES 3.CT 4.MRI, MRCP, ERCP
TREATMENT 1.UNFIT FOR SURGERY85% PALLIATIVE ENDOSCOPIC STENT 2.FIT FOR SURGERY & OPERABLE WHIPPLE OPERATION 3.INOPERABLE TUMOR BYPASS CHOLECYSTOJEJENOSTOMY
