Pancreas

I. Acute Pancreatitis

a. Pathology: most commonly gallstone obstruction; how EtOH causes it is unknown; ischemia after abdominal surgery (commonly gastric and biliary surgeries)

b. Diagnosis: noncrampy, epigastic pain; radiates to left or right upper quadrant, or to the back; fever; tachycardia; nausia and vomiting; elevated WBC, serum amylase and lipase; LFTs elevated in severe cases; CT is best test

c. Differential diagnosis: acute chole, perforated gastric ulcer, mesenteric ischemia, esophageal perforation, MI

d. Sequellae: chronic pancreatitis; outcome correlated to Ranson’s criteria; hypocalcemia; renal failure; pancreatic necrosis (<30% of tissue will resolve w/o treatment); infection and abscess have 40% mortality

e. Treatment:

i. Medical: IV fluids due to 3^rd spacing into retroperitoneum; antibiotics for gallstone pancreatitis (not useful in other kinds);

ii. Surgical: diagnostic laprotomy; gallstone removal in severe cases

II. Chronic Pancreatitis

a. Pathology: EtOH is most common; can be due to ductal damage; also cystic fibrosis, familial pancreatitis, or pancreatic divisum (failure for buds to fuse)

b. Diagnosis: intermittant pain until scarring and fibrosis causes incessant pain; B12 deficiency; CT scan is best test;

c. Differential diagnosis:

d. Sequellae: steatorrhea, fat malabsorption when pancreatic function is <10%; diabetes

e. Treatment:

i. Medical: low-fat diet; avoid EtOH; enzyme replacement

ii. Surgical: decompress “chain of lakes” duct into jejunum

III. Pseudocysts

a. Pathology: collections of pancreatic juices; lined by non-epithelial cells (typically fibrotic)

b. Diagnosis: epigastric pain, can be with nausia/vomiting; history of pancreatitis and jaundice; weight loss; persistantly elevated serum amylase, lipase; CT or ultrasound are good tests

c. Differential diagnosis:

d. Sequellae: infection (must be drained); hemorrhage into cyst (can be lethal); erosion into major vessel (also not good);

e. Treatment:

i. Medical: 30% resolve spontaneously when NPO;

ii. Surgical: after fibrotic wall forms, create fistula to stomach or jejunum; drain if symptomatic after 4-6 weeks;

IV. Pancreatic adenoma:

a. Pathology: 2/3rds in the head (Whipple candidates);

b. Diagnosis: correlated to smoking, but not to pancreatitis or EtOH; weight loss, jaundice and constant pain in the posterior epigastric radiating to the back; palpable, nontender gallbladder (Courvoisier’s sign); ultrasound for right upper quadrant, CT for visualizing pancreas;

c. Differential diagnosis:

d. Sequellae: mets to liver or peritoneal seeding; repairs often leak due to lipase; survival is poor regardless of treatment (<12 months);

e. Treatment:

i. Medical: vitamin K replacement due to liver injury;

ii. Surgical: Whipple for pancreatic head cancers; distal pancreatectomy if in tail; unresectable if mets to liver

V. Cystadenoma: typically in tail of pancreas in middle-aged women; best prognosis than adenoma

VI. Islet cell tumors

a. Insulinoma: Whipple’s triad: fasting, blood sugar <50, eating relieves symptoms;

b. Gastrinoma: Zollinger-Ellison

i. Pathology: excess gastrin

ii. Diagnosis: ulcers in strange places, recurrent duodenal ulcers, watery diarrhea or large gastric rugae; secretin test to confirm;

iii. Differential diagnosis: could be part of MEN

iv. Sequellae:

v. Treatment: find and remove tumor