Chronic Pancreatitis and Pancreatic

Cancer

DR WAQAS MANZOOR
SENIOR REGISTAR AL TIBRI MEDICAL
COLLEGE
Anatomy:

Retroperitoneal organ
15cm long, 70 – 100weighs
Physiology
• The pancreas contains Exocrine glands that
produce enzymes.
• Trypsin and Chymotrypsin to digest proteins
• Amylase for the digestion of carbohydrates
• Lipase to break down fats

• The Endocrine glands of the pancreas consists of

Islet cells (islets of Langerhans) secerets two
hormones
• Insulin and Glucagon
 Chronic Pancreatitis
• Definition:

Chronic inflammation, fibrosis and

eventual destruction of Ductal and
Parenchymal( exocrine and endocrine
tissue.
• More common in males.

• Disease of middle age with mostly diagnosed above age of

40 years.

• Prognosis of chronic pancreatitis is variable.

• Over all 10 year survival in patients with chronic

pancreatitis is about 70%

• The cause of death in chronic pancreatits is not

pancreatitis itself but due to smoking, continued alcohol
abuse,pancreatic carcinoma and postoperative
complications
 Causes of Chronic Pancreatitis
TIGAR- O

• Toxic-Metabolic
• Idiopathic
• Genetic
• Autoimmune
• Recurrent Acute Pancreatitis
• Obstructive
• Toxic- Metabolic: Recurent Acute Pacreatitis
• Alcohol PostNecrotic
• Tobacco
• Hypertriglyceridemia
• Hypercalcemia Autoimmune:

• Idiopathic Obstructive:
Pancreatic Divisum
• Genetic Celiac and Crohns
Hereditary Pancreatitis Ampullary carcinoma

Cystic fibrosis Pancreatic carcinoma

Pathophysiology
Pathogenesis
 Symptoms
• Abdominal Pain (Cardinal Symptom)

• Weight loss

• Steatorrhae

• Diabetes
 Abdominal Pain
• Tissue Ischemia (due to incresed pressure in
Pancreatic Parenchyma and Pancreatic Duct)

• Alteretion in peripheral and central nociceptive

nerves.

• Complications of Chronic Pancreatitis

Bile duct /Duodenal obstruction
Secondary Pancreatic cancer
 Steatorrhae
• Doesn’t Occur until pancreatic Lipase secretion is
reduced to less than 10% of maximum output

• Fat Malabsorption Occurs earlier than Protein and

Carbohydrates.

• Significant Weight loss is uncommon despite

Maldigestion

• Weight loss is commonly seen during painful flares

that prevents adequate oral intake
 Diabetes
• Type 3c Diabetes Occurs in chronic Pancreatitis.

• Type C diabetes is characterized by low levels of

insulin and glucagon, rare ketosis and treatment
induced hypoglycemia.

• Both cells beta and alpha cells are injured leading to

risk of prolonged and severe hypoglycemia
 Physical Examination
• Undernourished.

• Looking Wasted

• Jaundice

• Splenomegly
 Abdominal Examination
• Abdominal Tenderness

• Abdominal Mass

• Co-existing autoimmune features if autoimmune

pancreatitis

Salivary gland enlargement or lymphadenopathy

 Investigations
• General Workup

• Tests of Pancreatic Structure (imaging)

• Tests of Pancreatic Function

Investigations:
•Complete Blood Count
•Urea, creatinine and electrolytes
•Liver Function Tests
•Serum Amylase and Lipase
•Serum calcium,Mg,Triglycerides,Albumin
•Blood Random Sugar
 Test of Pancreatic Structure(Imagings)
• Plain x ray Abdomen

• Ultrasound Abdomen

• CT scan Whole Abdomen with contrast

• MRI with MRCP

• EUS ERCP
Plain X ray Abdomen
CT Abdomen Contrast
ERCP Image
 Test of Pancreatic Function
• Direct Tests:
Directly measure pancreatic function by measuring the
output of enzymes or Bicarbonate from pancreas.

• Indirect tests:
Measure Output of enzymes indirectly
(Through its action on substrate or its level in blood or
stool)
 Direct Tests of Pancreatic Function
• Hormonal stimulation Tests
Secretin stimulation tests
CCK stimulation tests

0.2ug/kg of secretin adminstered with Duodenal samples

collected from endoscope.

Samples with Bicarbonate concentration less than 40mEq/l

is Diagnostic
 Indirect Tests of Pancreatic Function
• Blood
Serum Trypsinogen levels

• Stool
Fecal Chymotrypsin
Fecal Elastase

Fecal Elastase less than 200ug/gram of stool

suggestive of exocrine pancreatic Insufficiency
 Management

• Cessation of smoking and Alcohol

• Pain Management medically, endoscopically and

surgically

• Manage steatorrhae with Pancreatic Enzyme

replacement Therapy

• Treat Diabetes with Oral Hypoglycemics/Insulin

 Pain Management
• Medical:
Analgesics like
Acetoaminphen,
Low Poent opoids(Tramadol)
High Potent Opoids like Morphine
Antidepressants,
Gabapentinoids

• Endoscopic Therapy
• Surgical Therapy
 Pain Management
• Endoscopic Therapy:
Done in Patients with dilated pancreatic Duct
greater than 5mm with single stone or stricture

1 :Pancreatic Duct Sphincterotomy

2: Pancreatic Duct stone removal/Stricture

Dilatation

3: Pancreatic Duct Stent Placement

 Pain Management
• Surgical Therapy:
Done for intractable Pain for which medical Therapy has
Failed.

• Whipple s Operation (Pancreaticoduodenectomy)

• Total Pancreatectomy with Islet cell Autotransplantation

Whipple Operation
 Pain Management
• Celiac Nerve Plexus Block

• Celiac Nerve Plexus Neurolysis

 Steatorrhae Management
• 90,000 USP units should be delivered to intestine
with each meal (in prandial and Postprandial phase)
,sufficient to eliminate steatorrhae

• Pancreatic Enzyme Replacement

(CREON)
 Diabetes Management
• Drug Metformin is preffered

• Appropiate Monitoring for Nephropathy ,

retinopathy and Neuropathy.

• Over vigorous Diabetic Control can lead to

Treatment induced hypoglycemia
 Complications
• Pancreatic Pseudocyst

• Portal and Splenic Vein Thrombosis

Leading to GI Bleed due to Gastric Varices

• PseudoAnuerysm

• Pancreatic Fistulas
 Complications
• Bile Duct Obstruction Leading to Secondary
Biliary Cirrhosis

• Duodenal Obstruction

• Pancreatic Carcinoma
Pancreatic Cancer
 Pancreatic Cancer
• Disease of Aging.

• Median age of diagnosis is 71 years.

• Incidence sharply rises after age of 50

• Male predominent

• 5 yr Survival is 8 %
 Causes/Risk factors
• Non Hereditary:
Smoking
Alcohol
Obesity
Chronic Pancreatitis

• Hereditary:
Hereditary Pancreatitis
Cystic Fibrosis
Lynch Syndrome
Peutz jegher Syndrome
• Most common Malignancy of Pancreas is Ductal
Adenocarcinoma.

• Commonly Occurs in head (60 – 70%)

In Body (5 to 10 %)
In Tail (10 – 15 %)

• Tumors In Head Obstruct Bile Duct and Pancreatic

Duct resulting in obstructive Juandice.

• Tail tumors not associated with biliary or pancreatic

ductal Obstruction
 Symptoms
• Obstructive Jaundice (Itching,dark urine/clay
stools)

• Abdominal Pain

• Nausea and Vomitings

• Anorexia and Weight loss

• Steatorrhae Diabetes
 Examination
• Wasted,Emaciated look

• Jaundice

• Abdominal Mass

• Hepatomegaly

• Enlarged Palpable Gall Bladder (Courvoisier sign/Law)

Investigations:

• Complete Blood Count

• Urea, creatinine and electrolytes
• Liver Function Tests
• Serum Amylase and Lipase
• Serum calcium,Mg,Triglycerides,Albumin
• Blood Random Sugar
• Tumor Marker- CA 19-9
 Imaging
• Ultraound Abdomen

• CT Scan Abdomen Contrast

• MRI

• PET

• EUS + FNA

• ERCP
 Staging
• T1: Limited to Pancreas less than 2cm in greatest
Dimension

• T2: Limited to Pancreas greater than 2cm in greatest

Dimension

• T3: Tumor extends beyond pancres but without celaic

plexus or SMA involvement

• T4:Tumor Involves Celiac Plexus/SMA

 Treatment
• Surgical Rection is most effective Curative
treatment for PC.

• Most Common Operation for Pancreatic

Cancer is

• Pylorus sparing Pancreaticoduodenectomy

(Whipple sProcedure)
• Resesctable Tumor : Surgery

• Unresectable Tumor : Chemotherapy and

Radiotherapy

• Metastatic Tumor (Palliative):

Good Perfomance Status: Chemotherapy
Poor Perfomance status: ERCP and Stenting
• Pain Management
with Celiac Plexus Neurolysis and Nutritional
Support /PERT
ERCP+SEMS
• THANKS