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Dr. Ajmal Hasan

MBBS, MD, DM (AIIMS, New Delhi)

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Dr. Ajmal Hasan

Pancreas & Gall Bladder

Acute pancreatitis

Chronic pancreatitis

Pancreatic tumors

Pancreatic pseudocyst

Pancreatic Necrotic Collection

Gall bladder cancer

Common bile duct stone

Cholangiocarcinoma

Gall bladder stone

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Acute pancreatitis

Acute pancreatitis is sudden onset severe inflammation of pancreas manifesting as pain abdomen, abdomen distension, vomiting and constipation
Patients with severe disease may have decreased urinary output and respiratory distress
Common causes of acute pancreatitis are
  • Gall bladder stone
  • Alcohol intake
  • Increased lipids in the blood
  • Hypercalcemia
  • Drugs
  • Hypertriglyceridemia
  • Tumor in pancreas or ampulla
  • Worms in the pancreatic duct
Diagnosis
In a patient with the history of pain suggestive of pancreatic in origin, the following test are done to confirm the diagnosis of acute pancreatitis
  • Serum Amylase and Lipase
  • USG abdomen
  • CECT abdomen
Treatment
Patients with acute pancreatitis should be hospitalized and should be treated with
  • Adequate IV fluids
  • Organ support in the case of organ failure
  • IV antibiotics in case of infection
  • Surgery or endoscopic/percutaneous drainage of infected collections

Chronic pancreatitis

Chronic pancreatitis is a long-standing inflammation of the pancreas resulting in pancreatic atrophy, fibrosis, and calcification
Common causes of chronic pancreatitis are

  • Alcohol
  • Autoimmune
  • Idiopathic
  • Hereditary
  • Hypercalcemia
    Autoimmune pancreatitis
  • Increased lipids in the blood

Symptoms

  • Pain abdomen
  • Diabetes
  • Steatorrhoea (Fat loss in stool)

Diagnosis
Following tests are done to confirm the diagnosis

  • Endoscopic ultrasonography
  • CECT abdomen
  • MRCP

Treatment

  • Pancreatic enzyme supplementation
  • Analgesics
  • Antioxidants
  • ERCP and stent placement
  • EUS guided Celiac plexus block

Pancreatic tumors

Pancreatic tumors can be benign or malignant and are categorized as adenocarcinoma, neuroendocrine tumors, and cystic neoplasm.
Pancreatic adenocarcinoma
Pancreatic adenocarcinoma is the most common tumor of the pancreas, risk factors are
  • Cigarette smoking
  • Tobacco chewing
  • Genetic mutations
  • Chronic pancreatitis

Symptoms of pancreatic cancer are

  • Pain in the upper abdomen
  • Jaundice
  • Loss of appetite
  • Weight loss
Diagnosis
Following tests are required in a patient with suspected adenocarcinoma 
  • Ultrasonography abdomen
  • CT scan
  • Diagnosis is confirmed by endoscopic ultrasound and fine-needle aspiration
Treatment
  • The best available treatment is surgical resection.
  • However, only 20 % of tumors are usually resectable
  • In the rest of cases, treatment options are chemotherapy and palliation with stent placement in common bile duct and duodenum for relief of jaundice and vomiting respectively
Neuroendocrine tumors
Neuroendocrine tumors arise from islet cells and are classified as
  • Insulinoma
  • Gastrinoma
  • Somatostatinoma
  • VIPoma
  • Non Functional tumor
Symptoms
Symptoms of a neuroendocrine tumor depend upon the type of tumor and secreted hormones. Common symptoms are
  • Diarrhea
  • Recurrent ulcer formation
  • Attacks of hypoglycemia
Treatment
  • Primary treatment of neuroendocrine tumor is surgery
  • Chemotherapy and somatostatin analogs are useful in metastatic diseases
Cystic neoplasm
Cystic neoplasm is usually detected incidentally and has to be differentiated from pseudocysts
The most common type of cystic neoplasm are

  • Serous cystadenoma
  • Mucinous cystadenoma
  • IPMN (Intraductal papillary mucinous neoplasm)
  • Solid pseudopapillary neoplasm
Symptoms
  • The small lesion is usually asymptomatic and detected incidentally on imaging
  • Large lesions can lead to pain/jaundice
Diagnosis
Following tests are required in a patient with suspected cystic neoplasm
  • EUS is the test of choice for diagnosis and differentiation
  • During EUS, cyst fluid can be aspirated for analysis
  • Ultrasonography abdomen
  • CT scan of the abdomen
  • Diagnosis is confirmed by endoscopic ultrasound and fine-needle aspiration
Treatment
  • Small asymptomatic lesions can be followed up
  • Large or symptomatic lesions should be resected

Pancreatic pseudocyst

Pancreatic pseudocysts are fluid collections around the pancreas, which are more common in chronic pancreatitis than in acute pancreatitis. 
Symptoms of pseudocysts are
  • Pain abdomen
  • Jaundice
  • Vomiting
  • Fever in the case of infected pseudocyst
  • The decrease in hemoglobin in case of bleed in cyst
Treatment options are
  • Asymptomatic cysts can be followed up
  • Cysts which are decreasing in size usually does not require treatment
  • Endoscopic or EUS guided drainage is done for symptomatic or persistent/enlarging pseudocysts
  • Percutaneous drainage is reserved for cysts not amenable to endoscopic drainage

Pancreatic Necrotic Collection (WOPN)

Some patients of acute pancreatitis may develop a fluid collection with a significant amount of necrotic material which is called walled of pancreatic necrosis (WOPN).

Symptoms of WOPN are
1. Pain abdomen
2. Jaundice
3. Vomiting
4. Fever in the case of infected WOPN
5. The decrease in hemoglobin in case of bleed in cyst

Treatment options are

surgery was the mainstay of treatment for many yrs, but now EUS Guided LAMS placement has taken center stage.It drains fluid internally in the stomach and endoscope may enter from stomach to retroperitoneal space via stent for debridement (necrosectomy) and lavage of the retroperitoneal cavity.
Main advantages are
1. It is incision and suture-free like an endoscopic procedure
2.Daycare procedure with less hospital stay and morbidity
3. More than 75 percent clinical success rate.

Gall bladder cancer

Gall bladder cancer is a common cancer of the biliary system and is usually diagnosed at an advanced stage

Risk factors are

  • The large stone in the gall bladder
  • Porcelain gall bladder (calcification of gall bladder wall)
  • Anomalous union of the pancreaticobiliary ductal system
  • Adenomyomatosis
  • Family history of gall bladder cancer

Symptoms of gall bladder cancer are

  • Persistent pain in the upper abdomen
  • Jaundice
  • Weight loss
  • Loss of appetite
  • Itching

Diagnosis

  • Diagnosis is suspected on ultrasonography, which may show irregular thickening of the gall bladder wall, or may show mass lesion.
  • CECT abdomen is the better modality for evaluation of suspected gall bladder cancer patients, and give information regarding the resectability

Treatment

  • Surgery offers the best chance of cure, however, less than 20 % of cases are operable at the time of presentation.
  • In unresectable patients, diagnosis is confirmed by FNA and microscopy, and chemotherapy can be started, which however has an only a limited role.
  • ERCP and stenting can be done in patients with advanced tumors, for palliation of itching, cholangitis

Common bile duct stone

Compared to gall bladder stones, CBD stones are more likely to cause symptoms, and more likely to cause serious complications. Stones in the CBD are mostly the passed down stones from the gall bladder, however, in some patients, stones can be formed de novo in CBD also
Symptoms
  • Pain upper abdomen and jaundice
  • Fever with chills
  • Low blood pressure
  • Decreased urine output
Diagnosis
  • Stones in CBD can be diagnosed on trans abdominal ultrasound, however, this test has limited sensitivity. MRCP and EUS are the better modalities for diagnosis of CBD stones
Treatment
  • All patients with CBD stones requires urgent treatment
  • ERCP is the standard procedure to remove CBD stones, during ERCP endoscope is introduced through the mouth once the patient is sedated, and with the help of various accessories, stones are taken out of the CBD
  • In patients with infection of biliary system, stent needs to be placed in CBD to drain the bile effectively

CBD stone removal during ERCP

Cholangiocarcinoma

Cholangiocarcinoma is the most common tumor of the bile duct. Cholangiocarcinoma may involve the bile duct at the liver hilum, lower CBD, or intrahepatic biliary system. Hilar is the most common type of cholangiocarcinoma

Risk factors are

  • Choledochal cyst
  • Clonorchis Sinensis
  • Hepaticolithiasis
  • Primary sclerosing cholangitis
  • Biliary-enteric drainage procedures

Symptoms

  • Painless jaundice
  • Itching
  • Weight loss and anorexia
  • Fever and pain abdomen in the case of cholangitis

Diagnosis

  • Diagnosis is suspected when USG/CT/MRCP reveals obstruction of the biliary system and a mass around the CBD
  • For tissue diagnosis, EUS – FNA, ERCP-brushings, and spyglass with biopsy are available options

Treatment

  • Surgery is the best option for resectable tumors
  • For unresectablehilarcholangiocarcinoma, chemo-radiotherapy followed by liver transplantation is the new treatment strategy.
  • For advanced tumors, ERCP and stenting can be done for palliation of jaundice/itching and fever

Gall bladder stone

Gall bladder stones are a common finding on ultrasonography, predisposing factors are
Parenteral nutrition
  • More common in middle-aged female
  • Obesity
  • Pregnancy
  • Medications such as ceftriaxone, and estrogens
  • Rapid weight loss
  • Diseases of the ileum
Symptoms
Gall bladder stones mat be asymptomatic and incidentally picked on routine ultrasonography. Common symptoms are
  • Pain in the upper abdomen
  • Vomiting
  • Fever
  • Jaundice
  • Stone can pass lower down in bile duct and can lead to fever, jaundice
  • Stones can pass down and transiently block the pancreatic duct and lead to attack pancreatitis
  • Large stone (>3cm) are a risk factor for gall bladder cancer
Diagnosis
  • Transabdominal Ultrasonography is the best investigation for diagnosis of gall bladder stones,
  • Endoscopic ultrasonography may be required for detection of very small stones in gal bladder
Treatment
  • Medical therapy is not very effective for gall bladder stones, surgery is the most effective treatment.
  • Symptomatic gall bladder stones should be operated,
  • Asymptomatic stone can be followed up, with close observation, however, gall bladder with large stone (3 cm) should be operated Stone passed out in CBD should be taken out by ERCP