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G46 Gastroenterology
Pancreas Toronto Notes 2019
■ decreases pancreatic secretion of pancreatic stone protein (lithostathine), which normally solubilizes calcium salts
◆ precipitation of calcium within pancreatic duct results in duct and gland destruction
■ toxic effect on acinar and duct cells – directly or via increasing free radicals
■ acinar cell injury leads to cytokine release, which stimulates pancreatic stellate cells to form collagen
(leading to fibrosis)
■ varying degrees of ductular dilatation, strictures, protein plugs, calcification
■ no satisfactory theory to explain why only a minority of individuals with alcohol use disorder
develop pancreatitis ■ unusual causes
• cysticfibrosis
■ severe protein-calorie malnutrition ■ hereditary
■ idiopathic
Signs and Symptoms
• earlystages
■ recurrent attacks of severe abdominal pain (upper abdomen and back) ■ chronic painless pancreatitis: 10%
• latestages:occursin15%ofpatients
■ malabsorption syndrome when >90% of function is lost, steatorrhea
■ diabetes, calcification, jaundice, weight loss, pseudocyst, ascites, GI bleed
Investigations
• laboratory
■ increaseinserumglucose
■ increase in serum ALP, less commonly bilirubin (jaundice) ■ serum amylase and lipase usually normal
■ stool elastase is low in steatorrhea
• AXR:pancreaticcalcifications
• U/SorCT:calcification,dilatedpancreaticducts,pseudocyst
• MRCPorERCP:abnormalitiesofpancreaticducts-narrowinganddilatation
• EUS:abnormalitiesofpancreaticparenchymaandpancreaticducts,mostsensitivetest
• 72hfecalfattest:measuresexocrinefunction
• secretintest:goldstandard,measuresexocrinefunctionbutdifficulttoperform,unpleasantforpatient,
expensive
• fecalpancreaticenzymemeasurement(elastase-1,chymotrypsin):availableonlyinselectedcentres
Treatment
• mostcommonproblemispain,difficulttocontrol
• generalmanagement
■ completeabstinencefromalcohol
■ enzyme replacement may help pain by resting pancreas via negative feedback ■ analgesics
■ celiac ganglion blocks
■ time: pain decreases with time as pancreas “burns out”
• endoscopy:sphincterotomy,stentifductdilated,removestonesfrompancreaticduct
• surgery:drainpancreaticduct(pancreaticojejunostomy)ifductdilated(moreeffectivethan
endoscopy); resect pancreas if duct contracted
• steatorrhea
■ pancreatic enzyme replacement
■ restrict fat, increase carbohydrate and protein (may also decrease pain) ■ neither endoscopy nor surgery can improve pancreatic function
Autoimmune Pancreatitis
• mostcommonlypresentsasamimickerofpancreaticcancer(pancreaticmassdetectedbecauseof jaundice ± abdominal pain)
Investigations
• histology:lymphocyteandplasmacellinfiltrationofpancreas
• imaging:focalordiffuseenlargementofpancreasonCTorMRI,sausageshaped,lowdensityrim
around pancreas
• serology:increasedserumIgG4
• otherorganinvolvement:sialadenitis,retroperitonealfibrosis,biliaryductnarrowing,nephritis
Treatment
• respondstoprednisone