Pancreatic Malformations😍

Pancreatic Malformations

Pancreas Divisum:

 

• M/c congenital anomaly of pancreas.

• Mechanism: 
• Failure of fusion of dorsal & ventral ducts
• leading to ineffective drainage.
• Increased risk of pancreatitis.

• Management: ERCP + Sphincterotomy.

Annular Pancreas:

• Mechanism: Failure of complete rotation of ventral pancreatic bud
• forming circular tissue around 2nd part of duodenum.
• Causes obstruction.

• Clinical Features:
• Non-bilious vomiting (M/c)
• Double bubble sign

• Management: Duodeno-duodenostomy.

Acute Pancreatitis

Causes:

• Gallstones (M/c)

• Alcohol (2nd m/c)

• Trauma (M/c cause in children)

• Drug induced (ART/Chemotherapy/Thiazides)

• Hyperparathyroidism

• Scorpion bite

Pathophysiology:

• Theory of co-localization: 
• Activation of pancreatic enzymes within pancreas leads to autodigestion and inflammation.

Clinical Features:

• Epigastric pain:
• Radiates to the back.
• Relieved by bending forward.

• Acute hemorrhagic pancreatitis:
• Cullen’s sign (Discoloration around umbilicus)
• Grey Turner sign (Discoloration in flanks)

Lab Investigations:

• Serum amylase (Sensitive)

• Serum lipase (Specific, late)

X-ray Acute Pancreatitis:

• Colon cutoff sign
• abrupt termination of gas within the proximal colon
• d/t functional spasm of infiltrating phrenicocolic ligament
• Suggest Localised Inflammation from the pancreas
• → spreads to the splenic flexure.
• → functional spasm/paralysis of the colon.

• Sentinel loop sign
• Early indicator of A/c Pancreatitis on Xray
• Isolated prominent bowel loop.
• Seen adjacent to the inflamed organ.

• Gasless abdomen

Severe pancreatitis (if score ≥3):

• Glasgow criteria ≥3.

• BISAP score ≥3.
• 60 yr () old Sir () nu Visappu (BISAP) → glassil () vellam () + Bun () konduvann

• Ranson's criteria ≥3.
• Assessed on admission and within 48 hours
• First → blood LAGAW (LDH, Age, Glucose, AST, WBC)
• Next → BUCHOW

• Mnemonic: 6 yr old Balan (balthazar → 6) → exam didnt cross cut off (cut off) → so senti (sentinal loop) ayi → ran (ranson) → to bishop (Bisap)

Collections

• Mx : Pigtail catheter
• Mnemonic:
• > 4 wks → wall presnt
• Necrosis → herterogenous

Local Complications of Acute Pancreatitis:

• Pseudocyst

• Pseudoaneurysm (in splenic artery)

• Splenic vein thrombosis leading to Portal Hypertension (HTN)

• Pleural effusion (left-sided)

• ARDS

Treatment

• NPO, IV Fluids, IV Analgesics

• Parenteral Nutrition is preferred in initial phase over NPO

• Early initiation of enteral feed

Early/Urgent ERCP in Gallstone Pancreatitis

Benefits

• Relieves biliary obstruction

• Reduces risk of cholangitis

• Shortens hospital stay

Indications for Early/Urgent ERCP in Gallstone Pancreatitis

• CBD stone on imaging

• Cholangitis

• Persistent biliary obstruction

• Worsening LFTs

Patient-Specific Indications

• Dilated CBD >8 mm
• Mnemonic: B ⇔ 8

• Rising bilirubin

• No signs of resolution

Chronic Pancreatitis

• Tiger (TIGAR) like person

• 2 hobbies
• Press (PRSS) → produce children → hereditary
• Spit (SPINK) → one time stone came → tropic calcific

• He ate cassava ()

• Got chronic pancreatitis ()

• Became a begger (Beger)

• Last he used Peu Peu - gun (Peustow) and Dies (Duval)

Causes (TIGAR-O classification):

• Toxins:
• Alcohol (M/c)
• Dietary

• Idiopathic

• Genetic/Hereditary:
• PRSS I mutation (Hereditary pancreatitis)
• SPINK I mutation (Tropical calcific pancreatitis):



• Due to cassava consumption.
• Increased risk of Cancer.

• Recurrent (due to stones)

• Obstruction

Clinical Features:

• Malabsorption & steatorrhea: 
• Due to exocrine insufficiency.

• Diabetes Mellitus (DM): 
• Due to endocrine insufficiency (decreased insulin).

• Pain: 
• Caused by stones in the main pancreatic duct (MPD) leading to ineffective drainage.

CECT

• Features:
• Atrophic pancreas (fibrosis, shrinkage).
• Dilated pancreatic duct.
• Calcifications.
• Chain of lakes appearance.

• Peripancreatic fluid accumulation is not seen.

• First image:
• Pancreatic calcification.
• Chronic pancreatitis

• Second image:
• Atrophic pancreas with calcification.
• MRCP shows a dilated pancreatic duct.
• Beaded pancreas with chain of lakes appearance.

Management:

• Medical:
• Exogenous enzymes
• Oral Hypoglycemic Agents (OHAs)
• Analgesics for pain
• If good response, continue.

• Intervention (If no response to medical therapy):
• Resection (for inflammation):
• If restricted to tail:
• Distal pancreatectomy.
• If restricted to head & neck:
• Beger’s procedure.
• Duodenum sparing
• Drainage (Based on MPD diameter):
• <5 mm: ERCP + sphincterotomy.
• ≥5 mm: Pancreaticojejunostomy.

Ans

Puestow procedure: Resection of tail followed by longitudinal pancreaticojejunostomy.

It is one of the drainage procedures done for chronic pancreatitis.

 

Pseudocyst

Features:

• False cyst: 
• Lined by granulation tissue.

• M/c site: Lesser sac.

Clinical Features:

• Epigastric mass

• Nausea & vomiting

• Decreased appetite

d’Egidio’s Classification:

• Di Edi Go → tell Psuedo person

IOC: CECT

• Fluid is gray with a wall.

Management:

• Mostly resolves spontaneously.

• Indications for intervention (rule of 6s):
• 6 mm thickness of wall
• 6 cm size
• 6 weeks old

• Intervention options:
• External drainage: For infected cyst.
• Contraindicated (C/I): 
• Communication with pancreatic duct (due to risk of fistula formation).
• Internal drainage:
• Cystogastrostomy
• Cystojejunostomy

Indications of Surgery in pseudocyst :