Pancreas

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Soft, lobulated gland about 12-15cm in length

Transversely Retroperitoneal
Between C loop of Duodenum and Spleen
Behind the stomach
Divided into: Head / Neck / Body / Tail
Consists of Exocrine and Endocrine glands
Exocrine secretions: Drained by pancreatic duct which joins the common bile duct to empty into 2nd part of duodenum at the duodenal papilla
Blood supply: Celiac trunk and superior mesenteric arteries

Pancreas

Exocrine:

Secretes 2.5 liters protein-rich alkaline Enzymes
Enzymes include: Trypsinogen / Amylase / Lipase / Ribonuclease
Also secretes: Electrolytes
Secretion is stimulated by: Secretin and cholecystokinin

Endocrine:

Insulin
Glucagon
Somatostatin

Serum/Urinary Pancreatic Enzyme Estimation
Abdominal Ultrasonography
Plain Radiography
Computerised Tomography/Contrast-enhanced Magnetic Resonance Imaging
Endoscopic Retrograde Cholangiopancreatography
Pancreatic exocrine function test

Inflammatory and Necrotic disorder of the pancreas

Acinar cell destruction: Caused by autodigestion from intra-parenchymal activation of pancreatic enzymes
Premature activation of trypsin: Causes parenchymal inflammation/necrosis

Relatively uncommon diagnosis in this environment

Etiology

Biliary tract stone disease
Alcohol (Ethanol) abuse: 70-80% of cases are due to these two causes
Medications: Steroids / Isoniazide / Enaleprine
Hyperlipidemia
Pancreatic duct obstruction
Hereditary/Genetic pancreatic enzyme anomaly
ERCP/Endoscopic maneuvers around the sphincter of Oddi
Autoimmune disease
Trauma
Toxins
Hypercalcemia

Presentation

Epigastric abdominal pain of acute onset

May involve adjacent quadrants
May radiate to the back.
Pain is constant
May be relieved by leaning forwards

Nausea and Vomiting

May be associated with Mallory Weiss tear

On Examination

Restless
Mild fever
Dehydrated / Hypovolemic
Tachypnea
Mild to moderate Jaundice
Altered sensorium
Abdominal distension / Tender with rebound / Tympanitic / Hypoactive bowel sounds
Epigastric tender mass
Flank Ecchymosis (Grey Turner's syndrome) / Periumbilical Ecchymosis (Cullen's syndrome)

Investigations

Elevated Serum Amylase/Lipase
Elevated Urinary Amylase
Other Blood tests:

Hematocrit
Electrolytes and urea
Glucose
Bilirubin
Triglyceride
Calcium

Abdominal Ultrasound: May reveal pancreatic edema / Gall or biliary stones
Plain Chest / Abdominal radiography:

Rule out Pneumonia / perforated hollow viscus/int obstruction

Contrast-enhanced Computerized Tomography
MRI

Pancreatic Edema
Pancreatic necrosis
Intra/peri pancreatic fluid accumulation

ERCP

Differential Diagnosis

Cholecystitis
Cholangitis
Perforated hollow viscus
Intestinal obstruction
Mesenteric ischemia/Infarction

Treatment

Fluid/Electrolyte resuscitation
Pain control
Naso-gastric decompression
Nutrition
Prophylactic antibiotics
Cholecystectomy/bile duct exploration

Complications

Pancreatic Necrosis

Infected Pancreatic Necrosis

Pancreatic Pseudocyst
Pancreatic Abscess
Splenic Vein thrombosis
Chronic Pancreatitis

Chronic progressive inflammation and destruction of the Pancreas. Characterized by pancreatic fibrosis and loss of pancreatic function.

Exocrine/Endocrine:

Associated with enlargement and hardening of pancreas from fibrosis
Duct distortion/Strictures
Intraductal calcification

Rare in this environment.

Presents with chronic epigastric pain / pancreatic insufficiency / obstructive jaundice. Associated with recurrent episodes of acute pancreatitis causing worsening pain.

Most frequently caused by alcoholism. Pancreatic duct obstruction from trauma / acute pancreatitis / Cancer. Hereditary pancreatitis / Idiopathic.