The Pancreas. Basic Anatomy. Endocrine pancreas. Exocrine pancreas. Pancreas vasculature. Islets of Langerhans. Acinar cells Ductal System

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1 SGNA: Back to Basics Rogelio G. Silva, MD Assistant Clinical Professor of Medicine University of Illinois at Chicago Department of Medicine Division of Gastroenterology Advocate Christ Medical Center GI Partners of Illinois

2 Outline Recognize the anatomical structure and basic function of the pancreas Basic anatomy and surrounding structures Description of endocrine pancreas Description of exocrine pancreas Describe the common pathological disorders of the pancreas and available diagnostic tests Acute Pancreatitis Chronic Pancreatitis Tests of pancreatic function and inflammation Review the basic therapeutic interventions of pancreatitis, pancreatic insufficiency and neoplasms of the pancreas Treatment of acute pancreatitis Therapy of chronic pancreatitis Pancreatic Enzyme Replacment Therapy Endoscopic interventions for pancreatic diseases

3 The Pancreas Basic Anatomy Endocrine pancreas Islets of Langerhans Exocrine pancreas Acinar cells Ductal System Pancreas vasculature

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5 The Endocrine Pancreas Islets of Langerhans Hormones Insulin Glucagon Pancreatic polypeptide Regulation of Glucose Metabolism Regulation of pancreatic enzyme secretion

6 Image of Islet of Langerhans

7 The Exocrine Pancreas Pancreatic enzyme secretion Lipase Digestion of fats in conjunction with bile salts and lingual lipases Amylase Carbohydrate digestion in conjunction with brush border enzymes and salivary amylase Protease Protein digestion in conjunction with gastric pepsin Bicarbonate secretion Role of the duodenum Cholecystokinin secretion Gallbladder contraction and secretion of bile for fat emulsification Secretin secretion Stimulation of bicarbonate secretion and reduction of acid secretion

8 Image of Acinar System

9 Pancreatic Ductal System Normal ductal anatomy Santorini (Accesory) Duct Wirsung (Main) Duct Major Papilla Minor Papilla Ductal variations Pancreas Divisum Incomplete Pancreas Divisum Anular pancreas

10 Pancreatic Duct Anatomy

11 Pancreas Divisum

12 Pancreatic Vasculature Arterial supply Celiac artery / Splenic artery Pancreaticoduodenal artery Venous drainage Portal vein via the splenic vein

13 Pancreatic Vasculature

14 Pancreatic Nervous System Celiac plexus Pancreatic cancer pain can be controlled via celiac plexus neurolysis

15 Pathology:

16 Diagnostic Tests Testing for pancreatitis Serum Amylase Serum Lipase Imaging Testing for pancreatic function Fecal Pancreatic Elastase (< 200 g/dl) Fecal Fat (72 hr, 24 hr, spot testing) Secretin Stimulation Testing Serum Trypsinogen

17 Imaging for the Pancreas CT Abdomen and Pelvis with contrast (Pancreas Protocol) MRI of the Pancreas with contrast (with secretin protocol) Magnetic Resonance Retrograde Cholangiopancreatography (MRCP) wo contrast Endoscopic Retrograde Cholangiopancreatography (ERCP) Endoscopic US (EUS)

18 Advantages of EUS May see smaller lesions not visible on CT or MRI No radiation or IV contrast May sample lesions at time of study May be therapeutic and diagnostic Can evaluate intraluminal structures at time of the study

19 Endoscopic Ultrasonography Radial EUS Linear (curved array) EUS

20 Ultrasound Processor Aloka F75 EU-ME-1 / 2

21 EUS Guided Fine Needle Biopsy Sharkcore Needle Allows for true surgical pathology biopsies obtained through fine needle device

22 SharkCore FNB [ Six cutting edge surfaces [ Cutting heels Longer sharp access tip Centered cutting lumen Opposing catch bevel Confidential 10/25/

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24

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26 MRCP VS ERCP MRCP is purely an MRI that digitally enhances the billiary and pancreatic ductal structures. Diagnostic only No therapeutic intervention Minimal Risk No contrast needed ERCP should be reserved for cases where intervention is required Removal of stones Stenting for biliary or pancreatic drainage Spyglass sampling of ductal lesions Increased risk for pancreatitis or complications

27 MRCP ERCP

28 CT vs MRI of Pancreas CT Requires IV and Oral contrast for adequate imaging IV contrast risk of renal injury or allergy Readily available at most institutions Limited utility in smaller lesions or ductal abnormalities Able to evaluate all abdominal and pelvis structures simultaneously MRI Also requires IV contrast but no oral contrast IV contrast risk in patients with renal impairment Less readily available Longer scanning time Issues with claustrophobia patients Excellent ductal imaging when combined with MRCP Better for smaller lesions

29 CT Pancreas Protocol

30 Diseases of the Pancreas Inflammatory Conditions Acute Pancreatitis Chronic Pancreatitis Neoplasm Primary carcinoma of the Pancreas Neuroendocrine carcinoma Metastatic tumors to the Pancreas Renal Cell Carcinoma Pancreatic Cystic lesions

31 Acute Pancreatitis Causes Gallstones Alcohol Abuse Hypertriglyceridemia Autoimmune Pancreatitis (IgG-4 mediated) Drug Induced Neoplasms (Solid or Cystic) Viruses Congenital Diseases / Ductal Disorders

32 Chronic Pancreatitis Causes Alcohol Tobacco Recurrent acute pancreatitis Autoimmune Ductal Disorders Genetic disorders Cystic Fibrosis (CFTR mutation) PRSS, SPINK-1 mutations

33 Chronic Calcific Pancreatitis

34 Pancreatic Neoplasms Adenocarcinoma of the Pancreas Ductal Acinar Metastatic carcinoma Neuroendocrine Tumors of the Pancreas Insulinoma, Glucagonoma, VIPoma, neuroendocrine carcinoma Other malignancies Lymphoma, plasmacytoma, GIST Solid and pseudopapillary tumor of the pancreas

35 Solid Pancreatic Tumors Pancreatic Head Nodule Normal CT of Abdomen 32 year-old female with 10 mm nodule of the head of the pancreas and recurrent hypoglycemic episodes

36 Head of pancreas; FNA biopsy: Suspicious for neuroendocrine neoplasm, grade 1 (differential diagnosis includes carcinoid and islet cell tumor)

37 Pancreatic cancer Venous Involvement

38 Metastatic renal carcinoma

39 Cystic Lesions of the Pancreas Benign Pseudocyst Serous cystadenoma Lymphoepithelial cysts Premalignant Intraductal Papillary Mucinous Neoplasm Mucinous cystadenoma Malignant Mucinous Cystadenocarcinoma

40 Cystic pancreatic lesions Non-neoplastic Pseudocysts 80-90% Simple Cysts/Retention Cysts Neoplastic 10-15% Mucinous Cystadenoma Serous Cystadenoma IPMN Neuroendocrine Tumor Adenocarcinoma Benign Malignant / Potentially malignant

41 Serous Cystadenoma of the Pancreas Gerke H, Silva R. Gastrointest Endosc Aug 2006

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43 How can we treat patients with pancreatic disease?

44 Acute Pancreatitis Management is mostly resuscitative Early aggressive fluid resuscitation to prevent end organ damage IV and / oral analgesics, antiemetics Gradual oral intake as symptoms resolve Management of underlying cause: Cholecystectomy Alcohol abstinence Management of hyperlipidemia Removal of offending agents

45 Exocrine Pancreatic Insufficiency Chronic Pancreatitis Pancreatic Enzyme Replacement Therapy Lipase, Amylase and protease replacement Creon (72,000 units per meal, 36,000 units with snacks) Zenpep Pancreaze Fat Soluble vitamin replacement Vitamins A, D, E and K Surveillance for pancreatic malignancy and metabolic complications Endoscopic management of complications

46 Pancreatic Neoplasms Multidisciplinary Management Surgical Oncology Whipple Procedure Distal Pancreatectomy Palliative gastrojejunostomy Medical and Radiation Endoscopic management of pain with celiac plexus block or neurolysis Endoluminal Stenting or biliary stenting

47 Celiac Plexus Neurolysis vs Block Neurolysis Alcohol and bupivacaine Celiac Block Triamcinolone and bupivacaine Indications Pancreatic cancer pain Effective Chronic pancreatitis pain Controversial Wiersema M. GIE

48 Pancreatic Cystic lesions Pseudocyst (due to acute pancreatitis) Endoscopic drainage Surgical / IR drainage for infected necrosis Cystic neoplasms Endoscopic drainage / surveillance of premalignant cysts Endoscopic ablation of premalignant cysts Surgical resection of advanced cystic lesions

49 Axios Stent Pseudocyst Drainage

50 Pancreatic Cyst Ablation Gastrointestinal Endoscopy , DOI: ( /j.gie )

51 Pancreatic Cyst Ablation Gastrointestinal Endoscopy , DOI: ( /j.gie )

52 Pancreatic Cyst Ablation Indications: Cyst >2 cm in patients with high surgical risk (side branch IPMN or MCN) Unilocular symptomatic or enlarging serous cystadenomas Success: 33% to 79% complete ablation Minimal adverse effects Abdominal pain (8%) Acute pancreatitis (2%) Gastrointestinal Endoscopy , DOI: ( /j.gie )

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