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
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
The Pancreas Basic Anatomy Endocrine pancreas Islets of Langerhans Exocrine pancreas Acinar cells Ductal System Pancreas vasculature
The Endocrine Pancreas Islets of Langerhans Hormones Insulin Glucagon Pancreatic polypeptide Regulation of Glucose Metabolism Regulation of pancreatic enzyme secretion
Image of Islet of Langerhans
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
Image of Acinar System
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
Pancreatic Duct Anatomy
Pancreas Divisum
Pancreatic Vasculature Arterial supply Celiac artery / Splenic artery Pancreaticoduodenal artery Venous drainage Portal vein via the splenic vein
Pancreatic Vasculature
Pancreatic Nervous System Celiac plexus Pancreatic cancer pain can be controlled via celiac plexus neurolysis
Pathology:
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
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)
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
Endoscopic Ultrasonography Radial EUS Linear (curved array) EUS
Ultrasound Processor Aloka F75 EU-ME-1 / 2
EUS Guided Fine Needle Biopsy Sharkcore Needle Allows for true surgical pathology biopsies obtained through fine needle device
SharkCore FNB [ Six cutting edge surfaces [ Cutting heels Longer sharp access tip Centered cutting lumen Opposing catch bevel Confidential 10/25/2017 22
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
MRCP ERCP
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
CT Pancreas Protocol
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
Acute Pancreatitis Causes Gallstones Alcohol Abuse Hypertriglyceridemia Autoimmune Pancreatitis (IgG-4 mediated) Drug Induced Neoplasms (Solid or Cystic) Viruses Congenital Diseases / Ductal Disorders
Chronic Pancreatitis Causes Alcohol Tobacco Recurrent acute pancreatitis Autoimmune Ductal Disorders Genetic disorders Cystic Fibrosis (CFTR mutation) PRSS, SPINK-1 mutations
Chronic Calcific Pancreatitis
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
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
Head of pancreas; FNA biopsy: Suspicious for neuroendocrine neoplasm, grade 1 (differential diagnosis includes carcinoid and islet cell tumor)
Pancreatic cancer Venous Involvement
Metastatic renal carcinoma
Cystic Lesions of the Pancreas Benign Pseudocyst Serous cystadenoma Lymphoepithelial cysts Premalignant Intraductal Papillary Mucinous Neoplasm Mucinous cystadenoma Malignant Mucinous Cystadenocarcinoma
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
Serous Cystadenoma of the Pancreas Gerke H, Silva R. Gastrointest Endosc Aug 2006
How can we treat patients with pancreatic disease?
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
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
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
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
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
Axios Stent Pseudocyst Drainage
Pancreatic Cyst Ablation Gastrointestinal Endoscopy 2013 77, 526-533DOI: (10.1016/j.gie.2012.10.033)
Pancreatic Cyst Ablation Gastrointestinal Endoscopy 2013 77, 526-533DOI: (10.1016/j.gie.2012.10.033)
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 2013 77, 526-533DOI: (10.1016/j.gie.2012.10.033)