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Pancreatic function testsPancreatic exocrine function can be assessed by directly measuring pancreatic secretion in response to a standardised stimulus. The stimulus to secretion can be physiological, e.g. ingestion of a test meal, as in the Lundh test, or pharmacological, e.g. intravenous injection of a hormone such as secretin or CCK. Measurement of the enzyme elastase in stool is simple and specific. E-Absence of the enzyme elastase indicates exocrine insufficiency.Investigation of the pancreas.Serum enzyme levelsPancreatic function testsMorphology Ultrasound scan Computed tomography Magnetic resonance imaging Endoscopic retrogradeCholangiopancreatography Endoscopic ultrasoundPlain radiography Chest Upper abdomenCauses of raised serum amylase level other than acute pancreatitis■ Upper gastrointestinal tract perforation ■ Mesenteric infarction ■ Torsion of an intra-abdominal viscus ■ Retroperitoneal haematoma■ Ectopic pregnancy■ Macroamylasaemia■ Renal failure ■ Salivary gland inflammationCONGENITAL ABNORMALITIES ;Cystic fibrosisThis is inherited as an autosomal recessive condition,and is characterised by elevated sodium and chloride ion concentrations in sweat. The mother may notice that the child is salty when kissed.Chronic pulmonary disease arises from plugging of bronchi and bronchioles. The diagnosis can be made by genetic testing (which may be part of prenatal or newborn screening) and by the sweat test. Levels of sodium and chloride ions in the sweat above 90 mmol/L confirm the diagnosis.Treatment is aimed at control of the secondary consequences of the disease. Pulmonary function is preserved with aggressive physiotherapy and antibiotics. Malabsorption is treated by administration of oral pancreatic enzyme preparations. The diet should be low in fat but contain added salt to replace the high losses in the sweat. Pancreas divisumPancreas divisum occurs when the embryological ventral and dorsal parts of the pancreas fail to fuse . The dorsal pancreatic duct becomes the main pancreatic duct and drains most of the pancreas through the minor or accessory papilla. The incidence of pancreas divisum ranges from 25 to 50 per cent in patients with recurrent acute pancreatitis, chronic pancreatitis and pancreatic pain. A large volume of secretions flowing through a narrow papilla probably leads to incomplete drainage, which may then cause obstructive pain or pancreatitis. Certainly in patients with idiopathic recurrent pancreatitis, pancreas divisum should be excluded. The diagnosis can be arrived at by MRCP, EUS or ERCP, augmented by injection of secretin if necessary. There may be changes indicative of obstruction or chronic inflammation in the dorsal duct system. Endoscopic sphincterotomy and stenting of the minor papilla may relieve the symptoms. Surgical intervention can take the form of sphincteroplasty, pancreatojejunostomy or even resection of the pancreatic head.Annular pancreasThis is the result of a failure of complete rotation of the ventral pancreatic bud during development, so that a ring of pancreatic tissue surrounds the second or third part of the duodenum. It is most often seen in association with congenital duodenal stenosis or atresia and is therefore more prevalent in children with Down’s syndrome. Duodenal obstruction typically causes vomiting in the neonate . The usual treatment is bypass (duodenoduodenostomy). The disease may occur in later life as one of the causes of pancreatitis, in which case resection of the head of the pancreas is preferable to lesser procedures.Ectopic pancreasIslands of ectopic pancreatic tissue can be found in the submucosa in parts of the stomach, duodenum or small intestine (including Meckel’s diverticulum), the gall bladder, adjoining the pancreas, in the hilum of the spleen and within the liver. Ectopic pancreas may also be found in the wall of an alimentary tract duplication cyst .Congenital cystic disease of the pancreasThis sometimes accompanies congenital disease of the kidneys and liver, and occurs as part of the von Hippel–Lindau syndrome.INJURIES TO THE PANCREAS ;External injury Presentation and management. If there is damage to the pancreas, it is often concomitant with injuries to other viscera, especially the liver,the spleen and the duodenum.The most important factor that determines treatment is whether the pancreatic duct has been disrupted.Blunt pancreatic trauma usually presents with epigastric pain, which may be minor at first, with the progressive development of more severe pain due to the sequelae of leakage of pancreatic fluid into the surrounding tissues. The clinical presentation can be quite deceptive; careful serial assessments and a high index of suspicion are required. A rise in serum amylase occurs in most cases. A CT scan of the pancreas will delineate the damage that has occurred to the pancreas .. If there is doubt about duct disruption, an urgent ERCP should be sought. Support with intravenous fluids and a nil by mouth regimen should be instituted while these investigations are performed.Operation is indicated if there is disruption of the main pancreatic duct; in almost all other cases, the patient will recover with conservative management. In penetrating injuries, especially if other organs are injured and the patient’s condition (is unstable, there is a greater need to perform an urgent surgical exploration.If the gland is transected in the body or tail, a distal pancreatectomy should be performed, with or without splenectomy. If damage is purely confined to the head of the pancreas, haemostasis and external drainage is normally effective. However, if there is severe injury to the pancreatic head and duodenum, then a pancreatoduodenectomy may be necessarya).Pancreatic fistulaPancreatic fistula usually follows operative trauma to the gland or occurs as a complication of acute or chronic pancreatitis. Management of pancreatic fistulae_ Tests Measure amylase level in fluid Determine the anatomy of the fistula Check whether the main pancreatic duct is blocked or disrupted_ Measures Correct fluid and electrolyte imbalances Protect the skin Drain adequately Parenteral or nasojejunal feeding Octreotide to suppress secretion Relieve pancreatic duct obstruction if possible (ERCP and stent)Treat underlying causePANCREATITISPancreatitis is inflammation of the gland parenchyma of the pancreas. Acute pancreatitis is defined as an acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation. Acute pancreatitis may recur.The underlying mechanism of injury in pancreatitis is premature activation of pancreatic enzymes within the pancreas, leading to a process of autodigestion. As inflammatory mediators are released into the circulation, systemic complications can arise, such as haemodynamic instability, bacteraemia (due to translocation of gut flora), acute respiratory distresssyndrome and pleural effusions, gastrointestinal haemorrhage, renal failure and disseminated intravascular coagulation (DIC). Mild acute pancreatitis is characterised by interstitial oedema of the gland and minimal organ dysfunction. Eighty per cent of patients will have a mild attack of pancreatitis, the mortality from which is around 1 per cent. Severe acute pancreatitis is characterized by pancreatic necrosis, a severe systemic inflammatory response and often multi-organ failure. In those who have a severe attackof pancreatitis, the mortality varies from 20 to 50 per cent.AetiologyThe two major causes of acute pancreatitis are biliary calculi, which occur in 50–70 per cent of patients, and alcohol abuse,which accounts for 25 per cent of cases. Gallstone pancreatitis is thought to be triggered by the passage of gallstones down the common bile duct. If the biliary and pancreatic ducts join toshare a common channel before ending at the ampulla, then obstruction of this passage may lead to reflux of bile or activated pancreatic enzymes into the pancreatic duct. Possible causes of acute pancreatitis_ Gallstones_ Alcoholism _ Post-ERCP _ Abdominal trauma _ Following biliary, upper gastrointestinal or cardiothoracicSurgery _ Ampullary tumour _ Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens)_ Hyperparathyroidism _ Hypercalcaemia _ Pancreas divisum _ Autoimmune pancreatitis_ Hereditary pancreatitis _ Viral infections (mumps, Coxsackie B) _ Malnutrition _ Scorpion bite _ IdiopathicInvestigations in acute pancreatitis should be aimed at answering three questions:_ Is a diagnosis of acute pancreatitis correct? _ How severe is the attack? _ What is the aetiology?Clinical presentationPain is the cardinal symptom. It characteristically develops quickly, reaching maximum intensity within minutes rather than hours and persists for hours or even days. The pain is frequently severe, constant and refractory to the usual doses of analgesics. Pain is usually experienced first in the epigastriumbut may be localised to either upper quadrant or felt diffusely throughout the abdomen. There is radiation to the back in about 50 per cent of patients, and some patients may gain relief by sitting or leaning forwards. In fact, acute pancreatitis can mimic most causes of the acute abdomen and should seldom be discounted in differential diagnosis.Nausea, repeated vomiting and retching are usually marked accompaniments. The retching may persist despite the stomach being kept empty by nasogastric aspiration. Hiccoughs can be due to gastric distension or irritation of the diaphragm.On examination, the appearance may be that of a patient who is well or, at the other extreme, one who is gravely ill with profound shock, toxicity and confusion. Tachypnoea is common, tachycardia is usual, and hypotension may be present. The body temperature is often normal or even subnormal, but frequentlyrises as inflammation develops. Mild icterus can be caused by biliary obstruction in gallstone pancreatitis, and an acute swinging pyrexia suggests cholangitis. Bleeding into the fascial planescan produce bluish discolouration of the flanks (Grey Turner’s sign) or umbilicus (Cullen’s sign). Neither sign is pathogno-monic of acute pancreatitis; Abdominal examination may reveal distension due to ileus or, more rarely, ascites with shifting dullness. Amass can develop in the epigastrium due to inflammation. There is usually muscle guarding in the upper abdomen, although marked rigidity is unusual. A pleural effusion is present in 10–20 per cent of patients.. The patient may be confused and exhibit the signs of metabolic derangement together with hypoxaemia.InvestigationsTypically, the diagnosis is made on the basis of the clinical presentation and an elevated serum amylase level. A serum amylase level three to four times above normal is indicative of the disease. A normal serum amylase level does not exclude acute pancreatitis, particularly if the patient has presented a few days later. If the serum lipase level can be checked, it provides a slightly more sensitive and specific test than amylase. If there is doubt, and other causes of acute abdomen have to be excluded, contrast-enhanced CT is probably the best single imaging investigationInvestigations in acute pancreatitis should be aimed at answering three questions:_ Is a diagnosis of acute pancreatitis correct? _ How severe is the attack? _ What is the aetiology?Assessment of severityScoring systems to predict the severity of acute pancreatitis: in both systems, disease is classified as severe when three or more factors are present.Ranson score Glasgow scoreRanson score RGlasgow scaleOn admission On admissionAge >55 years Age >55 yearsWhite blood cell count >16 × 109/L White blood cell count >15 × 109/LBlood glucose >10 mmol/L Blood glucose >10 mmol/L (no history of diabetes)LDH >700 units/L Serum urea >16 mmol/L (no response to intravenous fluids)AST >250 Sigma Frankel units per cent Arterial oxygen saturation (PaO2) <8 kPa (60 mmHg)Within 48 hours Within 48 hoursBlood urea nitrogen rise >5 mg per cent Serum calcium <2.0 mmol/LArterial oxygen saturation (PaO2) <8 kPa (60 mmHg) Serum albumin <32 g/LSerum calcium <2.0 mmol/L LDH >600 units/LBase deficit >4 mmol/L AST/ALT >600 units/LFluid sequestration >6 litresALT, alanine aminotransferase; AST, aspartate aminotransferase; LDH, lactate dehydrogenase; PaO2, arterial oxygen tension.ImagingPlain erect chest and abdominal radiographs are not diagnostic of acute pancreatitis, but are useful in the differential diagnosis. Non-specific findings in pancreatitis include a generalised orlocal ileus (sentinel loop), a colon cut-off sign and a renal halo sign. Occasionally, calcified gallstones or pancreatic calcification may be seen. A chest radiograph may show a pleural effusionand, in severe cases, a diffuse alveolar interstitial shadowing may suggest acute respiratory distress syndrome.Ultrasound does not establish a diagnosis of acute pancreatitis.The swollen pancreas may be seen, but ultrasonography should be performed within 24 hours in all patients to detect gallstones as a potential cause, rule out acute cholecystitis as a differential diagnosis and determine whether the common bile duct is dilated. CT is not necessary for all patients, particularly those deemed to have a mild attack on prognostic criteria. a contrast- enhanced CT is indicated? if there is diagnostic uncertainty or when a localised complication is suspected, such as fluid collection, pseudocyst or a pseudoaneurysm. or in patients with severe acute pancreatitis, to distinguish interstitial from necrotising pancreatitis . In the first 72 hours, CT may underestimate the extent of necrosis . ERCP allows the identification and removal of stones in the common bile duct in gallstone pancreatitis. Occasionally the diagnosis is only made at laparotomy. ManagementIf after initial assessment a patient is considered to have a mild attack of pancreatitis, a conservative approach is indicated with intravenous fluid administration and frequent, but non-invasive, observation. A brief period of fasting may be sensible in a patient who is nauseated and in pain. Antibiotics are not indicated. Apart from analgesics and anti-emetics, no drugs or interventions are warranted,and CT scanning is unnecessary unless there is evidence of deterioration. Adequate analgesia should be administered. Aggressive fluid resuscitation is important, guided by frequent measurement of vital signs, urine output and central venous pressure. Supplemental oxygen should be administered and serial arterial blood gas analysis performed.The haematocrit, clotting profile, blood glucose and serum levels of calcium and magnesium should be closely monitored. . The rationale is to prevent local and other septic complications. The regimens used include intravenous cefuroxime, or imipenem, or ciprofloxacin plus metronidazole. The duration of antibiotic prophylaxis should not exceed 14 days.If gallstones are the cause of an attack of predicted or proven severe pancreatitis, or if the patient has jaundice, cholangitis or a dilated common bile duct, urgent ERCP should be carried out within 72 hours of the onset of symptoms. There is evidence that sphincterotomy and clearance of the bile duct can reduce the incidence of infective complications in these patients. In patients with cholangitis, sphincterotomy should be carried out or a biliary stent placed to drain the duct. ERCP is an invasive procedure and carries a small risk of worsening the pancreatitis.Systemic complicationsPancreatitis may involve all organ systems .Patients with systemic complications should be managed by a multidisciplinary team that includes intensive care specialists. When there is organ failure, appropriate supportive therapies may include inotropic support for haemodynamic instability, haemofiltration in the event of renal failure, ventilatory support for respiratory failure and correction of coagulopathies (including DIC). ; surgical intervention is contemplatedonly in the patient who deteriorates as a result of local complications following successful plications of acute pancreatitis.Systemic Local(More common in the first week) (Usually develop after the first week)Cardiovascular Acute fluid collectionShock Sterile pancreatic necrosisArrhythmias Infected pancreatic necrosisPulmonary Pancreatic abscess, Pseudocyst , Pancreatic ascitesARDS Pleural effusion, Portal/splenic vein thrombosisRenal failure HaematologicalDICMetabolicHypocalcaemiaHyperglycaemiaHyperlipidaemiaGastrointestinalIleusNeurologicalVisual disturbancesConfusion, irritabilityEncephalopathyMiscellaneousSubcutaneous fat necrosisArthralgia.Pseudocyst A pseudocyst is a collection of amylase-rich fluid enclosed in a wall of fibrous or granulation tissue. Pseudocysts typically arise following an attack of acute pancreatitis, but can develop inchronic pancreatitis or after pancreatic trauma. Formation of a pseudocyst requires 4 weeks or more from the onset of acute pancreatitis They are often single but, occasionally, patients will develop multiple pseudocysts. If carefully investigated, more than half will be found to have a communication with the main pancreatic duct.A pseudocyst is usually identified on ultrasound or a CT scan. It is important to differentiate a pseudocyst from an acute fluid collection or an abscess; the clinical scenario and the radiological appearances should allow that distinction to be made. Occasionally, a cystic neoplasm may be confused with a chronic pseudocyst. EUS and aspiration of the cyst fluid is very useful in such a situation. The fluid should be sent for measurement of carcinoembryonic antigen (CEA) levels, amylase levels and cytology. . Pseudocysts will resolve spontaneously in most instances,but complications can develop. Pseudocysts that are thick-walled or large (over 6 cm in diameter), have lasted for a long time (over 12 weeks) or have arisen in the context of chronic pancreatitis are less likely to resolve spontaneouslyThere are three possible approaches to draining a pseudocyst: percutaneous, endoscopic and surgical. Percutaneous drainage to the exterior under radiological guidance should be avoided. Distinguishing a pseudocyst from a cystic neoplasm_ History Appearance on CT and ultrasound _ FNA of fluid, preferably under EUS guidance CEA (high level in mucinous tumours)Amylase (level usually high in pseudocysts, but occasionally in tumours) CytologyChronic pancreatitis; Chronic pancreatitis is defined as a continuing inflammatory disease of the pancreas characterised by irreversible morphological change typically causing pain and/or permanent loss of function. Many patients with chronic pancreatitis have painful exacerbations, but the condition may be completely painlessIn the early stages of its evolution, it is frequently complicated by attacks of acute pancreatitis, which are responsible for the recurrent pain that may be the only clinical symptom. The disease occurs more frequently in men (male to female ratio of 4:1), and the mean age of onset is about 40 years.Aetiology and pathologyHigh alcohol consumption is the most frequent cause of chronic pancreatitis, accounting for 60–70 per cent of cases, but only 5–10 per cent of people with alcoholism develop chronic pancreatitis..Other causes include pancreatic duct obstruction resulting from stricture formation after trauma, after acute pancreatitis or even occlusion of the duct by pancreatic cancer. Congenital abnormalities, such as pancreas divisum and annular pancreas, if associated with papillary stenosis, are rare causes of chronic pancreatitis.Hereditary pancreatitis, CF, infantile malnutrition and a large unexplained idiopathic group make up the remainder. Idiopathic chronic pancreatitis accounts for approximately 30 per cent of cases and has been subdivided into early-onset and late-onset forms. The importance of hereditary pancreatitis and pancreatitis occurring at a young age is that there is a markedly increased risk of developing pancreatic cancer, particularly if the patient smokes tobacco. Hyperlipidaemia and hypercalcaemia can lead to chronic pancreatitis.Clinical featuresPain is the outstanding symptom in the majority of patients.The site of pain depends to some extent on the main focus of the disease. If the disease is mainly in the head of the pancreas, then epigastric and right subcostal pain is common, whereas if it is limited to the left side of the pancreas, left subcostal and backpain are the presenting symptoms. In some patients, the pain is more diffuse. Radiation to the shoulder, usually the left shoulder,occurs. Nausea is common during attacks and vomiting may occur. The pain is often dull and gnawing.. Weight loss is common, because the patient does not feel like eating. The pain prevents sleep and time off work is frequent. The number of hospital admissions for acute exacerbations is a pointer towards the severity of the disease. Analgesic use and abuse is frequent. This, too, gives an indication of the severity of the disability. Loss of exocrine function leads to steatorrhoea in more than 30 per cent of patients with chronic pancreatitis.Loss of endocrine function and the development of diabetes are not uncommon, and the incidence increases as the disease progresses. InvestigationsOnly in the early stages of the disease will there be a rise in serum amylase. Tests of pancreatic function merely confirm the presence of pancreatic insufficiency or that more than 70 per cent of the gland has been destroyed. Pancreatic calcifications may be seen on abdominal x-ray. CT or MRI scan will show the outline of the gland, the main area of damage and the possibilities for surgical correction. Calcification is seen very well on CT, but not on MRI. An MRCP will identifythe presence of biliary obstruction and the state of the pancreatic duct. The use of intravenous secretin during the study may demonstrate a pancreatic duct stricture that is notapparent on a standard MRCP, but a normal-looking pancreas on CT or MRI does not rule out chronic pancreatitis. ERCP is the most accurate way of elucidating the anatomy of the duct and, in conjunction with the whole organ morphology, can help to determine the type of operation required, if operative interventionis indicated. Histologically proven chronic pancreatitis can, however, occur in the settingof normal findings on pancreatography. EUS can also be very useful. Sonographic findings characteristic of chronic pancreatitis include the presence of stones, visible side branches, cysts, lobularity, an irregular main pancreatic duct, hyperechoic foci and strands, dilation of the main pancreatic duct and hyperechoic margins of the main pancreatic duct. The presence of four or more of these features is highly suggestive of chronic pancreatitis.TreatmentMost patients can be managed with medical measures .Endoscopic, radiological or surgical interventions are indicated mainly to relieve obstruction of the pancreatic duct, bile duct or the duodenum, or in dealing with complications (e.g. pseudocyst, abscess, fistula, ascites or variceal haemorrhage).Decompressing an obstructed pancreatic duct can provide pain relief in some patients .Endoscopic pancreatic sphincterotomy might be beneficial in patients with papillary stenosis and a high sphincter pressure and pancreatic ductal pressure. Patients with a dominant pancreaticduct stricture and upstream dilatation may benefit by placement of a stent across the stricture The role of surgery is to overcome obstruction and remove mass lesions. Some patients have a mass in the head of the pancreas, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate. If the duct is markedly dilated,then a longitudinal pancreatojejunostomy. CARCINOMA OF THE PANCREAS Worldwide, it constitutes 2–3 per cent of all cancers Risk factors for the development of pancreatic cancer. Demographic factors Age (peak incidence 65–75 years)Male gender Black ethnicity Environment/lifestyle Cigarette smoking Genetic factors and medical conditionsFamily history Two first-degree relatives with pancreas cancer: relative risk increases 18- to 57-foldHereditary pancreatitis (50- to 70-fold increased risk) Chronic pancreatitis (5- to 15-fold increased risk) PathologyMore than 85 per cent of pancreatic cancers are ductal adenocarcinomas .Endocrine tumours of the pancreas are rare. Ductal adenocarcinomas arise most commonly in the head of the gland. Ductal adenocarcinomas infiltrate locally, typically along nerve sheaths, along lymphatics and into blood vessels. Liver and peritoneal metastases are common..Cystic tumours of the pancreas may be serous or mucinous The serous are benign. Mucinous tumours, on the other hand, have the potential for malignant transformation. . Mucinous tumours can be confused with pseudocysts .Tumours arising from the ampulla or from the distal common bile duct can present as a mass in the head of the pancreas, and constitute around a third of all tumours in that area. 19- Ampullary carcinomasAmpullary adenocarcinomas often present early with biliary obstruction.Tumours arising from the ampulla can present as a mass in the head of the pancreas .Their natural history is distinctly more favourable compared with pancreatic ductal adenocarcinoma. Ampullary carcinomas are relatively large when diagnosed.Tumours of the ampulla have a good prognosis and should, if at all possible, be resected. Ampullary adenocarcinomas often present early with biliary obstruction. Their natural history is distinctly more favourable compared with pancreatic ductal adenocarcinoma. Ampullary carcinomas are relatively small when diagnosed, which may account for their better prognosis.Clinical featuresJaundice secondary to obstruction of the distal bile duct is the most common symptom that draws attention to ampullary and pancreatic head tumours. It is characteristically painless jaundice but may be associated with nausea and epigastric discomfort. Pruritus, dark urine and pale stools with steatorrhoea are common accompaniments of jaundice. In the absence of jaundice, symptoms are often non-specific, namely vague discomfort, anorexia and weight loss, and are frequently dismissed by both patient and doctor. Upper abdominal symptoms in a recently diagnosed diabetic, especially in one above 50 yearsof age, with no family history or obesity, should raise suspicion. Occasionally, a patient will present with an unexplained attack of pancreatitis; all such patients should have follow-up imaging of the pancreas. Tumours of the body and tail of the gland often grow silently, and present at an advanced unresectable stage.Back pain is a worrying symptom, raising the possibility of retroperitoneal infiltration.On examination, there may be evidence of jaundice, weight loss, a palpable liver and a palpable gall bladder. Courvoisier : when the common duct is obstructed by a stone, distension of the gall bladder (which is likely to be chronically inflamed) is rare; when the duct is obstructed in some other way, such as a neoplasm, distension of the normal gall bladder is common. Other signs of intra-abdominal malignancy should be looked for with care, such as a palpable mass, ascites, supraclavicular nodes and tumour deposits in the pelvis; when present, they indicate a grim prognosis.InvestigationIn a jaundiced patient, the usual blood tests and ultrasound scan should be performed. Ultrasound will determine whether or not the bile duct is dilated. If it is, and there is a genuine suspicion of a tumour in the head of the pancreas, the preferred test is a contrast-enhanced CT scan. In the majority of instances, this should establish if there is a tumour in the pancreas and if it is resectable. The presence of hepatic or peritoneal metastases, lymph node metastases distant from the pancreatic head, encasement of the superior mesenteric, hepatic or coeliac artery by tumour are clear contraindications to surgical resection. If the tumour abuts or minimally invades the portal or superior mesenteric vein, this is not a contraindication to surgery (as part of the vein can be resected if necessary), but complete encasement and occlusion of the vein is. MRI and MRA can provide information comparable to CT. ERCP and biliary stenting should be carried out if there is any suggestion of cholangitis, if there is diagnostic doubt (small ampullary lesions may not be seen on CT, and ERCP is the best way to identify them), if the patient is deeply jaundiced (serum bilirubin >250 mmol/L), or there are distressing symptoms (e.g. pruritus) and there is likely to be a delay between diagnosis and surgery. It relieves the jaundice and can also provide a brush cytology or biopsy specimen to confirm the diagnosis . The prothrombin time should be checked, and clotting abnormalities should be corrected with vitamin K or fresh-frozen plasma prior to ERCP. EUS is useful if CT fails to demonstrate a tumour, if tissue diagnosis is required prior to surgery Transduodenal or transgastric FNA or Trucut biopsy performed under EUS guidance avoids spillage of tumour cells into the peritoneal cavity. Percutaneous transperitoneal biopsy of potentially resectable pancreatic tumours should be avoided as far as possible. Histological confirmation of malignancy is desirable but not essential, particularly if the imaging clearly demonstrates a resectable tumour. The lack of a tissue diagnosis should not delay appropriate surgical therapy..Diagnostic laparoscopy prior to an attempt at resection can spare a proportion of patients an unnecessary laparotomy by identifying small peritoneal and liver metastases. It can be combined with laparoscopic ultrasonography. The tumour marker CA19-9 is not highly specific or sensitive, but a baseline levelshould be established; if it is initially raised, it can be useful later in identifying recurrence.ManagementAt the time of presentation, more than 85 per cent of patients with ductal adenocarcinoma are unsuitable for resection because the disease is too advanced. If imaging shows that the tumour is potentially resectable, the patient should be considered for surgical resection, as that offers the only (albeit small) chance of a cure. If a cystic tumour is encountered, no matter how large, surgical resection should be considered, as it carries a reasonable chance of cure. Tumours of the ampulla have a good prognosis and should, if at all possible, be resected. Surgical resectionThe standard resection for a tumour of the pancreatic head or the ampulla is a pylorus-preserving pancreatoduodenectomy (PPPD). This involves removal of the duodenum and the pancreatichead, including the distal part of the bile duct. The original pancreatoduodenectomy as proposed by Whippleincluded resection of the gastric antrum. Preserving the antrum and the pylorus is thought to result in a more physiological outcome with no difference in survival or recurrence rates. PancreatoduodenectomyThe patient’s coagulation screen should be checked. The operation has three distinct phases: ? exploration and assessment; ? resection; ? reconstruction.Octreotide may be administered in the perioperative period to suppress secretion and reduce the likelihoodof a leak, but the evidence for its efficacy is still debatable.Following surgical resection, the pathological tumour–node– metastasis (TNM) stage should be documented.Adjuvant therapyPatients with resected ampullary tumours have a five-year survival of 40 per cent, and cystic tumours and neuroendocrine tumours can often be cured by surgical resection.The high recurrence rate following resection has inevitably led to the consideration of adjuvant treatments to improve outcome. Most patients with resected ductal adenocarcinoma are now offered adjuvant chemotherapy, using gemcitabine or 5-FU. Palliation of pancreatic cancer_ Relieve jaundice and treat biliary sepsisSurgical biliary bypass Stent placed at ERCP or percutaneous transhepat ic cholangiography _ Improve gastric emptying Surgical gastroenterostomy Duodenal stent_ Pain relief Stepwise escalation of analgesia Coeliac plexus block Transthoracic splanchnicectomy_ Symptom relief and quality of life Encourage normal activities Enzyme replacement for steatorrhoea Treat diabetes_ Consider chemotherapy ................
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