Page 224 - Medicine and Surgery

P1: KPE
BLUK007-05 BLUK007-Kendall May 25, 2005 8:52 Char Count= 0

220 Chapter 5: Hepatic, biliary and pancreatic systems

particularly those with biliary obstruction or sepsis, with profound weight loss and oedema due to hypoal-
urgent ERCP and papillotomy is indicated. buminaemia.
Laparotomy may be required to drain retroperitoneal

collections of pus, resect any necrotic pancreatic and
Complications
peripancreatic tissue, and perform peritoneal irriga-
Predisposes to pancreatic cysts, pseudocysts and pancre-
tion. Pancreatic pseudocysts which do not resolve
atic cancer. Ascites and persistent obstructive jaundice
with conservative management require laparoscopic
may occur.
drainage into the stomach.
Investigations
Prognosis
Serum amylase fluctuates, but may be moderately raised
Pancreatitis is a serious condition: overall mortality is
on testing.
10%. The prognostic factors are listed in Table 5.7. If
Plain abdominal X-ray may show calcification.
less than three criteria are met then the pancreatitis is
Ultrasound and CT scanning demonstrates cysts, cal-
considered mild and has <3% mortality. If more than
cification and enlarged ducts.
threecriteriaaremetthepancreatitisisconsideredsevere
Endoscopic retrograde cholangiopancreatography
and has >60% mortality.
mayshowscarringoftheductalsystemandevenstonesin
the pancreatic duct. Magnetic resonance cholangiopan-
Chronic pancreatitis creatography is increasingly being used.
Definition
Chronic pancreatitis is an inflammatory condition that Management
results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re-
ment of exocrine and endocrine function. moved. Adequate analgesia is required, thoracoscopic
splanchnicectomymayberequiredinrefractorypainnot
Age associated with main pancreatic duct dilatation. Steator-
Usually >40 years. rhoea is managed with pancreatic enzyme supplemen-
tation and diabetes may need oral hypoglycaemics or
Sex insulin. Surgery is indicated for obstruction. Surgical
M > F techniques include sphincteromy or sphincteroplasty,
partial pancreatectomy or opening the pancreatic duct
Aetiology/pathophysiology along its length and anastomosing it with the duodenum
Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out,
relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin.
stepwise deterioration, or a truly chronic gradual deteri-
oration leading to pancreatic insufficiency. Risk factors
includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas
struction (e.g. trauma, pseudocysts, stones, tumours), Carcinoma of the pancreas
systemic lupus erythematosus and cystic fibrosis. Hy-
percalcaemia, hyperlipidaemia and congenital pancre-
Definition
atic malformations are recognised associations.
Malignant tumours of the exocrine pancreas.
Clinical features
Incidence
Patients may present with an acute episode of pancre-
10 per 100,000 per annum and rising.
atitis or an insidious onset with persistent or recurrent
episodes of abdominal pain and weight loss. Late com-
plications include impaired glucose tolerance, diabetes Age
mellitus and malabsorption (steatorrhoea) associated Mainly >60 years.