this voiceover actually begins on page four of the class packet the first three pages are review of the normal anatomy and physiology of the pancreas this voice over powerpoint will discuss disorders of the pancreas with the focus on acute pancreatitis and pancreatic cancer the first objective for this voice over is to explain the process whereby a trigger can result in pancreatitis there are varied ideologies but they can have similar signs and symptoms when the individual has pancreatitis regardless of the etiology the signs and symptoms can be the same so whether it's virus bacteria trauma there's inflammation with capillary dilation and movement of plasma fluid into the surrounding tissue space that swelling causes the tissue to compress the ducts in the pancreas enzymes produced by the pancreas cannot escape the pancreas starts digesting itself that's called auto digestion that auto digestion results in acute onset of pain and other signs and symptoms suggested for pancreatitis so to summarize there are varied etiologies but they result in inflammation and swelling of the pancreas and the ducts swell shut the initial signs and symptoms will be the same regardless of the etiology auto digestion of the pancreas is occurring enzymes that cannot escape begin to digest the pancreas itself alcohol is an etiology for acute pancreatitis the exact etiology for pancreatitis related to alcohol use is not known but it may stimulate pancreatic secretions alcohol may also partially obstruct the sphincter of odie the opening into the ampoule of water the focus for this presentation is going to be cholethiasis and the related concern of pancreatitis we're going to talk about how you get from gallstones to pancreatitis notice the arrow on this slide there's a gallstone obstructing the ampoule of water pancreatic enzymes cannot escape into the duodenum and the pancreas begins to digest itself a process known as auto digestion your paper says to recall definitions coley means gall or bile lithiasis is a condition of stones and coley daco means common bile duct so stones in the distal common bile duct could result in pancreatitis and we'll talk about that explains how chole lithiasis and chole dacholithiasis can result in pancreatitis that's what we'll talk about next notice on this slide gallstones are obstructing the ampule of water and also the sphincter of od that will block both the flow of bile from the common bile duct and pancreatic enzymes coming from the pancreas the blockage in the common bile duct is responsible for bilirubin rise and jaundice blocking of the pancreatic duct is responsible for auto digestion of the pancreas and pancreatitis notice on this slide cholethiasis there's a gallstone blocking the common bile duct that would be called a choledachylithiasis and notice how that stone is blocking both the common bile duct and the pancreatic duct this stone which we're going to call position three and notice how it's compressing the pancreatic duct it's blocking the distal common bile duct but that stone is also compressing the pancreatic duct a stone in this position blocks the flow of pancreatic enzymes enzymes back up into the pancreas and the pancreas digests itself a process known as auto digestion recognizes the class act associated with pancreatitis notice on your packet the class act when you interview the person the character of the pain may be described in a lot of different ways it depends on how the person describes their pain under the location abdominal left upper quadrant epigastric referring to the back on this slide we might say it's position 2 epigastric 5 abdominal or 3 left upper quadrant and referring around to the back aggravating factors can include lying flat where stretching of the pancreas can aggravate inflammatory pain the severity is often at least 10 over 10. the setting the same as the aggravating factors often in the setting of a meal aggravated by eating remember when you eat that stimulates release of enzymes that cannot escape into the duodenum the enzymes back up and auto digest the pancreas resulting in pain there's a blockage the pancreas releases enzymes when you eat but they can't make it out of the pancreas into the duodenum auto digestion associated signs and symptoms might include nausea and vomiting this is an autonomic nervous system fight or flight situation that slows down the gi tract under client perception the person is not likely to know what's going on and timing and treatment the onset of pain is often abrupt and may follow a heavy meal or an alcoholic binge the person may say they feel better if they don't eat but the symptoms continue for hours lists significant history and physical findings suggestive for pancreatitis when someone presents with possible acute pancreatitis the history may be suggestive for gallbladder disease cholethiasis alcohol abuse may be in their history or the person may have started on a new drug that has pancreatitis as a potential side effect in the physical exam left upper quadrant pain and tenderness to palpation the tenderness may also be in the epigastric region over the head of the pancreas or in the abdominal area with more severe forms of pancreatitis there may be diminished or absent bowel sounds and autonomic nervous system effect the sympathetic nervous system would shut down the gi tract and the bowel sounds would be high proactive or even absent describes the diagnostic signs that suggest or accompany pancreatitis explains the rationale behind an elevated serum amylase and lipase why do the amylase and lipase levels go up in the blood in a person who has pancreatitis notice the red spot on this slide that represents an obstructing gallstone and look at the back and forth arrow that represents enzymes that are generated by the pancreas that are blocked by the obstructing gallstone instead of going into the duodenum the enzymes back up into the pancreas which begins the process of auto digestion those enzymes are then reabsorbed into the blood and the serum amylase and lipase levels rise the white blood cell count can rise that's called leukocytosis the reason for the change in the white blood cells is inflammation which is a non-specific immune response to the tissue injury in this case phagocytosis occurs neutrophils are the most predominant white blood cell and are responsible for the phagocytosis this person would have an increased white blood cell count primarily because of inflammation and a shift to neutrophils the blood sugar hyperglycemia may be related to the stress response fight or flight cortisol and other hormones raise the blood sugar explains the rationale behind a rise in the serum bilirubin let's look at the slide first and then we'll read what's on your class packet notice that the stone in position 3 that bile from the common bile duct cannot drain into the duodenum which is why it backs up notice also that this stone in position 3 is compressing the pancreatic duct and this person would have signs and symptoms of pancreatitis now let's look at the class packet the serum bilirubin may rise why because blockage at the ampoule of water results in bile that can't flow into the duodenum bile backs up into the common bile duct and into the hepatic duct and into the liver where bilirubin is reabsorbed into the blood resulting in hyperbilirubinemia if the serum bilirubin gets high enough the skin and sclera may be discolored the color is yellow and the condition would be called jaundice jaundice which usually means there's obstruction in the flow of bile not always but usually and in this case the obstruction is caused by a gallstone that is obstructing the flow of bile from the common bile duct into the duodenum bilirubin has an affinity for connective tissue so the eyeball the sclera of the eye becomes yellow or jaundiced as well as other tissues in the body describes ultrasound and cat scan results that can accompany pancreatitis because of inflammation the pancreas will swell the pancreas itself may appear swollen and there may be what is referred to as peripancreatic fluid which the arrows are pointing to on this slide fluid around the pancreas that's generated as a result of inflammation fluid and electrolyte problems are here for your information but they're not testable in this course the most common etiologies for pancreatitis gallbladder disease and alcohol-induced pancreatitis usually do not cause fluid and electrolyte imbalance however if fluid and electrolyte imbalances occur it may include fluid shifting into the peritoneum resulting in ascites that's fluid accumulation in the abdominal cavity and that results in intravascular volume depletion and the person may have signs of hypovolemia such as hypotension tachycardia and cool skin hypocalcemia is also possible pancreatic lipase in the process of digesting the pancreas can result in free fatty acids which bind with calcium resulting in a low serum calcium level as you can see on this slide the pancreas enzymes which have been blocked by a stone or duct have resulted in auto digestion and that has caused inflammation enzymes back up resulting in lipolysis fatty acids bind with the calcium and you have hypocalcemia and you can also see on this slide accumulation of inflammatory fluid in the abdominal cavity but this is a for your information only slide in this course is not a common complication of pancreatitis when the pancreatitis is related to gallstones or cholethiasis however when hypoxia occurs it occurs because of fluid movement from the abdomen into the pleural space that results in collapse of part of the lung or atelectasis usually on the left side that interferes with oxygen diffusion related to collapse of the lung and fluid in the pleural space the person has hypoxia and shortness of breath the x-ray on this slide shows pancreatic inflammatory fluid atelectasis and the person would likely be short of breath recognizes how removal of an obstructing gallstone will relieve signs and symptoms of pancreatitis relieving the obstruction may require a sphincterotomy using a procedure known as endoscopic retrograde cholangio pancreatography or ercp click on this website and see how this is done enlarge the upper right hand video at this site click and listen to the ercp procedure at some point you need to remove the source of the stones a cholecystectomy can be performed laparoscopic which is what you're seeing on this slide or an open incision click on this link if you would like to see how laparoscopic cholecystectomy is performed and remember you do fine without your gallbladder the gallbladder stores concentrates and releases bile without your gallbladder you still make bile in the liver and you can still deliver bile to the duodenum so emulsification of fats will still occur provides a summary of the concept cholethiasis to pancreatitis complete the steps in order exercise on your class handout provides an overview of treatment for pancreatitis discusses the concept of pancreatic rest notice on your class packet are you listening to your pancreas pain control is an important part of the management of someone with acute pancreatitis the pain of pancreatitis can be abrupt in onset following a meal when the pancreas is asked to produce enzymes for example i can cause pain that is abrupt in onset i can cause pain that is felt in the upper abdomen or epigastric region in the abdomen or the pain can refer to the back pain management is an important aspect of the treatment for acute pancreatitis pancreatic rest means asking the pancreas not to do its job asking the pancreas not to produce digestive enzymes and how is that done nil peros nothing by mouth or npo don't put anything in the person's mouth the pancreas will then have no need to produce digestive enzymes digestive enzymes that are now digesting the pancreas itself one way to eliminate the cause of pancreatitis produced by an obstructing gallstone is to do an endoscopic retrograde calangio pancreatography a scope goes down the mouth the esophagus the stomach to the duodenum once the scope gets near the sphincter of od a probe goes retrograde backwards through the sphincter up into the common bile duct to snag or snare that stone and bring it out a small snip might need to be made in the sphincter in order to allow space for the gall stones to fall into the duodenum once the gallstones leave the common bile duct and enter the duodenum the obstruction is relieved the gallbladder will eventually be removed remove the source of the stones and remember you don't need your gallbladder to live the gallbladder stores concentrates and releases bile without the gallbladder the liver still makes bile the bile passes directly from the liver through the hepatic duct the common bile duct directly to the duodenum provides evidence that suggests the pancreatitis has resolved how would you know the procedure to remove stones was successful or the procedure to remove any obstruction or any time the person has pancreatitis how would you know the treatment was successful the serum amylase and lipase what goes up because of obstruction will go down when the obstruction is relieved dropping to normal levels indicate improvement in inflammation signs and symptoms of pancreatitis would be monitored and managed as evidenced by complaints of pain would decrease amylase and lipase would decrease x-ray evidence would show that the pancreas is shrinking when inflammation subsides there's less swelling the bilirubin if elevated would drop as bile would now flow freely into the duodenum take a moment and complete the review question once you've completed the question read the discussion i don't know how many of you remember michael landon little house on the prairie but michael landon died of pancreatic cancer explains why pancreatic cancer is often found at a higher stage cancer of the pancreas is one of the most deadly malignancies and accounts for two to three percent of new cancer cases and there is no recommended screening for asymptomatic persons reasons for the high mortality rate no early warning signs no easy reliable diagnostic tests and unfortunately fewer than 20 percent of persons diagnosed with pancreatic cancer are alive at one year symptoms and signs when they occur are usually related to obstruction which is why you often see jaundice as a presenting sign in someone who turns out to have pancreatic cancer the exact cause of pancreatic cancer is unknown now we know that dna mutation causes cancer but the exact trigger is unknown the single most prevalent risk factor is smoking and there might be a genetic link such as non-polyposis colon cancer along with brca2 mutation and other hereditary factors identifies the most common location for cancer in the pancreas explains the relationship between location of the tumor and jaundice cancer at the head of the pancreas is the most common location that obstructs the flow of bile which backs up into the common bile duct the hepatic duct which increases blood levels of bilirubin staining the skin the connective tissues which is referred to as jaundice so jaundice is often a presenting sign in individuals who are later diagnosed with cancer at the head of the pancreas pain is related to pressure on the duodenum and surrounding structures remember cancer grows by invasion that causes a lot of tissue injury and pain pain may also be related to pancreatitis in addition to obstructing the flow of bile the flow of pancreatic enzymes is blocked when there's a tumor at the head of the pancreas that results in auto-digestion of the pancreas and inflammation there are some associated factors anorexia which may be related to tumor necrosis factor recall that tnf is released in response to tumor growth and affects the appetite center fatigue recall that cellular division requires a lot of energy expenditure in addition the person may not be eating because of anorexia and may not be digesting food because of decrease in pancreatic enzymes into the duodenum plus if they have pancreatitis it hurts every time they eat dietary changes may cause an anemia which may also contribute to the fatigue the history and physical the history may not tell you much it may show some weight loss related to impaired digestion or pain that occurs with eating and the person doesn't eat pancreatic enzymes may not be able to get into the duodenum in individuals who have a tumor at the head of the pancreas and anorexia may be present so weight loss may be present in the physical exam there may be left upper quadrant and epigastric pain over the pancreas and jaundice remember the common bile duct passes through the head of the pancreas a tumor in the head of the pancreas would obstruct the common bile duct raising the bilirubin levels and the person would appear jaundiced describes the diagnostic workup for a person suspected to have pancreatic cancer why might a person with cancer of the pancreas also have pancreatitis lab studies the amylase and lipase would be elevated if obstruction occurs in the pancreatic duct the bilirubin would be elevated with obstruction to the flow of bile and the person would be jaundiced notice on this picture the tumor at the head of the pancreas the most common location the tumor is compressing the pancreatic duct which obstructs the flow of pancreatic enzymes those enzymes back up into the pancreas and become active resulting in pancreatitis the amylase and lipase levels in the blood would rise notice also that the tumor is compressing the common bile duct that is responsible for the elevated bilirubin and the jaundice tumor markers would be checked although we know they are non-specific and unreliable tumor markers cea and ca 19 9 may be elevated again recall that these non-specific tumor markers are antigens that are present on the surface of the tumors but they are non-specific and unreliable if this person is treated for pancreatic cancer successfully these tumor markers should go down and if they go back up again it suggests recurrence just as a review let's look at this ultrasound image notice the apparent tumor obstructing the common bile duct now that would be responsible for the jaundice cbd common bile duct and it's dilated because the bile cannot enter the duodenum it's backing up into the common bile duct a dilated duct suggests obstruction and then look at the pancreatic duct that's obstructed and dilated which is the reason this individual could present with pancreatitis when you see a dilated duct that suggests obstruction in this case obstruction by a tumor a cat scan can be done which would show the presence of a tumor a biopsy would still need to be done to confirm that it was in fact pancreatic cancer magnetic resonance imaging or mri can also be done to identify tumors that can be suggestive for cancer recognizes biopsy as the definitive diagnostic test for cancer pancreatic cancer identifies the cell type and identifies the likely grade of the malignant cells cancer of the pancreas is an adenocarcinoma this means the tumor is arising from glandular epithelial tissue because cancer of the pancreas is advanced at the time of diagnosis you would expect the tumor to be a grade four this means that the tumor is poorly differentiated or anaplastic remember the differentiation means how closely does the malignant cell resemble the cell it was supposed to be in this case it has no resemblance to the cell it was supposed to be it is grade 4 poorly differentiated discusses the concept of metastasis in persons with pancreatic cancer first let's talk about metastasis again metastasis means that there is a second tumor in the person's body totally separate from the primary site a staging workup means to determine where in the body the cancer has spread based on the concept of predictable pattern of spread liver duodenum lungs those are areas where you would expect to find pancreatic cancer if it has metastasized and cancer of the pancreas has often metastasized at the time of diagnosis this means the cancer has moved well beyond the site of origin and there's a separate tumor somewhere in that person's body cancer of the pancreas would likely be stage 4 at the time of diagnosis provides an overview of treatment for many individuals who have pancreatic cancer treatment is supportive not curative supportive care is most often indicated this means controlling the person's symptoms chemo or radiation therapy may be prescribed surgery may be a treatment for localized tumors but tumors are rarely localized procedures may be done to relieve obstruction for example to push back a tumor open up the pancreatic and common bile ducts relieve symptoms of pancreatitis and relieve itching related to increased bile salts in the blood on the skin this slide is showing normal flow of bile into the duodenum and you could also see normal flow of pancreatic enzymes which is the duct right below the common bile duct in this image you can certainly see that the common bile duct is obstructed this person would have elevated bilirubin levels and would have presented with jaundice we need to relieve the obstruction a stent can be placed into the common bile duct using the endoscopic retrograde calangio pancreatography concept moving retrograde or back up into the common bile duct and deploy that stent the bilirubin levels would come down and the person would have relief of the itching in this example both the common bile duct and the pancreatic duct were stented so if you were evaluating the labs what would you expect the bilirubin to do go down the amylase and lipase levels go down recognizes the impact of pancreatectomy on digestion and absorption if the person is in a stage of their disease where pancreatectomy is an option a whipple procedure would be performed remember the cancer is in the head of the pancreas and cancer grows by invasion so you need to remove the cancer and all of its tentacles you want the surgical margins to be free of tumor to do that you remove the duodenum a portion of the stomach the head of the pancreas and then notice that because you remove the duodenum the common bile duct has to be attached to the jejunum click on this website to see how the whipple procedure is done following a whipple procedure the patient has lost their asanar cells the cells that produce digestive enzymes those enzymes need to be replaced without enzymes you can't digest and if you can't digest food you can't absorb if you lose your pancreas for any reason pancreatectomy or chronic pancreatitis chronic inflammation fibrosis and scarring of the pancreas can cause the person to lose their ability to produce digestive enzymes those enzymes would have to be replaced what follows is a case study review on pancreatitis this will not be voiced over but each slide is followed by the discussion you