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108
M. Krell et al.
Acute pancreatitis
Mortality Bimodal mortality distribution seen with severe acute pancreatitis
In the early phase (< 2weeks), mortality is secondary to multiorgan failure. This results from a
severe systemic inammatory response
In the late phase (> 2weeks), mortality occurs due to septic/infectious complications
Necrotizing pancreatitis
Denition Necrotizing pancreatitis involves necrosis of >30% of pancreatic parenchyma or peripancreatic
tissue and accounts for only 10–15% of acute pancreatitis cases
Infected
necrotizing
pancreatitis
Diagnosis
Management
Infected necrotizing pancreatitis will often have a worsening clinical course, persistent fevers, and
CT ndings of extraluminal gas in the collection
Diagnosed with CT scan+IV contrast
A key distinction in these patients is the presence or absence of infected necrosis, because
noninfected necrotizing pancreatitis has a mortality rate of 15% versus 30% in infected necrotizing
pancreatitis
Intervention for sterile necrotizing pancreatitis should be delayed➔as two-thirds will resolve with
no intervention, and should intervention be necessary, later intervention on more mature collections
is more easily performed minimally invasively, with percutaneous, endoscopic, or videoscopic
interventions
Options for treatment of necrotizing pancreatitis include open necrosectomy, videoscopic drainage,
endoscopic drainage, or percutaneous drainage
Videoscopic drainage is aimed at remaining in the retroperitoneal space to avoid peritoneal
contamination. Access is assisted by following the tract of an existing drain, previously placed
percutaneously, an approach often referred to as the “step-up” approach
Procedure Endoscopic
debridement
Indications
Easiest for collections
conned to the lesser
sac and within reach
of an endoscope
hemorrhagic
transformation or
proximity to vessels
may limit feasibility
Necrosis must be
walled off; most
efcient when
necrosis is in the form
of a pseudocyst/ liquid
Video-assisted
retroperitoneal
debridement (VARD)
Most appropriate for
collections conned to
the retroperitoneum,
with adequate size to
accommodate multiple
trocars and instruments
Open
necrosectomy
May be necessary based
on lack of availability of
expertise, in cases of
patient instability, or
based on anatomy of
collections (for instance,
difcult-to-access or
multiple collections in the
paracolic gutters, or
within the mesocolon)
Key steps
Endoscopic drainage
and debridement of
pancreatic necrosis
Perform percutaneous
drainage to guide
access to the cavity for
debridement
Goal is complete
drainage and removal of
all necrotic tissue
4 Pancreas andSpleen
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Research
Reference Findings
109
Working Group IAP/APA Acute Pancreatitis
Guidelines. IAP/APA evidence-based guidelines for
the management of acute pancreatitis. Pancreatology.
2013;13(4 Suppl 2):e1–5
Petrov MS, van Santvoort HC, Besselink MG, etal.
Enteral nutrition and the risk of mortality and
infectious complications in patients with severe acute
pancreatitis: A meta- analysis of randomized trials.
Arch Surg. 2008;143(11):1111–7
van Santvoort HC, Besselink MG, Bakker OJ, etal.;
Dutch Pancreatitis Study Group. A step-up approach
or open necrosectomy for necrotizing pancreatitis. N
Engl J Med. 2010;362(16):1491–1502
Evans RP, Mourad MM, Pall G, Fisher SG, Bramhall
SR.Pancreatitis: preventing catastrophic
haemorrhage. World J Gastroenterol.
2017;23(30):5460–8
Autoimmune pancreatitis
Commonly presents as an inammatory mass and malignancy must be excluded
A meta-analysis of 14 trials of patients with severe acute
pancreatitis did not support prophylactic antibiotic use. The
guidelines from the International Association of
Pancreatology and American Pancreatic Association (IAP/
APA) recommend against intravenous antibiotic prophylaxis
A meta-analysis of 5 randomized controlled trials of enteral
versus parental nutrition in patients with severe acute
pancreatitis showed a decreased incidence of pancreatic
infections and mortality with early (dened as within
3days) enteral nutrition
For necrotizing pancreatitis with infected necrotic tissue, a
minimally invasive step-up approach is associated with
fewer major complications and deaths when compared to
open necrosectomy
For patients presenting with hemorrhage associated with
necrotizing pancreatitis. Hemorrhage can be due to arterial or
venous etiologies. Arterial etiologies include ruptured
pseudoaneurysm, hemorrhagic pseudocysts without
pseudoaneurysm, or direct bleeding from vessel injury from
drain placement. The next step is angiography and embolization
33% of patients will not have control of bleeding with
angiography and will require exploratory laparotomy
Characteristics
Management
Gallstone pancreatitis
Characteristics
Management
Biopsy ndings: Lymphocyte-only inltration of pancreatic parenchyma without atypical
cells
Elevated serum IgG4
Resolves completely with steroid therapy
If resolution does not occur➔alternative diagnosis should be sought
40% of pancreatitis cases in USA
Gallstones: Can obstruct the ampulla of Vater➔impaired extrusion of zymogen granules
and activation of degradation enzymes➔pancreatic auto- digestion
Pancreatic injury is the result of excessive pressure inside the pancreatic duct
If persistent biliary obstruction➔endoscopic retrograde cholangiopancreatography
(ERCP) for patients who develop cholangitis and those with persistent bile duct
obstruction
Cholecystectomy should be performed during the index admission after symptoms have
resolved and laboratory values have normalized
If cholecystectomy does not take place, there is a 25% recurrence rate of pancreatitis
within 3months
110
Acute pancreatitis s/p ERCP
Usually mild
Characteristics
Risk of pancreatitis is 5% for all patients undergoing endoscopic retrograde
cholangiopancreatography (ERCP)
Risk is increased in patients with sphincter of Oddi dysfunction
M. Krell et al.
Technical risk factors
Protective maneuvers Include pancreatic stent placement and indomethacin
Management Supportive measures
Multiple attempts at ductal cannulation and visualization of secondary pancreatic ducts
after injection of contrast material
Chronic Pancreatitis
Chronic pancreatitis (irreversible parenchymal brosis)
Alcohol (most common cause), smoking, cassava ingestion (South American root vegetable),
Risk factors
Pathophysiology
Symptoms
Diagnosis
genetic pancreatitis, autoimmune pancreatitis, pancreas divisum
Idiopathic second most common cause
Alcohol causes protein precipitation➔pancreatic duct plugging, weakens intra-acinar cell
organelles➔premature activation of digestive enzymes, activates pancreatic stellate
cells➔pancreatic brosis
Abdominal pain, exocrine dysfunction (weight loss, malabsorption, steatorrhea, >90% of
pancreatic parenchyma lost)
Endocrine function usually preserved (islet cells preserved)
Diagnosis of chronic pancreatitis is typically made clinically, by the presence of abdominal
pain, diarrhea, steatorrhea, or diabetes mellitus
Pancreatic exocrine insufciency
Fecal elastase-1 (< 100μg/g)
Fecal fat and weight estimation test (stool fat content >7g/d)
24-hour fecal fat (>20g➔pancreatic; <20g➔intestinal)
A reduction in fecal fat can be used to demonstrate adequate replacement of pancreatic
enzymes
4 Pancreas andSpleen
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Chronic pancreatitis (irreversible parenchymal brosis)
111
Diagnostic
imaging
Complications of
chronic
pancreatitis
Classic
CT
ndings
Ductal stricture is best evaluated by magnetic resonance cholangiopancreatography (MRCP) or
endoscopic retrograde cholangiopancreatography (ERCP)
Pseudocyst/splenic vein thrombosis/pancreatic ascites/pleural effusions/common bile duct
stricture/biliary stenosis and dilation
Calcications Atrophy of pancreas, dilation
of PD
Axial abdominal CT image
Axial abdominal CT
image with IV
contrast demonstrated
a severely atrophic
and calcied pancreas
(arrows)
without contrast demonstrated
a severely atrophic pancreas
without signicant
calcications or pancreatic
duct dilation (arrows)
Chain of lakes (alternating
dilated and stenotic PD)
Axial abdominal MR
image with IV contrast
demonstrated a diffusely
atrophic pancreas with an
alternating segments of
main pancreatic duct
stricture and dilation,
creating a “chain-of- lakes”
appearance (arrows). Also
note the 9mm stone in the
main pancreatic duct
(black circle)
Pancreatic cancer
Management
Risk factors for pancreatic cancer in patients with chronic pancreatitis: Older age/ new
constitutional symptoms/no history of heavy alcohol use/duct obstruction with proximal gland
atrophy
Patients with chronic pancreatitis can be a harbinger of pancreatic cancer
If any abnormality is noted in CT scan➔endoscopic ultrasound+ne needle aspiration➔if
no abnormality on endoscopic ultrasound (EUS)➔endoscopic retrograde
cholangiopancreatography (ERCP)
First step in management is lifestyle modication (low-fat diet, abstain from alcohol and
tobacco+pain control including splanchnic nerve blocks)
Surgery is an option with chronic pancreatitis
Case Management
Obstructing pancreatic duct stone Endoscopic removal of stone
Biliary stricture Endoscopic ultrasound (EUS)+ne needle aspiration
(FNA)
Dilate±stent
Pseudocyst Drainage
Dilated pancreatic duct (>7mm)
large duct disease
Nondilated pancreatic duct
Small duct disease
Drainage type procedure (Puestow or
Frey)➔improvement in pain 60–80%; but results
diminish with time, minimal risk of endocrine or exocrine
insufciency
Resection type procedure➔improvement in pain 90%
(long term relief)
112
Research
M. Krell et al.
Reference Findings
Issa Y, Kempeneers MA, van Santvoort HC, Bollen TL,
Bipat S, Boermeester MA.Diagnostic performance of
imaging modalities in chronic pancreatitis: A systematic
review and meta-analysis. Eur Radiol.
2017;27(9):3820–44
Faghih M, Garcia Gonzalez F, Makary MA, Singh
VK.Total pancreatectomy for recurrent acute and
chronic pancreatitis: A critical review of patient
selection criteria. Curr Opin Gastroenterol.
2017;33(5):330–8
van Santvoort HC, Besselink MG, Bakker OJ, Hofker
HS, Boermeester MA, Dejong CH, van Goor H,
Schaapherder AF, van Eijck CH, Bollen TL, van
Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris
JS, Kruyt PM, Manusama ER, van der Harst E, van der
Schelling GP, Karsten T, Hesselink EJ, van Laarhoven
CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van
Leeuwen MS, Buskens E, Gooszen HG; Dutch
Pancreatitis Study Group. A step-up approach or open
necrosectomy for necrotizing pancreatitis. N Engl J
Med. 2010;362(16):1491–502. https://doi.org/10.1056/
NEJMoa0908821. PMID: 20410514.
Drainage of pancreatic pseudocyst
Most pseudocysts regress in 6weeks especially if they are <4cm, no obstruction of duct or
communication with pancreatic duct
EUS, ERCP, MRI, and CT all have comparable high
diagnostic accuracy in the initial diagnosis of chronic
pancreatitis
Duration of pain more than 2–3years and opioid use
are associated with poor pain outcome after
intervention for chronic pancreatitis
A minimally invasive step-up approach, as compared
with open necrosectomy, reduced the rate of the
composite end point of major complications or death
among patients with necrotizing pancreatitis and
infected necrotic tissue
Management
Avoid intervention in the early period (high morbidity and mortality)
Intervene for symptomatic patients (persistent pain, early satiety, weight loss, gastric outlet
obstruction, acute bleeding from pseudoaneurysm)
Endoscopic techniques are preferred given lower morbidity
Endoscopic drainage Operative drainage
Types Transgastric
Transduodenal
Transpapillary
Indications If anatomy permits • If cannot be drained endoscopically
• Cystogastrostomy (if pseudocyst adjacent to
stomach)
• Cystoduodenostomy
• Roux-en-Y cystojejunostomy
• Failed endoscopic management
• Cyst wall is thick (>1cm)
• Cyst does not contact the stomach or
duodenum
4 Pancreas andSpleen
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Surgical procedures for chronic pancreatitis
Procedure Berger procedure Frey procedure Puestow procedure
113
Indications Pancreatic duct obstruction with
pancreatic head inammation
Duodenum-preserving
pancreatic head resection
Transecting the pancreatic neck
Key steps
Technical
concerns
followed by coring-out of the
pancreatic head
Reconstruction involves two
pancreaticojejunostomies
Provides a technically greater
resection of the pancreatic head
while preserving the duodenum
Because of the inherent
difculties associated with a
Beger procedure, many
pancreatic surgeons would
choose a pylorus-preserving
pancreaticoduodenectomy in
this situation
Pancreatic duct obstruction
with pancreatic head
inammation+dilated
pancreatic duct
Pancreatic head resection with
longitudinal
pancreaticojejunostomy
Pancreatic duct drainage and a
focal pancreatic head resection
leaving a 1cm rim of
pancreatic tissue along the
duodenal margin
Similar resection and drainage
operation that preserves the
duodenum but does not require
division of the pancreatic neck
Chronic pancreatitis+dilated
pancreatic duct secondary to
stones or strictures
Longitudinal
pancreaticojejunostomy
Pancreatic duct drainage
Long-term outcomes are
improved when the
anastomosis ≥6cm
Longer than 10cm will likely
involve the pancreatic head,
which is anatomically difcult
to localize and suture to
Successful outcomes for ducts
>6mm in diameter
Disadvantages
Incidence of exocrine
dysfunction is 25%
25% of patients develop
new-onset diabetes
Most common cause of death is
cardiovascular due to endocrine
deciency
Most common cause of death
is cardiovascular due to
endocrine deciency
30% of cases will recur
(3–5years after surgery)
Does not achieve durable pain
relief
Research
Reference Findings
Tillou JD, Tatum JA, Jolissaint JS, etal. operative
management of chronic pancreatitis: A review. Am J surg.
2017;214(2):347–57
Operative management of chronic pancreatitis often
improves quality of life and is associated with low
rates of morbidity and mortality
114
Cases of chronic pancreatitis and their management
Case Management Advantages Disadvantages
M. Krell et al.
Pancreatic duct dilation secondary
to duct stones or strictures
(PD>6mm) without pancreatic
head enlargement
Pancreatic duct dilation secondary
to a single stricture that is proximal
to the papilla
Chronic pancreatitis+suspected
pancreatic cancer
Single distal obstruction Distal pancreatectomy
Enlarged pancreatic head (focal
inammatory mass)+small PD
Dilated PD secondary to a benign
stricture in the head of the
pancreas+severe inammation,
scarring, or portal hypertension
surrounding the head of the
pancreas that precludes a safe
pancreaticoduodenectomy
Modied Puestow
procedure (lateral
pancreaticojejunostomy)
Pancreaticoduodenectomy
vs. ERCP with pancreatic
duct stent
Pancreaticoduodenectomy
Beger procedure Offers symptomatic relief
Frey procedure 62% of patients are
Provides palliation of pain
in 80% of cases
Preserve parenchyma
that is equivalent to the
pancreaticoduodenectomy
completely free of pain and
95% of patients have
satisfactory pain control
after this procedure
30% of cases will
recur (3–5years
after surgery)
Does not achieve
durable pain relief
Pancreatic
insufciency,
chance of
endocrine
dysfunction
Most common
cause of death is
cardiovascular due
to endocrine
deciency
Most common
cause of death is
cardiovascular due
to endocrine
deciency
Chronic pancreatitis+nondilated
duct+diffuse gland
involvement+pain refractory to
medical management
Total
pancreatectomy±auto islet
transplantation
Pancreatic
insufciency
4 Pancreas andSpleen
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Pancreatic Cysts
Pancreatic cystic neoplasms
115
Serous
cystadenoma
Type Pseudocyst
Communicate
with PD
Malignancy
rate
Location Evenly
distributed
Gender F=M F>>>M F>>>>M M>F M>F
Age 40–60 60–70 50–60 60–70
Fluid No mucin
Low CEA
High amylase
Genetic +KRAS +KRAS +KRAS
Characteristics
Cyst wall:
Collagen and
granulation
tissue
-no epithelium
(SCA)
Lack of communication with pancreatic
duct
Benign lesion 10–50% 60% 10–30%
Head> body, tail Body, tail Head>body/tail Head> body/tail
No mucin
Low CEA
Low amylase
Epithelial cells
contain glycogen
➔ positive
periodic
acid–Schiff stain
Mucinous cystic
neoplasm
(MCN)
Mucin
High CEA>192
Low amylase
Most common
Large
Macrocystic
Peripheral
calcications
Ovarian-like stroma
Branch duct
MD-IPMNs and
mixed types
Yes Ye s
Mucin
High CEA
High amylase
Variable size,
Irregular mass,
Main duct dilation
EUS➔classic “sh
mouth” appearance
of the papilla,
sometimes with
extruding mucin
IPMN
(BD-IPMNs)
Mucin
High CEA
High amylase
“Cluster of
grapes”
Radiologic
features
Central
calcication
surrounded by
multiple cysts
Solitary cyst
Fine septations
-surrounded by a rim
of calcication
Manifest as a dilated
main pancreatic duct
full of mucin
“Cluster of
grapes” with
communication
with the
pancreatic duct
often visible
116
Pancreatic cystic neoplasms
M. Krell et al.
Type Pseudocyst
Treatment See pancreatic
pseudocyst
drainage
Serous
cystadenoma
(SCA)
Operate if large
or signicant
growth,
symptoms from
local effects, or
diagnostic
uncertainty
Mucinous cystic
neoplasm
(MCN)
Resect because of
risk of malignancy
-often in tail ➔
distal
pancreatectomy ±
splenectomy
Branch duct
MD-IPMNs and
mixed types
Resection generally
recommended
secondary to higher
risk of malignancy
Worrisome features High-risk
• Size >3cm
• Main duct 5–9mm
• Nonenhancing
mural nodule
• Thickened
enhancing cyst
walls
• Abrupt caliber
change
• Lymphadenopathy
• Pancreatitis
IPMN
(BD-IPMNs)
Observe except
high-risk
stigmata and
worrisome
features, which
may prompt
resection or
EUS+FNA
Absolute
indication for
resection:
Jaundice,
cytology with
high-grade
dysplasia or
cancer, >5mm
contrast
enhancing mural
nodule, solid
mass
features
• Main
duct>1cm
• Enhancing solid
component
• Jaundice
Recurrence/
surveillance
No recurrence ➔ no
further surveillance
is required
Lifelong surveillance
IPMN can affect the entire
gland➔perform surveillance even after
resection
Patients with an IPMN measuring
≥3cm have a 5% risk of developing
malignancy within 3years compared to
the 5year disease-free survival after
resection of IPMN of 96%
4 Pancreas andSpleen
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Research
117
Reference Findings
Crippa S, Pergolini I, Rubini C, etal. Risk of misdiagnosis
and overtreatment in patients with main pancreatic duct
dilatation and suspected combined/main-duct intraductal
papillary mucinous neoplasms. Surgery.
2016;159(4):1041–49
Ma GK, Goldberg DS, Thiruvengadam N, etal. comparing
American gastroenterological association pancreatic cyst
management guidelines with Fukuoka consensus
guidelines as predictors of advanced neoplasia in patients
with suspected pancreatic cystic neoplasms. J Am Coll
Surg. 2016;223(5):729–37.e1.
The European Study Group on Cystic Tumours of the
pancreas. Gut 2018;67:789–804.
Tanaka M, Fernández-del Castillo C, Adsay V, Chari S,
Falconi M, Jang JY, Kimura W, Levy P, Pitman MB,
Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K,
Yamao K; International Association of Pancreatology.
International consensus guidelines 2012 for the
management of IPMN and MCN of the pancreas.
Pancreatology. 2012;12(3):183–97. https://doi.
org/10.1016/j.pan.2012.04.004. Epub 2012 Apr 16
Cyst size >3cm increases the risk of malignancy
approximately threefold, and the presence of a solid
component on cross-sectional imaging increases the
probability of a malignancy approximately eightfold
This study compared the Fukuoka to the American
gastrointestinal association guidelines and found that
they produced similar surgical outcomes—Both have a
fair positive predictive value for the diagnosis of
advanced neoplasia, and both miss cases of invasive
cancer and high-grade dysplasia
Both sets of guidelines Fukuoka and AGA for
managing pancreatic cysts are similar with exception:
Fukuoka guidelines add jaundice to these “high-risk”
criteria. Fukuoka guidelines add a history of
pancreatitis and a thickened enhancing cyst wall for
worrisome features
European guidelines for management of pancreatic
cystic neoplasms. 2018: Recommendations include
conservative management, relative and absolute
indications for surgery. A conservative approach is
recommended for asymptomatic MCN and IPMN
measuring 5mm, and MPD diameter>10mm.
Lifelong follow-up of IPMN is recommended in
patients who are t for surgery
International consensus guidelines 2012 for the
management of IPMN and MCN of the pancreas
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