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Examinations in Chronic Abdominal Conditions
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Digital Examination of Rectum
It is done to look for secondaries (Blumer shelf) in
anterior aspect above the prostate level. It is nodular
hard with free mucosa (not adherent). It suggests
advanced malignancy. It is due to peritoneal spread.
It is useful in Crohn’s disease (fissure in ano or fistula
in ano), and other chronic conditions.
Pervaginal examination is a must in females
especially in lower abdomen masses and when
Krukenberg tumour (Carcinoma stomach) of ovary
is suspected.
Systemic Examinations
Examination of respiratory system, spine (for secondaries or tuberculosis), central nervous system is
essential (Figs 20.23 and 20.24).
Fig. 20.23: Psoas spasm causing hip in flexion due to
Investigations
Detailed investigations and discussions of different
conditions are beyond the scope of this book. Students
should refer SRBs Manual of Surgery, 3rd edn and
Bedside Clinics in Surgery for in detail discussions.
Blood – Hb%, ESR, relevant tumour markers.
Stool examination: Occult blood, steatorrhoea (fat),
creatorrhoea (muscle fibres seen in chronic pancreatitis), mucous in stool, microscopy, culture.
Gastric Function Tests
Patient is overnight fasting; should not take any antacids
and anticholinergics for 24 hours. Nasogastric tube is
passed early morning and gastric juice is aspirated
under fluoroscopy after confirming the tip of tube is at
mid stomach level. Normally it is around 70 ml. If it
is more it suggests pyloric stenosis or hypersecretion.
Tube now is connected to low pressure 5 cm Hg suction
to have continuous aspiration. Later one hour aspiration
is collected. It is called as morning basal secretion. Free
acid level means only HCl level; total acid level means
HCl plus other acids in the stomach.
Dragstedt test: Gastric content is aspirated through
continuous low pressure suction for 12 hours from
9. PM to 9. AM and the juice is collected. Normal
volume is 400 ml. It is increased in duodenal ulcer
due to vagal hyperactivity; increased very much morethan a litre in Zollinger-Ellison syndrome. Normal
HCl level in this is 10–20 mEq. It is 40-80 mEq in
duodenal ulcer (↑); 100-300 mEq in ZE syndrome
(↑↑); 5-15 mEq in gastric ulcer (↓). Basal secretion
is the secretion from the parietal cell mass in resting
condition. It is < 5 mEq/hour normally; > 5 mEq in
duodenal ulcer; 1-2 mEq in gastric ulcer. Peak/maximal
secretion is secretion in one hour after stimulation.
Stimulation may be using pentagastrin (now used)/
Kay’s augmented histamine/Hollander’s insulin. It
gives maximal/ peak acid output.
Fig. 20.24: Examination of spine is essential.
Pentagastrin test: Initial basal secretion is collected.
6 µ gm of pentagastrin is injected IM/SC and 15 minutes
gastric samples are taken for one hour . Peak/maximum
acid output is assessed. Normal is 25-27 mEq; in gastric
ulcer it is upto 15 mEq; in duodenal ulcer it is
35-38 mEq; in ZE syndrome it is > 60 mEq/very high;
in carcinoma stomach it is very low.
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Kay’s augmented histamine test: After collection of
basal fasting sample, mepyramine maleate 100 mg
IM is injected to neutralise histamine side effects
without interfering gastric effects. After 30 minutes,
histamine acid phosphate 0.04 mg/kg is injected
S/C. Free acid level (only HCl) is assessed. In stomal
ulcer it is 30-35 mEq; in duodenal ulcer it is 3040 mEq; in gastric ulcer it is less than 15 mEq.
Hollander’s insulin test: It is useful to assess postoperatively and confirm the completeness of vagotomy.
0.2 units/kg wt of insulin is injected IV to a fasting
patient so as to create hypoglycaemia below 35 mg%
which stimulates the parietal cells through hypothalamus and vagus causing acid secretion. Patient with
complete vagotomy will not show the increased acid
level. Increase in acid secretion in first one hour
is called as early response and if it is more than
30 mmols/L suggests incomplete vagotomy . Delayed
response is between 1st and 2nd hours and is due to
delayed gastrin release.
Chew and spit test: Nasogastric tube is passed. Patient
chews a meal and spits it out to stimaulate acid
production through vagus. Gastric contents are
aspirated and studied for acid level.
Barium/Contrast Studies
Barium meal X-ray: Barium meal X-ray is done using
barium sulphate (95% w/v) solution of which 400–
600 ml is given orally . Gastrograffin is also often used.
It is done in empty stomach. Microcrystalised barium
sulphate solution is better. Procedure should be done
under fluoroscopic guidance. Buscopan injection is
given to the patient to delay the gastric emptying.
Glucagon also can be used. Effervescent tablet
(calcium carbonate and antifoaming agent) is given
to the patient. 200 ml of barium sulphate solution is
given to drink. X-rays are taken to get double contrast
barium meal X-rays. Indications for barium meal
X-ray—Duodenal ulcer—shows absent/deformed
duodenal cap; Benign gastric ulcer—shows niche (due
to ulcer) and notch (due to spasm); Gastric outlet
obstruction; Carcinoma stomach—irregular filling
defect; Carcinoma head of pancreas—pad sign;
Periampullary carcinoma – Fr ostberg reverse ‘3’ sign;
Chronic duodenal ileus—obstruction at mid 3rd part
of the duodenum; Stomal ulcer—ulcer crater at stoma;
Duodenal diverticula–trifoliate duodenum; Trichobezoars; Gastric fistulas; Pseudocyst of pancreas–
widened vertebrogastric angle.
Barium meal follow through X-ray is done as late films
often after giving prokinetic agents like metoclopramide.
Enteroclysis (small bowel enema): It is visualisation
of entire length of small intestine –to assess anatomical
problems. Indications are small bowel diseases/
ileocaecal tuberculosis, stricture, small bowel tumours,
partial obstruction and Crohn’s disease. Technique –
Patient is prepared overnight with empty stomach and
laxatives. Nasojejunal tube is passed. Prokinetic drug
like metoclopramide is given. Microbarium sulphate
solution (50% w/v) or gastrograffin or water soluble
iodine dye solution is (500-800 ml) passed through
the tube. Under fluoroscopic guidance X-rays are taken
as required. Features such as narrowing, smooth/
irregular filling defect, localised dilatation, obstruction
or features of specific conditions are looked for. In
conditions like ileocaecal tuberculosis enteroclysis and
barium enema X-rays are combined. Problems with
enteroclysis are poor patient acceptance, and technical
better options to visualise the small bowel. When
nasojejunal tube is not able to be passed barium meal
follow through X-ray is done by taking late films of
barium meal (Figs 20.25 to 20.28).
Fig. 20.25: Barium meal X-ray showing
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Fig. 20.26: Barium meal X-ray showing
Fig. 20.28: Trifoliate duodenum–late effect of chronic
the colorectum using a enema tube from an enema
can. Patient will be initially in left lateral position and
later in prone position. In children a Foley’s catheter
with inflation is used to maintain the retention of enema.
Procedure is often observed under fluoroscopy.
Injection buscopan is injected (20 mg IV) to relax
the colon. X-ray film is taken after complete filling.
Patient is asked to evacuate the barium and later postevacuation film is taken. Air is insufflated into the
colon to get air contrast film. Additional dif ferent view
films are taken to see the suspected area properly.
Fig. 20.27: Benign gastric ulcer showing
Barium Enema X-ray
Technique of barium enema X-ray-24 hours liquid
diet, laxatives for two nights and enema on previous
night are the required preparations for barium enema
X-ray . About one litre of barium sulphate/microbarium
sulphate solution (25% w/v) is infused per anally into
Indications for barium enema are carcinoma colon;
Ileocaecal tuberculosis [combined with Enteroclysis;]
Ulcerative colitis; Crohn’s disease; Ischaemic colitis;
Colonic polyps; Intussusception; Congenital megacolon; Gastrojejunocolic fistula; Congenital diaphragmatic hernia (Bochdalek).
Different findings: a. Hirschsprung’ s disease: Barium
enema is done to look for the extent of disease and
three zones. Foley’s catheter should not be used while
doing barium enema in case of Hirschsprung’ s disease.
Here barium in dilute saline is used – not in water.
1. Distal immobile spastic segment, i.e. aganglionic
zone. 2. A proximal, middle transitional zone of about
1-5 cm length with less, sparse number of ganglions
(Cone). 3. A still more proximal, hypertrophied dilated
segment is actually the normal ganglionic area.
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b.Carcinoma colon: Irregular filling defect; Apple core
lesion especially on left side; Metachronous growths
(growths in different parts of the colon) should be
looked for – 5% common; Narrowing – left sided
lesion. c. Ulcerative colitis: Loss of haustrations;
Contracted smooth colon; Presence of pseudopolyps;
Collar button ulcers–contiguous mucosal involvement; Hose pipe/pipe stem lesions; Increased presacral
space more than normal (normal is < 1 cm); Reflux
ileitis; Rectum is almost always involved. d. Ileocaecal
tuberculosis - Pulled up caecum due to fibrosis and
contraction; Obtuse ileo caecal angle (normal angle
is acute); Hurrying of barium due to rapid flow – Stierlin
sign; Narrow ileum with thickened ileocaecal valve,
Fleischner–inverted umbrella sign; Incompetent
ileocaecal valve; Ulcers and strictures in terminal
ileum– napkin lesions; Gooseneck appearance – ileum
hanging from fibrosed; pulled up caecum. e. Crohn’s
disease: Aphthoid ulceration; Skip lesions; Rectum
is not commonly involved; String sign of Kantor;
Cobble stone appearance–pseudosacculations;
Raspberry/rose thorn appearance; Fistula or strictures.
f. Sigmoid diverticula: Saw teeth appearance of
sigmoid colon – concertina like – serrated appearance;
Champagne glass sign – partial filling of barium with
stercolith inside the diverticula; Fistula to adjacent
structures. g. Intussusception - Claw sign – coiled
spring sign: pincer end; Empty right iliac fossa – mainly
in plain X-ray abdomen with multiple air fluid levels
(on ultrasound – target sign/pseudokidney sign/bull’ s
eye sign). h. Ischaemic colitis: Thumb print sign in
splenic flexure.
Fig. 20.29: Barium enema X-ray showing typical claw sign/
Other signs in barium enema X-ray: Stacked coin
appearance due to submucosal haemorrhages in
Henoch Schonlein purpura; Scalloped edges in colon
in pneumatosis intestinalis (Figs 20.29 and 20.30).
Hypotonic duodenography: It is same as barium meal
X-ray but duodenal hypotonia is achieved by giving
injection glucagon or buscopan so that air contrast
hypotonic barium X-ray study shows better pictures.
Oral Cholecystography (OCG, Graham-Cole Test)
Patient is advised to have fat free diet for 3 days.
Previous night 6 tablets of iopanoic acid (T elepaque)
is given orally. Next morning plain X-ray abdomen
is taken to visualise the gallbladder. Later fatty meal
Fig. 20.30: Barium enema X-ray showing growth
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is given and X-rays are taken at 10, 15, 30 and 60
minutes to see the change in the size of the gallbladder
(which should be less in size compared to the earlier
film, as the gallbladder contracts on stimulation if it
is functioning normally) (Fig. 20.31). Smooth filling
defect signifies non-opaque stone.
or using propofol anaesthesia. Patient is placed in prone
position with the head turned towards right. After
passing gastroduodenoscope, sphincter is identified
and cannulated. Under visualisation 3 ml of water
soluble iodine contrast is injected into the bile duct
and pancreatic duct. When cannula goes upwards
beside vertebra, it is in bile duct; and if cannula goes
across the vertebra it is in pancreatic duct.
Indications—Malignancy—irregular filling defect;
Chronic pancreatitis—chain-of-lakes appearance;
Congenital anomalies, stones (Fig. 20.32); Stricture
of biliary tree; Choledochal cyst; For sampling of
biliary and pancreatic juices for analysis and cytology;
Brush biopsy from tumour site.
Fig. 20.31: Oral cholecystogram done to see the
Contraindications: Patients with serum bilirubin
> 3 mg%, acute cholecystitis. OCG is not done now.
Intravenous cholangiography: It is done to visualise
bile ducts and biliary tree, by injecting IV Meglumine
ioglycamate (Biligram) and taking X-Ray abdomen.
It can be combined with OCG. Problems with this
method are poor visualisation, drug reaction. It is not
very useful if serum bilirubin is >3 mg%.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Through a side viewing gastroduodenoscope, sphincter
of Oddi is cannulated, dye is injected and biliary and
pancreatic tree is visualised. It is done under C-ARM
guidance. It is done under sedation like midazolam
Fig. 20.32: ERCP showing stone in common bile duct.
Therapeutic uses—Extraction of biliary duct stone;
Nasobiliary drainage; Stenting of tumour in the CBD
or in the pancreas; Dilatation of the biliary stricture;
Endoscopic papillotomy.
Complications – Pancreatitis; Duodenal injury;
Cholangitis; Bleeding.
Relative contraindications—Acute pancreatitis;
Previous gastrectomy; Altered prothrombin time
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(corrected by injection Vitamin K, FFP); Bleeding
disorders.
Percutaneous Transhepatic Cholangiography
(PTC)
It is done in case of severe obstructive jaundice under
coverage of appropriate antibiotics and after control
of any bleeding tendency . With the help of fluoroscopy ,
Chiba (university) or Okuda needle which is long,
flexible, thin, blunt, without beveled end, is passed
into the liver through right 8th intercostal space in
midaxillary line. Once needle is in the dilated biliary
radicle, bile is aspirated (sent for culture, cytology,
analysis); and then water soluble iodine dye is injected
into the same so as to visualise the dilated biliary
radicles, also the site and extent of any obstruction
(i.e. tumour, stricture). Procedure can be used for
therapeutic stenting across the biliary tree through any
obstruction either in the hepatic ducts or in the CBD
into the duodenum. Complications: Bleeding, biliary
leak, biliary peritonitis and septicaemia.
Magnetic Resonance Cholangiopancreatography (MRCP)
MRCP is a non-contrast imaging method, better than
ERCP as diagnostic tool in biliary and pancreatic
diseases. T2 W1 images are used.
scopy; polyp removal; submucosal resection; for
ERCP—diagnostic and therapeutic procedures.
Procedure: Gastroscopy is done following eight hours
of fasting. After lignocaine spray into the oral cavity;
gastroscope is passed gently down the oesophagus
when the patient does the swallowing action. Once
the scope is inside the stomach, air is inflated and
different parts of the stomach are visualised. Fundus
is visualised by retropulsion. Scope is passed through
the pylorus to see 1st and 2nd parts of the duodenum.
Looked for any pathology and if required biopsy is
taken (Figs 20.33 and 20.34). Often midazolam
sedation is beneficial to have an easy passage.
Complications: Bleeding, aspiration, perforation
(rarely).
Gastroscopy
It is visualisation of interior of stomach, duodenum
and oesophagus. It is used for diagnosing any
pathology—Gastric ulcer; duodenal ulcer; gastritis;
stomal ulcer; carcinoma stomach; oesophagitis;
oesophageal varices. Biopsies from the suspected cases
of malignancy or for Helicobacter pylori can be taken.
Endosonography can be done to assess the staging,
operability of carcinoma stomach or oesophagus.
Fibreoptic flexible gastroduodenoscopy also can be
used. Videoendoscopy is used not only for diagnosis
but also mainly for therapeutic procedures. Both end
viewing and side viewing gastroscopes are available.
For therapeutic procedures and ERCP, side viewing
gastroscope is required.
Therapeutic procedures: Variceal injection or ligation;
Stenting of pseudocyst of pancreas through gastro-
Fig. 20.33: Gastroscopy is being done.
US Abdomen
It is very useful to identify gallstones, liver pathology.
But not a good method for assessing the pancreas.
Radioisotope Scanning
Inorganic iodide is given orally 2 days prior to block
the thyroid. I
99m
Technetium is administered. 10 minutes later
131
labelled serum albumin or
scanning is done in supine position. It is useful to
find out focal and diffuse diseases; abscess like in
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Fig. 20.34: Endosonography of stomach.
liver or subphrenic space; inflammatory pathology.
75
Se-labelled methionine is used to scan pancreatic
lesions. It is also useful in GI bleeding. Blood loss
is measured with help of RBCs labeled with Cr51 which
is injected intravenously.
in midepigastrium; Periodicity, haematemesis/melaena
(25%) are other features.
Complications are – hour glass contracture, tea-pot
deformity, erosion into left gastric/splenic arteries,
perforation and malignant transformation. Risk of
carcinoma is 6-23%. Patients with gastric ulcer treated
with anti-ulcer drugs like proton pump inhibitor will
become symptomatically better but ulcer heals partially
and retains its potentiality to transform into carcinoma
stomach. Giant gastric ulcer is benign gastric ulcer
more than 3 cm in size. Benign ulcer occurs usually
in the lesser curve whereas ulcer in greater curve is
commonly malignant. Barium meal X-ray shows niche
(ulcer crater) and notch on opposite side (due to spasm
of circular muscle). Lesser curve ulcer is usually
benign; greater curve ulcer is commonly malignant
(Fig. 20.35).
Selective angiography of superior mesenteric artery
and inferior mesenteric artery is often helpful in
detecting the site of bleed. Once identified, therapeutic
embolisation can be used to control the bleeding.
Bleeding of 0.5 ml/minute can be detected.
Diagnostic laparoscopy; laparoscopic ultrasound are
also useful.
Features of Chronic benign Gastric Ulcer
It may be due to atrophic gastritis, smoking, alcohol;
Typical pain is more after taking food and is relieved
by inducing vomiting. Vomiting per se as a symptom
is seen in 15% cases. Appetite is normal but avoids
food due to pain and so looses weight. Deep tenderness
Types of gastric ulcer (Daintree Johnson)
Fig. 20.35: Multiple ulcers in the stomach on
Features of Duodenal Ulcer
‘Hurry, worry, curry’—stress, anxiety are the basic
aetiological factors; Common in blood group O
positive; Helicobacter pylori infection is seen in more
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than 90% of duodenal ulcer. Other causes are NSAIDs,
steroids, alcohol, smoking, hyperparathyroidism.
Anterior ulcer perforates (2%); posterior ulcer bleeds
(5%). Pain is typically in duodenal point. Haematemesis and melaena is more common. Patient has more
appetite and eats more to relieve pain and so gains
weight. Hunger pain, early morning pain, periodicity,
water brash, melaena are other features. Complications
are pyloric stenosis, bleeding, perforation and
penetration into pancreas. Chronic duodenal ulcer will
never turn into malignancy. Gastroscopy, biopsy for
Helicobacter pylori is needed. Barium meal X-ray
shows deformed or absent duodenal cap (Fig. 20.36).
Carcinoma Stomach
It is the captain of men of death. It is more common
in Japan. It can be familial (Napolean family). H. pylori
is the main causative agent. Diet (smoked fish), gastric
polyp, pernicious anaemia, gastric remnant, smoking,
alcohol, benign gastric ulcer, chronic gastritis are the
other causes.
Clinical features: Recent onset of loss of appetite
and weight; upper abdominal pain; vomiting with
features of gastric outlet obstruction, i.e. (VGP+ve,
auscultopercussion test, +ve succussion splash); Mass
abdomen: Mass in pylorus lies above the umbilicus,
nodular, hard, with impaired resonance, mobile, moves
with respiration, all border well made out; Dysphagia
when mass is in upper epigastrium; When it arises
from the body of stomach, it may present as only mass
abdomen. Along with jaundice, liver may be palpable
with secondaries which are hard, nodular (50%) with
umbilication. Ascites; +ve Troisier’s sign (Virchow’s
node in neck) ; +ve rectovesical secondaries (Blumer
shelf); +ve T rousseau sign - migrating thrombophlebitis, also seen in carcinoma pancreas; anaemia,
cachexia; haematemesis, malaena; occasionally carcinoma stomach can present as perforation to begin with.
Rarely present as secondaries in the liver with silent
primary in stomach. Secondaries in umbilicus, as sister
Joseph’s nodules.
Fig. 20.36: Duodenal ulcer location.
Features of Gastric Outlet Obstruction
Pyloric stenosis is due to congenital/chronic duodenal
ulcer/carcinoma pylorus. Hypochloremic, hyponatraemic, hypokalaemic, hypocalcaemic, hypomagnesemic
metabolic alkalosis with paradoxical aciduria is
typical. Persistent pain, vomiting, decreased appetite
and loss of weight, without any periodicity, visible
gastric peristalsis, positive succussion splash, positive
auscultopercussion test are the special features. Barium
meal X-ray shows—Absent duodenal cap, if it is due
to cicatrised chronic duodenal ulcer; Greater curvature
is below the level of iliac crest; Mottled stomach due
to retained food particles which gives coated/mosaic
appearance; Barium will not pass into the duodenum;
Dilated stomach.
Classifications: Lauren’ s–intestinal, diffuse. Japanese
(for early gastric cancer – involvement of mucosa or
submucosa with or without lymph nodes) – protruded,
superficial elevated or flat or depressed, excavated.
Borrmann’s (for advanced cancer–involvement
muscularis or serosa with or without lymph node
spread) – polypoid; ulcerated with clear margin or
without clear margin; diffuse; unclassified. Leather
bottle stomach (Linitis plastica) is diffuse type of
carcinoma of stomach with mother of pearl look with
enormous proliferation of fibrous tissue in submucosa
(Fig. 20.37).
Gallstones and Chronic Cholecystitis
Gallstones
Types: (1) Cholesterol stones are 6% common, often
solitary . (2) Mixed stones are 90% common. It contains
cholesterol, calcium salts of phosphate, carbonate,
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Fig. 20.37: Gastroscope view of bleeding
palmitate, proteins and are multiple, faceted.
(3) Pigment stones: are small, black or greenish black,
multiple, often they can be sludge like. Common in
‘Fat, Fertile, Forty , Flatulent, Female’. Common in
western countries and in North East India.Effects of
the gallstones: (a) In the gallbladder—Silent
asymptomatic stones; Acute cholecystitis; Chronic
cholecystitis; Empyema gallbladder; Perforation
causing biliary peritonitis or peri cholecystitic
abscess; Mucocele of gallbladder; Limey gallbladder;
Carcinoma gallbladder. (b) In the CBD —Secondary
CBD stones; Cholangitis; Pancreatitis; Mirizzi
syndrome (compression of CBD by stone from cystic
duct or cholecystocholedochal fistula). (c) In the
intestine—Cholecystoduodenal fistula causing gallstone ileus and so intestinal obstruction.
Trichobezoar
It is hair-ball commonly seen in a stomach of females
with psychiatric illness who swallow hair regularly.
It forms a ball like mass occupying the full stomach
(Figs 20.38A and B).
Clinical features: Haematemesis; Gastritis; Loss
of appetite; Perforation; occasionally mass in the
epigastrium which can be molded. Barium meal is
confirmative.
A
Chronic cholecystitis: It is chronically inflamed,
thickened gallbladder, which is non-functioning and
nondistending. Causes: Gallstones; Cholecystoses;
Chronic acalculous cholecystitis.
Clinical features: 1. Pain in right hypochondrium may
be colicky, or persistent. 2.Positive Murphy’s sign
where, in sitting position during deep inspiration,
patient winces with pain at the summit of the respiration
while palpating in right hypochondrium. 3. Flatulent
dyspepsia.
B
Figs 20.38A and B: Trichobezoar—endoscopic view and
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Chronic Pancreatitis
It is persistent progressive irreversible damage of the
pancreas due to chronic inflammation. It can be chronic
relapsing pancreatitis or chronic pancreatitis. It can
be chronic non-calcifying or calcifying pancreatitis.
Stones may be in the duct or in the parenchyma. Chronic
pancreatitis is more common in males, common in
Kerala South India (Induced by diet rich in T apioca).
Aetiology: Alcohol; stones in biliary tree; malnutrition, diet; hyperparathyroidism; hereditary (Familial
hereditary pancreatitis); idiopathic; trauma; congenital
anomaly, etc. (Pancreatic divisum).
Pathology: It shows atrophy of acini, hyperplasia of
duct epithelium, interlobular fibrosis, calcifications,
ductal dilatation, with strictures in the duct.
Clinical features: (1) Pain in epigastric region,
persistent and severe, which radiates to back. This pain
is due to irritation of retropancreatic nerves, or due to
ductal dilatation and stasis, or due to chronic
inflammation itself. (2) Exocrine dysfunction:
Diarrhoea, asthenia, loss of weight and appetite,
steatorrhoea (signifies severe pancreatic insufficiency),
malabsorption, etc. (3) Endocrine dysfunction:
Diabetes mellitus. (4) Mild jaundice is due to narrowing
of retropancreatic bile duct and cholangitis. (5) Mass
per abdomen, just above the umbilicus, tender, nodular ,
hard, felt on deep palpation, not moving with respiration, not mobile, resonant on percussion. Chronic
pancreatitis can lead to carcinoma pancreas.
Complications of chronic pancreatitis: Pseudocyst
of pancreas; Pancreatic ascitis; CBD stricture;
Duodenal stenosis; Portal or splenic vein thrombosis;
Peptic ulcer; Carcinoma pancreas (Fig. 20.39).
Pancreatic Tumours
Classification
A: Exocrine tumours: Benign: Benign cystadenoma.
It is rare. Malignant: (a) Adenocarcinoma in ampulla
or periampullary region or head of pancreas. Periampullary carcinoma may consist any of the component
- duodenal mucosa, CBD, pancreatic duct component
or all. Occasionally squamous cell carcinoma or
combination of adenosquamous can occur. (b) Cystadenocarcinoma of pancreas occurs commonly in body
and tail of the pancreas, which usually attains a large
size (5%). B: Endocrine tumours. C: Lymphomas.
Exocrine pancreatic tumours: Aetiology: Smoking;
alcohol; high energy diet rich in fat; chronic pancreatitis; familial pancreatitis.
Sites: Head and neck region; Ampullary and periampullary region; Body and tail.
Pathology: (a) 75% are adenocarcinoma, common
in elderly people. Arising from primitive cells or acinar
cells or duct cells. It is common in head, neck and
ampullary region. Most often it begins as carcinoma
in situ. (b) Cystadenocarcinomas occurs 1% of all
pancreatic malignancies. They are large cystic tumours,
which are slow growing, occurring in the body and tail
of the pancreas. They are commonly papillary- cystic
tumours. Occasionally mucinous cystic tumours are
also seen.
Clinical features: Ampullary tumours mainly present
with jaundice and weight loss. Carcinoma head and
neck tumours present with weight loss and jaundice.
Cystadenocarcinoma of pancreas present with pain,
weight loss and mass.
Jaundice is of obstructive nature which is of short
duration, severe, progressive, associated with pruritus
(due to deposition of bile salts in the skin which releases
histamine). Painless jaundice is seen in ampullary
malignancies. In periampullary carcinoma necrosis of
tumour occurs sometimes, as a result of which jaundice
may reduce temporarily thus becoming intermittent.
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