Pancreas

Acute pancreatits
Work-up
If unsure of dx of acute epigastric pain, start with gastrograffin swallow to r/o perf'd ulcer, Boerhaave's, gastric volvulus. Could also be acute MI (EKG, enzymes), AAA (will be seen on the US/CT you are gonna do for pancreatitis), ischemic bowel.
abdominal films
EKG
US/CT

Treatment
NPO, NGT, maybe TPN
IVF
H2 blockers
Abx? - when ?
Early ERCP + sphincterotomy in severe cases can help, but has risks, so do only to decompress obstructed CBD in septic pt.
Somatostatin does not help

If pt doesn't get better ...
CT, if necrosis, then needle aspiration and G/S + culture
If sterile but still not getting better in 24h, or if infected, abx + laparotomy.
1. Debride devitalized tissue, lavage
2. Drains in lesser sac, or marsupialize
3. Feeding tube

If CT shows pancreatic fluid collection ...
FNA and culture to distinguisg pseudocyst, sterile fluid, or pancreatic abscess
If it's a pancreatic abscess, IR drain, or surgical external drainage + feeding tube

Pseudocyst
If under 4 cm and asymptomatic, follow with serial US
If 5-6 cm or symptomatic (pain, obstruction, bleeding, infection) ...
ERCP - communicating with pancreatic duct?
If non-communicating, larger than 4cm, not very symptomatic, can do IR aspiration (even repeatedly, 3-4x). If that doesn't work or things get worse, surgical internal drainage.

If larger than 6cm, symptomatic, and communicates with pancreatic duct, make sure it's 6wks old and do surgical internal drainage (not if infected or bleeding). Roux-en Y cystojej is usual choice. Can do distal pancreatectomy if cyst is in the tail. If it's sticking right into the appropriate organ, can do cysto-duo or cysto-gastostomy.

If you operate, biopsy cyst wall to look for CA.

If infected, external drainage (IR or surgery).
If bleeding (sudden pain, shock; CT with IV contrast for dx if stable), go to IR if stable, laprotomy if unstable. Ligate vessel, open cyst, pack, ligate bleeders, external drainage.
Bleeding in a pseudocyst patient can be into cyst (erosion into vessel), into bowel (cyst erodes thru bowel wall), from gastric varices (2/2/ splenic vein thrombosis - do splenectomy). Do A gram if you can!

Pancreatic true cyst
serous or mucinous cystadenoma or cystadenocarcinoma
Mucinous - body/tail, higher malig potl
Serous - head, low malig potl

If suspect true cyst, get FNA and send:
CEA - hi in mucinous, low in serous and pseudo
CA125 - hi in malig, low in pseudo, variable in benign
Amylase/lipase - hi in pseudo
Viscosity - hi in mucinous
Cytology - look for CA
Wall bx - no epithelial lining in pseudo

Treatment
Surgery even if mets

Pancreatic ascites
Pt with h/o pancreatitis/pseudocyst with abdominal distention, fluid wave.

Work-up
CT abdomen
Paracentesis - protein, glucose, amylase, bile, cells
If amylase hi, it's pancreatic ascites.

Conservative treatment
NPO + TPN
somatostatin 150mg sq q8
repeated paracentesis
ERCP to stent across leak (unless significant debris in cyst)
75% success in 4 wks
repeat ERCP in 6 wks if doing well - remove stent if healed

If conservative fails:
pancreatectomy (Whipple or distal)
internal drainage if leak from cyst
Peustow is rare

Chronic pancreatitis
Indicated for complications:
pseudocyst, biliary or GI obstruction, abscess, splenic vein thrombosis with L portal HTN, pain

Factors to consider:
size of duct - large: Peustow; small: pancreatic resection (Whipple better pain results than distal, and not-as-bad diabetes)
failure of drainage procedure: resection
ampullary stenosis: sphincteroplasty and septoplasty

Workup
ERCP/PTC

If biliary obstruction, can treat with choledocho-jej, drainage of pseudocyst, or resection, depending on cause.
GI obstruction can be treated by pseudocyst drainage, or gastro-jej if you know it's not tumor

To differentiate pancreatic CA from localized chronic pancreatitis:
Look for mets with imaging
Best test is ERCP with brushings, biopsies, and fluid cytology
If ERCP inclonclusive, explore and do multiple biopsies

Pancreas divisum