further exacerbated by concomitant exocrine insufficiency, resulting in malabsorption. While diabetes is relatively uncommon in chronic pancreatitis, it is a nearly inevitable consequence of major pancreatic resection such as Whipple surgery (see Chapter 86).
Management of chronic pancreatitis
Pain is relatively less common in the elderly with chronic pancreatitis, but when it occurs, it impairs the quality of life. Opiate drugs should be avoided because of the risks of narcotic medications in the elderly, including narcotic dependence. Non‐steroidal anti‐inflammatory drugs (NSAIDs), tricyclic antidepressants, and neuromodulators (e.g. gabapentin) are often first‐line therapies.
If drug therapy fails to control pain, other options, such as deafferentation techniques (e.g. celiac axis block), have been tried with variable success. If imaging shows clinically significant pancreatic duct strictures or large obstructing pancreatic duct stones, ERCP can be an option before surgical techniques are considered. In general, surgery for chronic pancreatitis should be rare, and the best outcomes are generally in the subgroup of patients with a distinct pancreatic ductal stricture causing a ductal obstruction that can be relieved surgically. Surgical pancreatic resections or total pancreatectomy with islet autotransplantation (TPIAT) have gained increasing success in the younger population for the treatment of CP; however, they have not been well studied in the older population.
Attempts to control steatorrhea by orally administered pancreatic enzymes are worthwhile, and the dose should be titrated to achieve a normal bowel movement frequency. Malabsorption of fat‐soluble vitamins occurs and should be treated with appropriate supplements.
Pancreatic cysts and tumours
Cystic lesions of the pancreas
Cystic lesions of the pancreas are very common findings in the era of modern cross‐sectional imaging and are usually discovered incidentally. Recent studies have shown that up to 40% of adults will have a small pancreatic cyst noted incidentally on abdominal MRI scans.21
Broadly speaking, pancreatic cysts can be divided into neoplastic and non‐neoplastic categories. Of the non‐neoplastic cysts, the majority are inflammatory lesions, most commonly pseudocysts, which can be encountered as a sequalae of acute pancreatitis. These inflammatory cysts are variably symptomatic, and depending on their anatomical location and morphology, EUS sampling or drainage may be indicated and should be referred for evaluation by a gastroenterologist. Other non‐neoplastic cysts are fairly rare but include true cysts, retention cysts, mucinous non‐neoplastic cysts, and lymphoepithelial cysts, all of which may be difficult to definitely diagnose and are beyond the scope of this chapter.
Neoplastic cysts are quite common, and certain categories of pancreatic cystic neoplasms may require surveillance or even consideration of resection because of malignancy risk. The two most common types of pancreatic cystic neoplasms are intraductal papillary mucinous neoplasms (IPMNs), which are precancerous and typically require surveillance, and serous cystadenomas (SCAs), which are typically benign and may not require surveillance. There are several other, less common, pancreatic cystic neoplasms, including mucinous cystic neoplasm (MCN) and pseudopapillary neoplasm, extensive discussion of which is beyond the scope of this chapter.
As a general rule, any pancreatic cystic lesion greater than 1 cm should, even if incidentally discovered, be referred to a gastroenterologist to help determine appropriate additional testing and/or surveillance modality and interval. If there is uncertainty regarding the nature of a pancreatic cyst <1 cm in size, then interval MRCP imaging (typically at 6–12 months) or referral to a gastroenterologist are both reasonable considerations; however, the clinical significance of a diminutive pancreatic cyst in an elderly patient is questionable, particularly if other chronic health conditions are present.
Table 21.1 Pancreatic endocrine tumours.
| Type | Age at diagnosis (years) | Five‐year survival rate (%) | Clinical characteristics |
|---|---|---|---|
| Insulinoma | 50–60 | 90 | Fatigue, hypoglycaemia |
| Gastrinoma | 60–70 | 55 | Gastric pain, weight loss |
| Glucagonoma | 50–60 | 90 | Weight loss, diabetes, rash |
| Somatostatinoma | 60–70 | 30 | Diabetes, gallstones, weight loss, steatorrhea |
| VIPoma | 40–60 | 45 | Flushing |
| Pancreatic peptideomas | 40–60 | 40 | None |
Endocrine tumours of the pancreas
Endocrine tumours of the pancreas are rare. These tumours are classified according to the hormone they excrete, which typically correlates with the clinical presentation, although some low‐grade pancreatic neuroendocrine tumours may be found incidentally on imaging without clinical symptoms. Table 21.1 describes the common pancreatic endocrine tumours and their clinical characteristics.22
Most pancreatic neuroendocrine tumours have malignant potential and may be part of the multiple endocrine neoplasia syndrome. Suspicion of a pancreatic neuroendocrine tumour, either on clinical grounds or based on imaging findings, should generally prompt referral to a multidisciplinary team including a gastroenterologist and surgeon. Endoscopic‐ultrasound guided biopsy is typically the first step in the diagnostic approach.
Pancreatic adenocarcinoma
Exocrine pancreatic cancer is diagnosed in over 56,000 people in the US each year. 85% of these are adenocarcinomas.23 Early diagnosis can be difficult because symptoms may be absent or vague in the early stages of the disease. Thus only ∼15–20% of patients have tumours amenable to surgical resection at presentation. The overall five‐year survival rate is less than 10%, but it is higher for patients diagnosed at earlier stages.
The predominant risk factor is age, although there is a relationship to cigarette smoking. Genetic and general medical conditions such as familial breast cancer, hereditary pancreatitis, chronic pancreatitis, and diabetes are also risk factors.
Clinical features
Cancer of the head of the pancreas presents with jaundice, often with epigastric or back discomfort. Later in the clinical course, other symptoms of cholestatic jaundice such as itching, pale stools, and dark urine occur. Anorexia and weight loss are common. Tumours of the body and tail of the pancreas present more insidiously and are often recognized only when distal spread of the disease has occurred.
