8.2 Pancreatic Disease

Question 1

Describe two ways by which pancreatic ductal obstruction can lead to premature pancreatic protease activation

Answer 1

1. Acinar cell injury causes premature activation of proteases
2. Inflammatory mediators cause intracellular calcium buildup, leading to premature trypsinogen activation

Question 2

How can early inflammation lead to pancreatic ductal obstruction? What can this cause?

Answer 2

Can cause
- Oedema/swelling
- Fibrosis/scarring
- Sludge debris formation (like gallstones)

This can lead to acinar cell injury and calcium buildup, causing pancreatitis

Question 3

What are the consequences (symptoms/signs) of exocrine pancreas insufficiency?

Answer 3

• Malabsorption (less enzymatic breakdown)
• Steatorrhoea (less TAG absorption)
• Abdo pain (/duodenal damage, pancreatic inflammation)
• Unexplained weight loss (2° to malabsorption)

Question 4

Is acute pancreatitis a medical emergency? What are the complications/natural history?

Answer 4

Yes, it is a medical emergency. Can lead to:

• Multiorgan failure (due to systemic inflammation)
• Necrosis and infection of the pancreas can then occur, which can cause sepsis
• Pancreatic haemorrhage
• Hypovolaemia (2° to haemorrhage or oedematous necrosis)

Question 5

List some symptoms/signs of acute pancreatitis, and explain their mechs

Answer 5

• Pain (inflammation/autodigestion)
• Nausea/vomiting (irritating surrounding structures, no fat emulsification, gastroparesis)
• Jaundice (inflammation causes compression of common bile duct)

Question 6

List four biochemical disturbances that can occur in pancreatitis, and explain how they occur

Answer 6

1. Hyperglycaemia (loss of insulin control)
2. Hypocalcaemia (calcium salt formation in pancreas)
3. Hyperbilirubinaemia (2° to common bile duct obstruction; therefore conjugated)
4. Elevated pancreatic enzymes (instead of GI, dying cells leak into bloodstream)

Question 7

Provide a proper mech for how hypercholesterolaemia predisposes to gallstone formation

Answer 7

• Ordinarily, cholesterol can be used to make bile salts
• In hypercholesterolaemia, we have excess cholesterol, meaning there is too much to all be converted into bile salts
• So, some of the cholesterol precipitates out of solution, forming cholesterol gallstones

Question 8

What biomarkers might we use to assess pancreas function/pathology?

Answer 8

• Ca 19-9 (screen for possible cancer)
• Lipase/amylase (elevated in pancreatitis)
• INR or Platelets may be decreased if comborbid w/ liver dysfunction
• Serum bicarbonate (low in exocrine dysfunction of the pancreas)

Question 9

How do we treat pancreatic cancer?

Answer 9

• Surgery
• Radiotherapy
• Chemotherapy

Question 10

How do we treat pancreatitis?

Answer 10

• Fasting (lower need for digestive enzymes)
• IV fluids (esp. if oedema/haemorrhage)
• Antibiotics (prevent necrosis -> infection)
• Pain relief
• Other organ support (in the setting of multiorgan failure)
• Surgery/endoscopic drainage (in the setting of necrosis)

Question 11

List four triggers that can cause premature activation of trypsinogen, leading to autodigestion and pancreatitis

Answer 11

• Gallstone blockage (pressure buildup if pancreatic duct is blocked)
• Alcoholism (can damage acinar cells)
• High triglycerides (high levels of resultant fatty acids can cause enzyme activation)
• Infection (initial inflammation causes enzyme activation, leading to more inflammation)