Acute pancreatitis Flashcards
Definition of acute pancreatits
abdominal pain and elevated amylase/lipase levels with an inflamed pancreas
types of pathology in acute pancreatitis
interstitial or hemorrhagic
interstitial: edematous process with preservation of the gross architecture.
hemorrhagic: tissue necrosis and hemorrhage in the pancreas. necrosis and large hematomas in the retroperitoneal space are possible
Describe the initiation of pancreatitis
activation of zymogens within pancreatic acinar cells. trypsinogen may autoactivat or cathepsin B may activate the trypsinogen.
pancreatic duct obstruction
pancreatic ischemia
What are the secondary events of pancreatitis?
- injury causes cytokine release
- inflammatory cells enter the pancreas
- vascular damage and ischemia are caused by ROS and kinins. additionally, enzymes continue to attack normal tissue –> damage and cell death
etiologies of acute pancreatitis
cholelithiasis and alcohol
other causes: structural, toxins, infections, metabolic, vascular
How do gallstones cause acute pancreatitis?
gallstones, esp. small gallstones, may obstruct the papilla (opening of both the pancreas and the bile duct into the small intestine)
how does alcohol cause acute pancreatitis?
unclear. many possibilities: obstruction of pancreatic ducts through protein plugs, spasm of the sphincter of Oddi, direct toxic effects, incr. hypertriglyceridemia
What are some causes of sphincter of Oddi spasm/stenosis?
trauma, AIDS infections, surgery, endoscopic sphincterotomy
what is pancreas divisum?
pancreas is an organ that results from the fusion of the dorsal and ventral pancreatic buds. each bud had its own opening into the small intestine. the ducts normally join when the organ fuses, but in some cases the ducts remain separate. most pancreatic outflow comes from the dorsal duct, but the dorsal duct originally flows into the minor duct. Pts with pancreas divisum continue to drain through the minor duct rather than the major duct- may be predisposed to pancreatic obstruction and pancreatitis
drugs that can cause pancreatitis
didanosine, estrogens, ACE-Is, valproate
Infections that can cause pancreatitis
mumps, coxsackie B; shigella, campylobacter, hemorrhagic e coli, legionella; CMV, mycobacterium avium, cryptococcus, toxomplasma. ascaris
How can hyperlipidemia cause pancreatitis?
if triglycerides above 2000-3000. lipase action on these high lipid levels –> toxic free fatty acids. May be induced by EtOH, estrogens, HIV protease inhibitors
Iatrogenic causes of pancreatitis. Who is most susceptible?
post-ERCP pancreatitis.
Most likely in pts who are young, female, and have normal ducts, anicteric, or in cases that require excess dye. may also (rarely) be post-operative (post-op hyperamylasemia is common but rarely progresses all the way to pancreatitis)
Clinical presentation of acute pancreatitis
PAIN: most common symptom. usually in the epigastric/umbilical region; radiating to the low thoracic back. may be reduced by leaning forward. Most pts also have nausea and vomiting.
Other sx: low grade fever, tachycardia/hypotension from enhanced vascular permeability, hemorrhage, vasodilation.
Physical exam findings for acute pancreatitis
low grade fever, tachycardia, abdominal tenderness and guarding, decr. bowel sounds. maybe left pleural effusion. mild jaundice possible but bilirubin shouldn’t be above 4 mg/dl (if it is, think liver disease or extra-hepatic obstruction, not pancreatitis)
potentially Grey-Turner discoloration of the back or Cullen discoloration in the periumbilical region due to retroperitoneal hemorrhage
