Acute pancreatitis

Question 1

Give an endocrine function of the pancreas.

Answer 1

Alpha cells of the pancreas produce glucagon

Beta cells produce insulin.

Question 2

Give an exocrine function of the pancreas.

Answer 2

Acinar cells produce digestive enzymes.

Question 3

What are zymogens? Give one example.

Answer 3

Zymogens are inactive forms of pancreatic enzymes, which can be activated by cleavage by proteases. They are stored in vesicles called zymogen granules with protease inhibitors. An example is tryspinogen.

Question 4

Define acute pancreatitis.

Answer 4

Auto-digestion of the pancreas by its own digestive enzymes.

Question 5

Describe the pathophysiology of acute pancreatitis and give the 2 main causes.

Answer 5

If acinar cells become damaged (by alcohol) or pancreatic ducts blocked (by gallstones), zymogens may be prematurely activated to enzymes. These digest the pancreatic tissues.

Question 6

How does alcohol cause pancreatitis?

Answer 6

1. Increased zymogen secretion, decreased fluid and bicarbonate production -> increased viscosity of pancreatic fluids -> duct blockage -> distension, increased pressure -> chaotic membrane trafficking -> zygmogen granules may fuse with lysosomes. ->
   Tripsinogen -> tripsin -> activates other enzymes -> destruction.
2. Causes acinar cells to release inflammatory cytokines, which attracts strong immune reaction. Neutrophils come to the pancreas and release proteases (which activate zymogens) and superoxides.
3. Undergo oxidative metabolism, forming reactive oxygen species’ which damage the pancreas.

Question 7

How do gallstones cause pancreatitis?

Answer 7

Gallstones get lodged in the sphincter of Oddi, which blocks release of pancreatic juices.

Question 8

How does liquefactive haemorrhagic necrosis occur?

Answer 8

Pancreatic tissue destruction from proteases and inflammatory response causes blood vessel leakage and rupture. This causes swelling, which causes lipases to destroy peripancreatic fat. The digestion and bleeding can liquefy tissue (=LHN).

Question 9

How does disseminated intravascular coagulation occur?

Answer 9

DIC is when tiny blood clots form throughout the body, using up clotting factors, making it paradoxically easier to bleed. It can be caused by acute pancreatitis.

Question 10

What is the main cause of death in people with acute pancreatitis and what is the physiology?

Answer 10

Adult respiratory distress syndrome (ARDS). Inflammation causes blood vessels to become leaky, which causes difficulty breathing.

Question 11

How does acute pancreatitis cause hypovolaemia?

Answer 11

1. Oedema and fluid shifts - ECF trapped in gut, peritoneum and retroperitoneum.
2. Blood vessel damage causing haemorrhage

Question 12

What might cause fever, leukocytosis, abdominal pain, loss of appetite and a palpable mass in a patient with acute pancreatitis? Describe the physiology.

Answer 12

Pancreatic pseudocyst.
Fibrous tissue surround liquefactive necrotic tissue and the resulting cavity fills with pancreatic juice (pain, anorexia,mass).
It can grow and rupture, leading to inflammation, and/or infection (fever and leukocytosis).

Question 13

How is pancreatic pseudocyst diagnosed?

Answer 13

Abdo CT

Bloods: raised amylase, lipase and bilirubin.

Question 14

Give 5 causes of acute pancreatitis.

Answer 14

Idiopathic (10%)
Gallstones (35%)
Ethanol abuse (35%)
Trauma (1.5%)
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridemia/ hypercalcaemia
ERCP (5%), Emboli
Drugs

Question 15

What is Cullen’s sign?

Answer 15

Periumbilical bruising due to necrosis-induced haemorrhage spreading to soft tissue in the periumbilical area.

Question 16

What is Grey-Turner’s sign?

Answer 16

Flank bruising due to necrosis-induced haemorrhage spreading to soft tissue in the flank.

Question 17

Give 3 signs of acute pancreatitis other than bruising.

Answer 17

Tachycardia, fever, jaundice, shock, hypocalcaemia (due to fat necrosis)

Question 18

Give 3 symptoms of acute pancreatitis.

Answer 18

Nausea
Vomiting
Severe epigastric pain radiating to back. May be relieved by sitting forward.

Question 19

What investigations would you do for suspected pancreatitis?

Answer 19

1. Serum amylase and lipase: raised.
2. ABG (monitor oxygen and acid-base status)
3. Abdo CT (assess severity and complications)
   USS (if gallstones + high AST)
   AXR (no psoas shadow due to increased retroperitoneal fluid)

Question 20

Which serum marker is more specific more acute pancreatitis, amylase or lipase?

Answer 20

Lipase, but both are raised.

Question 21

What would you expect to see on a CT scan in someone with acute pancreatitis?

Answer 21

Inflammation, necrosis, pseudocysts.

Question 22

What else could cause epigastric pain, other than acute pancreatitis?

Answer 22

GORD - obesity, stress
Gastritis - worse after eating
Peptic ulcer - gnawing/burning pain.
(patient.info)
Chronic pancreatitis - more constant, not as 'piercing'.

Question 23

Other than alcohol, give 3 risk factors for acute pancreatitis.

Answer 23

Middle-aged women,
Slightly younger peak in men
Gallstones
(BMJ).

Question 24

Describe the management of acute pancreatitis.

Answer 24

1. Severity assessment using Glasgow scoring system.
2. Bowel rest/ nil by mouth, IV nutrition and saline.
3. Urinary catheter
4. Pain management eg morphine
5. Hourly vital signs, daily bloods.

Question 25

What defines severe pancreatitis?

Answer 25

3 or more from the Glasgow criteria within 48 hours of onset:
PaO2 <8kPa
Age >55yrs
Neutrophilia: WBC>15x10^9/L
Calcium <2mmol/L
Renal function: urea >16mmol/L
Enzymes: LDH >600iu/L, AST >200iu/L
Albumin <32g/L (serum)
Sugar >10mmol/L.

Question 26

What genetic disorder can cause pancreatitis and what is the pathophysiology?

Answer 26

Cystic fibrosis
Mutation in CFTR gene disrupts ion transport. Pancreatic secretions become thick and sticky. Main cause of chronic pancreatitis in children.