Lecture 31: Acute and Chronic Pancreatitis Flashcards
What is acute pancreatitis?
A CHEMICAL BURN
An intraabdominal burn
Acute inflammation of the pancreas and associated adjacent organs without evidence of chronic pancreatitis
What is the Atlanta symposium of acute pancreatitis?
2 of 3 need to be present
- Typical pancreatic type pain
- Radiographic findings of acute pancreatitis
- Elevations in blood chemistries (typically amylase or lipase)
What are the histological features of pancreas?
No acini
Infiltration of polys all over
Necrosis
What are the basic clinical features of acute pancreatitis?
- severe pain (upper abdomen and radiate into back)
- starts quickly (10-20 mins) and lasts days
- 90% vomit
- 5-10% is painless!
- fevers occur even in the absence in infection!
What are the complications of acute pancreatitis?
- Early
2. Late (usually infection)
What are the types of early acute pancreatitis?
- cholangitis (fever, RUQ, jaundice)
- hypotension (cuz all the fluid is flowing to the pancreas)
- Systemic inflammatory response (SIRS)
- Renal failure
- Third spacing/ascites (refers to situation in which fluid shifts out of blood into a body cavity or tissue where it is no longer available as a circulating fluid, ie peritonitis)
- hypoxia (because fluid in the lungs)
- Hypocalcemia (because lipase breakdown fat, negative charge attracts calcium, brings about saponification, so you get “soap” in pancreas)
- Death from the fact that you have HYPOcalcemia from pancreatitis
ORGAN SHUTDOWN
Remember saponification
What are the late types of acute pancreatitis?
- splenic vein thrombosis (gastric varices)
2. infected necrosis and abscess
How do the acute pancreatitis complications come about?
Trypsin is activated
Autodigests and leaks out even more trypsin zymogen
Polys come rushing in
Neutrophil elastase is released, thereby recruiting a shitload of neutrophils
Fluid comes rushing in because the endothelium becomes leaky
Fluid then leaks into the lungs
What are the etiologies of acute pancreatitis?
- Alcoholic
- Biliary
- idiopathic
- Other (like ischemia, trauma, ERCP, neoplasia lol, metabolic causes like hypertriglyceridenemia, autoimmune)
- IgG4 = autoimmune, common in Asians
What are the characteristics of biliary etiology?
- comes from gallstones or sludge
- most common etiology of pancreatitis in worl
- obstruction at major papilla
- because of obstruction, bile goes up the pancreatic ducts and bile triggers inflammatory response (because they usually don’t see bile)
What is the pathophysiology of EtOH damage?
- changes pancreatic blood flow (poor blood flow)
- Radical production by necrosis of lysosomes = ROS injury of pancreas
- Sensitization of acini to CCK, leads to zymogen activation/cytokine generation
- causes spasm of sphincter of Oddi to lead to acute obstructive injury
Hypothetical shit
Where is CCK made?
“I”-cells of the duodenum
What are important things to know about hypertriglyceridemia as a cause of acute pancreatitis?
Patients have HYPERglycemia
Can have NORMAL amylase and lipase
What is the recommendation for a patient who has unexplained pancreatitis over the age of 50?
Should have CT 6 weeks later
This is because it could be a cancer!!
What is the pathophysiology of acute pancreatitis?
Premature/intracellular activation of trypsin
Trypsin is the major catalyst for pancreatitis
Leads to activation of chymotripsinogen, trypsinogen, elastase, phospholipase A2
Then leads to autodigestion
What are the characteristics of trypsin?
Trypsin = PRSS1
Has an autolysis loop (R122)
Mutation in autolysis loop (R122) means you cant inactivate trypsin
Activated by CALCIUM
Has SPINK1 portion that inactivates trypsin (PSTI)
Any mutation to SPINK1 = activation of trypsin
What activates the zymogens from pancreas?
Enterokinase from the enterocytes converts those
Inactive enzymes to active ones (trypsin)
What upregulates digestion?
- bile
- low pH
- trypsin
- high calcium, triglyceride
- CCK
- vagal stimulation
What downregulates trypsin/digestion?
- SPINK1
2. somatostatin
What triggers zymogen activation/generation of inflammatory mediatrs/ischemia?
Insult/trauma
Exacerbated by obesity and smoking
How do you manage acute pancreatitis?
NPO/IV fluids/pain control
Bunch of tests to rule out need for surgery, etc
What is chronic pancreatitis?
Permanent damage to the pancreas
Exocrine/endocrine dysfunction or destruction of such tissue on biopsy
How do you know there is chronic pancreatitis?
- calcifications
- pancreatic duct stones
- dilated irregular pancreatic duct without mass
- beads on a string
- atrophy without mass
What do calcifications and stones in pancreatic duct suggest?
Chronic pancreatitis
