Pancreatitis Flashcards
What are the two components of pancreatic juice?
viscous, enzyme rich juice in low volume
watery, HCO3- rich juice in high volume
What cells produce the enzyme rich juice?
Acinar cells
What cells produce the HCO3- juice?
Duct and centroacinar cells
How are enzymes stored in the pancreas
as zymogens
why are enzymes released as zymogens?
to prevent autodigestion of acini and ducts
where are pancreatic enzymes activated?
duodenum
what protective inhibitor is also present in the pancreas?
trypsin inhibitor (prevent trypsin activation)
what converts trypsinogen - trypsin
enterokinase
what does trypsin do in the duodenum other than act as a digestive enzyme?
activated all other proteolytic enzymes, some lipolytic
where is enterokinase found
brush border of duodenum
what is acute pancreatitis?
rapid onset inflammation of the pancreas
what is chronic pancreatitis?
long-standing inflammation of the pancreas
what are the causes of pancreatitis? GETSMASHED
Gallstones Ethanol Trauma Steroids Mumps +other viruses e.g EBV Autoimmune Scorpion/snake bite Hypercalcaemia, hypertriglyceridaemia, hypothermia ERCP (complications) Drugs (Steroids/sulfonamides, azothiopire, NSAIDs, diuretics)
name a few pathophysiological causes of acute pancreatitis
pressure increases
bile reflux
reflux of duodenal contents
enzyme diffusion, protein precipitation (alcohol)
premature intracellular enzyme activation
increased permeability of pancreatic duct
how does alcohol cause pancreatitis?
precipitates proteins in ducts, causes a plug, increasing upstream pressure leading to pancreatitis
how can pancreatic enzymes be activated intracellularly?
zymogens and lysosomal proteases incorporated to same vesicles may activate trypsin
what are the consequences of trypsin activation?
autocatalysis, activation of prothrombin, complement, phospolipase A2, elastase, kallikrein.
what are the symptoms associated with the consequences of trypsin activation?
hypocalcaemia, hyperglycaemia, pancreatic gangrene, pain, shock, hypoxia and anuria
what is oedematous pancreatitis
AP where fat necrosis and oedema occur first
what is hemorrhagic pancreatitis
AP where mass bleeding predominates (enzymes break down tissue)
what is necrotic pancreatitis
AP sometimes + infection
dead tissue
what are grey turners and cullens sign associated with?
haemorrhagic pancreatitis
what are the main symptoms of acute pancreatitis?
epigastric pain (radiate to back), relieved by sitting forward
nausea and vomiting +++
fever
what are some differential diagnoses for acute pancreatitis?
gallstone disease, peptic ulcer, leaking/ruptured AAA, raised amylase
what blood test is performed for acute pancreatitis?
amylase/lipase (should be increased)
what X rays may be performed for acute pancreatitis?
erect chest, plain abdo
why may you use ultrasound for someone with AP?
investigate gallstones as a cause
when may you perform a CT for AP
patients not settling w conservative treatment & 48-72hrs after onset
when may you perform MRCP for AP?
if gallstones are suspected with abnormal LFTs
when may you perform ERCP for AP
to remove CBD gallstones
how is the severity of AP assessed?
modified glasgow criteria
what is included in the Modified glasgow criteria? PANCREAS
Po2 Age (>55) Neutrophil/WBC Calcium (low) Renal (urea increased) Enzymes AST, LDH Albumin low Sugar high
what score suggests severe pancreatitis?
3+
what other than modified glasgow can suggest severe pancreatitis?
CRP >200
how do you manage AP?
ABC Fluid resuscitation (iv fluids, monitoring) Analgesia Pancreatic rest (NJ feeding, TPN) Determine underlying cause
what is rarely required for AP?
surgery
what are the systemic complications of AP?
hypocalcaemia hyperglycaemia possible diabetes systemic inflammatory response syndrome acute renal failure adult respiratory distress syndrome disseminated intravascular coagulation multi organ failure death
what is the causation behind hypocalcaemia?
lipase - free fatty acids - chelate Ca2+ salts - decreased serum Ca2+ (saponification)
what are the local complications of AP?
necrosis abcess psuedocyst hemorrhage thrombosis chronic pancreatitis
what is a pancreatic psuedocyst?
peri-pancreatic fluid collection
increased pancreatic enzymes within fibrous capsule
presents >6 weeks after AP
when may pseudocysts need drained?
pain
it causes obstruction of CBD etc
infected (abcess)
where may thrombosis appear in AP
splenic vein, superior mesenteric vein, portal vein
what are the main symptoms of chronic pancreatitis?
pain weight loss (malabsorption) diabetes mellitus (type1) diarrhoea steatorrhoea obstructive jaundice
what are some causes of CP
tumours, alcohol abuse, papillary stenosis
how can tumours cause CP
cause main pancreatic duct occlusion, duct distension activating chronic inflammation
how can alcohol cause CP
decrease HCO3- increasing proenzyme conc. leads to activation and a protein plug
decrease citrate, lithostatin. leads to calcium precipitation and deposition. also helps activate enzymes
how is CP managed
no intervention unless in pain
how may surgery help CP
drainage, attach small bowel to head of pancreas, total pancreatectomy
how may stones be removed for CP
endoscopically - lithotripsy, possible stent
