Acute Pancreatitis

PREPARED BY: MUHAMMAD ARIFF B. MAHDZUBBACHELOR MEDICINE AND SURGERY (MBBS)UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

MD-2508 (DIGESTIVE SYSTEM)PROBLEM BASED LEARNING (PBL)

ACUTE PANCREATITIS

TRIGGER 1

• Man• 44 Y/O• 160 pound (72 kg)

• Suffer epigastric pain (last 3 hour), radiate to back

• Anatomical organ related• Differential diagnose related

TRIGGER 2 (History)

• Already vomited clear material three times• Alcoholic• Likes fatty meal & has elevate fat in blood

TRIGGERS 3 (physical examination)

• Pulse 110/min• Bp: 120/70 mmHg (normal)• Esp. rate: 16/min (normal)• temp: 38.3 C

• Exm abdomen • Distension epigastrium, bowel sound are hypoactive, percussion

tenderness, involuntary guarding, referred tenderness

• No diabetes, htn• Sister had gallbladder removed

d/word

• percussion tenderness: Pain feel at area of percussion

• involuntary guarding: abdominal muscle spasm, caused by retroperitoneal inflammation

• referred tenderness: Called reflex pain, pain at other site

Trigger 4 (investigation)

• X-ray : dilated transvers colon with no-free air• Hemoglobin: 15 g/dl• Wbc: 15,000/ ul• Serum amylase: 2,000 units/l (high)

• Acute pancreatitis

• Site of tenderness• Onset of tenderness (when)• Associating factor (symptom)• Duration of pain (how long)• Does it radiate to other part• Characteristic of pain (crushing, burning,

palpate)• What make pain worst• How patient react to relieve the pain

ABDOMINAL REGION

TRANSPYLORIC PLANE : An upper transverse line also known as Addison's Plane, located halfway between the jugular notch and the upper border of the pubic symphysis. The plane in most cases cuts through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra.

TRANSTUBECULAR PLANE : passing through the iliac tubercles; behind, its plane cuts the body of the fifth lumbar vertebra.

Abdomen Regions

Organs

Right Hypochondriu

m

Liver, Gallbladder, Right Kidney, Small Intestine

Left Hypochondriu

m

Spleen, Colon, Left Kidney, Pancreas

Epigastrium Stomach, Liver, Pancreas, Duodenum, Spleen, Adrenal Glands

Right Lumber Region

Gallbladder, Liver, Right Colon

Left Lumber Region

Descending Colon, Left Kidney

Umbilical Region

Umbilicus, Jejunum, Ileum, Duodenum

Right Iliac Fossa

Appendix, Cecum

Left Iliac Fossa Descending Colon, Sigmoid Colon

Hypogastrium Urinary Bladder, Sigmoid Colon, Female Reproductive Organs

What is Abdominal Pain?

• the term abdominal pain generally is used to describe : – pain originating from organs within the abdominal

cavity. – Organs of the abdomen include the stomach, small

intestine, colon, liver, gallbladder, spleen, and pancreas. – Abdominal pain can range in intensity from a mild

stomach ache to severe acute pain. – The pain is often nonspecific and can be caused by a

variety of conditions.

What Causes Abdominal Pain?

• Inflammation (appendicitis, diverticulitis, colitis), • Stretching or distention of an organ (obstruction

of the intestine, blockage of a bile duct by gallstones, swelling of the liver with hepatitis)

• Loss of the supply of blood to an organ (ischemic colitis).

• Constipation• Diarrhoea• Acid reflux

Pancreas: type of cell and secretion

THE PANCREAS• Combination of two glands

a. Exocrine pancreas o Secrete substances into the intestine

o enzymes

b. Endocrine pancreaso Secrete substances into the bloodstream

o hormones

The exocrine pancreas• It has 2 types of cells:

–Acinar cells : • Produce digestive

enzymes:– Protease, amylase, lipase

and peptidases

–Duct cells :• Alkaline Fluids

– Bicarbonate ions– Water

The endocrine pancreas• Part of pancreas that made up endocrine function

is Islets of Langerhans• 4 main types of cells:

– α alpha cells : Glucagon– β beta cells : Insulin– Δ delta cells : Somatostatin– PP cells (γ (gamma) cells) : Pancretic polypeptide

• The islets of Langerhans play an imperative role in glucose metabolism and regulation of blood glucose concentration

CAUSES OF PANCREATITIS

CAUSES OF PANCREATITIS GALLSTONES

Hard pieces of stone-likeProduced in the gallbladderBlock the bile ductStopping pancreatic enzymes from traveling to the small intestineForcing them back into the pancreasIt begin to irritate the cells of the pancreasCausing the inflammation

CAUSES OF PANCREATITISALCOHOLISM How alcohol actually triggers the inflammation in the pancreas

is not clear. The molecules in alcohol interfere with the cells of the

pancreas. Causing the enzymes to start digesting it. Stopping them working properly.

CAUSES OF PANCREATITIS INJURY TO PANCREAS Car accident or bad fall leading to abdominal trauma. accidental damage during a procedure to remove gallstones or examine the

pancreas

AUTOIMMUNE DISEASE own immune system attacks healthy cell Associated with lupus or Sjogren's syndrome

INFECTION Viral – mumps virus , HIV

IDIOPATHIC Idiopathic pancreatitis No obvious cause was identified

Pathophysiology of Acute Pancreatitis

Pathogenesis of acute pancreatitis

Interstitial oedema

Impaired blood flow

Ischaemia

Acinar cell injury

Interstitial inflammation oedema

GallstoneChronic alcoholism

Release of intracellular proenzymes and lysosomal hydrolases

Activation of enzymes

ACTIVATED ENZYMES

Delivery of proenzymes to lysosomal compartment

Intracellular activation of enzymes

Proteolysis(proteases)

Fat necrosis(lipase, phospholipase)

Haemorrhage(elastase)

Alcohol, drugstrauma, ischaemia,viruses

Metabolic injury(experimental)Alcohol, duct obstruction

DUCT OBSTRUCTION ACINAR CELL INJURY DEFECTIVE INTRACELLULAR TRANSPORT

pathogenesis

progression

Acute Pancreatitis; Haemorrhage and necrosis

Normal pancreas

Acute pancreatitis

MARIA

INTRODUCTION OF VOMITTING

• Known as emesis / throwing up• Involuntary, forceful expulsion of the contents of

one's stomach through the mouth and sometimes the nose.

• Not same as regurgitation.

MARIA

WHAT CAN YOU EXPECT FROM THE VOMITUS?

QUANTITY COLOUR

CONTENTS ONSET & DURATION

MARIA

1. Quantity

•Large amount.•Small amount.

MARIA

2. Colour

GREEN/DARK YELLOW

FRESH BRIGHT RED

BROWNISH - RED

FROTHY PINK COLOUR

COFFEE-GROUND

GREEN/DARK YELLOW

FRESH BRIGHT RED

BROWNISH RED

FROTHY PINK COFFEE GROUND

MARIA

3.Contents

• Depend on the onset of the vomitting.

Undigested foodBloodBileFaecal content

MARIA

Undigested food

Blood

Bile Fecal MARIA

4.Onset and duration

• Sudden vomitting.• Intermittent or persistent.• Persistent is consider as severe vomitting

more than 10 times in 24 hours.

MARIA

AMYLASE

•  enzyme • begins the chemical process of digestion•  catalyses the hydrolysis  starch—sugars• 3 type-α-Amylase, β-Amylase, γ-Amylase• Pancreas, salivary gland -alpha amylase• hydrolyse dietary starch 

- disaccharides ,trisaccharides converted by other enzymes to glucose -energy

• Foods large amounts of starch, little sugar, ( rice,potatoes) -slightly sweet taste as chewed- amylase degrades starch – sugar

• producing salivary amylase-gene AMY1,-originated in pancreas

amylase

The normal range is 23 to 85 units per liter

(U/L). Some laboratories give a

range of 40 to 140 U/L

pancreas damage @ inflamed-amylase in

bloodurine

By blood@urine sampleSome can affect

amount of detectable amylase

Amylase blood test

• Some medications that could heighten the amount of amylase in the blood include:

• asparaginase• aspirin• birth control pills• cholinergic medications• ethacrynic acid• methyldopa• opiates (codeine, meperidine, morphine)• thiazide diuretics (chlorothiazide, hydrochlorothiazide,

indapamide, metolazone)

Indication of high amylase count

• Acute or chronic pancreatitis: enzymes - help break down food in intestines -malfunction - begin breaking down the tissues of the pancreas. Acute pancreatitis - sudden - not last long, chronic pancreatitis does improve , worsens over time.

• Cholecystitis: inflammation of the gallbladder. Cholecystitis is usually caused by gallstones. Gallstones are deposits of hardened cholesterol or other substances that can form in the gallbladder, and cause blockages. This condition can also sometimes be caused by tumors.

• Macroamylasemia: the presence of macroamylase in the blood. This is an abnormal compound of the enzyme and a protein.

• Gastroenteritis: inflammation of the gastrointestinal tract.

• Tubal pregnancy: the fertilized egg (embryo) is in one of the fallopian tubes (tubes that connect the ovaries to the uterus) instead of in the uterus. This is also called an ectopic pregnancy, which is a pregnancy that takes place outside the uterus.

• Other conditions: can also cause elevated amylase counts, including salivary gland infections, or intestinal blockages.

Indications of low count of amylase

• preeclampsia: a condition in pregnant women, also called toxemia of pregnancy. Signs of this condition also include high blood pressure.

• damaged pancreas• kidney disease

FAT METABOLISM

• The body has limited supply of glucose.• 3 sources of fatty acid for energy metabolism - dietry tryacylglycerol - tryacylglycerol that synthesize in liver - tryacylglycerol stored in adipocytes• When foods enter the stomach, it will breakdown

into components such as carbohydrates, proteins and fats.

• Dietry tryacylglycerol comes from the fat in the foods we eat and the process of breakdown start to occurs in small intestine not in the stomach.

In the small intestine, bile salt from the gall bladder will emulsify the realtively insoluble dietry fat to form micelles.

The micelles have non-polarcore and surrounded by bilesalts.

R-group are non-polar andso they point towards the centre of the micelles.

After that, as micelles movingdownwards the small intestine, pancreatic lipase will degrades the triacylglycerol into fatty acids and glycerol.

Then, the 3 Fatty acids and 1 glycerol packaged withapoprotein and cholesterolinto blood-soluble-complexcalled chylomicrons.

The chylomicrons willcross blood vessel membrane and move into blood stream.

From here on, the chylomicrons will have 2 possible pathways:-Stored in adipocytes-Move to muscle cells

For fat storage in adipocytes,the triacylglycerol is cleaved on the wall of blood vessel by lipoprotein lipase into fatty acid and glycerol.

Then it will move to adipocyte cells and stored as fat droplets.

However, if the person exercise or do hard chorus after that, the fat then will be utilized by muscle cells as energy through beta-oxidationto form carbon dioxide and ATP.

Up to this point we have described dietry fatty acid pathway either stored in the adipocytes or immediately utilized.

During strenous exercise,muscle use up the small amount of the body’s stored glycogen. So, in order to compensate that insufficientenergy, the energy that stored as fat droplets in adipocytes is released.

Epinephrin or glucagon leaves bloodstream and binds to adipocytes receptor.

This will allow adenylate cyclase to convert ATP into cAMP.

Then, cAMP will bind to proteinkinase and activates it.

Activated protein kinase willProceeds to bind to triacylglycerol lipase and activating it.

Once activated, the triacylglycerol lipase is able to break triacylglycerol intofatty acid and glycerol.

Then fatty acid molecules are pick up by the protein albuminin the blood stream.

Serum albumin travels throughthe blood vessels and release the fatty acid molecules into myocytes.

Finally, the fatty acid will undergo beta-oxidation to produce carbon dioxide and ATP

Complication of Pancreatitis.

Early complications

infections

Malnutrition

Abdominal swelling

Systemic inflammatory response

High blood glucose

Severe respiratory failure

Late complications

Recurrent pancreatitis

Pancreatitic pseudocyst

Acute necrotizing pancreatitis

Early complicationsInfection. • make pancreas vulnerable to bacteria and infection inflammations

interruption to blood supply necrosis• require intensive treatment, such as surgery to remove the infected tissue.

Diabetes. • Damage to insulin-producing cells in pancreas• from chronic pancreatitis can lead to diabetes• affects the way our body uses blood sugar.

Kidney failure• can be treated with dialysis if the kidney failure is severe and persistent.

Malnutrition. • Both acute and chronic pancreatitis can cause pancreas to produce fewer of the

enzymes that are needed to break down and process nutrients from the food• lead to malnutrition, diarrhea and weight loss, even though patient may be eating

the same foods or the same amount of food..

Pleural effusion pain

Shallow breathing

Breathing problems.

Lung collapseSevere

respiratory complications

Pancreatic enzymes may attack the lungs inflammation

Severe inflammation

lead to intra-abdominal hypertension

and abdominal compartment syndrome

impaired renal and respiratory function

Late complicationsRecurrent pancreatitis• Pancrease permanently damaged & chronic pancreatitis develops

Pseudocyst. • fluid and debris to collect in cyst-like pockets in pancreas and walled off by scar tissue• may cause pain, become infected, rupture and bleed• May cause bloating, indigestion and a dull abdominal pain

Acute necrotizing pancreatitis• pancreatic abscess (a collection of pus caused by necrosis, liquefaction and infection)• Hypovolemic shock (ascites decreasing the blood volume & BP)• Prone to infection bacteremia multiple organ failure

Pancreatic cancer.• Long-standing inflammation in pancreas caused by chronic pancreatitis is a risk factor

for developing pancreatic cancer

Treatment and management of acute

pancreatitis

Aim of treatment

1.Focus on relieving the symptoms2.Preventing further complication 3.Support body functions

Treatment & management • Determine and treat etiology (avoid alcohol)• No solid food should be taken by mouth for a

few days (bowel rest)• Adopt a liquid diet consisting of foods like

soups. These simple foods may allow the inflammation process to get better.

• Administration of pain killer• IV replacement of fluids • If the attack lasts longer than a few days,

nutritional supplements are administered through an IV line.

Treatment & management• Nasogastric (NG) tube. The thin, flexible plastic tube

is inserted through the nose and down into the stomach to suck out the stomach juices. This suction of the stomach juices rests the intestine further, helping the pancreas recover

• By giving antiemetic• Prevent infection by antibiotic• Indication to surgery if pancreatitis not respond to

treatment

INVESTIGATION OF ACUTE PANCREATITIS

PANCREATIC ENZYME

• Amylase- after 2 to 12 hours- 23-85 U/L (normal range)- Most accurate diagnosed when at least twice of normal range

• Lipase– 4 to 8– 0-160 U/L (normal range)– Increased sensitivity in alcohol-induced

pancreatitis– more specific and sensitive than amylase for

detecting acute pancreatitis

Complete blood count (CBC) and hematocrit;

• Normal hematocrit value Male: 38.8-50.0 percent

Female: 34.9-44.5 percent• To evaluate RBC count• To evaluate WBC count

Trypsinogen activation peptide

• Within a few hours• Early marker for acute pancreatitis and close

correlation to severity

Blood glucose test

• Pancreas released insulin to handle level of blood glucose

• In pancreatitis, - pancreas may does not make enough insulin- The insulin does not work properly

• Using fasting blood glucose level• Normal value (3.9 to 5.5 mmol/L)

Why do abdominal X-ray?

• Acute pancreatitis- low sensitivity- localised ileus (blockage of intestine)- colon cut-off sign ( dilated colon to colon with no air seen beyond the splenic flexure. This is due to extension of inflammation along mesocolon)- pleural effusion

• Chronic pancreatitis- calcification