Pancreatitis

Question 1

What are the 2 components of the pancreatic juice and where are they secreted?

Answer 1

↓ vol, viscous, enzyme-rich - Acinar cells

↑ vol, watery, HCO3- rich - Duct & Centroacinar cells

Question 2

What 3 protective mechanisms are there in the pancreas to prevent autodigestion?

Answer 2

Proteases are released as inactive pro-enzymes protects acini & ducts from auto-digestion

Pancreas contains a trypsin inhibitor to prevent trypsin activation

Enzymes only activated in duodenum

Question 3

What are pancreatic enzymes synthesised and stored in prior to activation?

Answer 3

Zymogen granules

Question 4

Where is enterokinase produced and what is its function?

Answer 4

Produced in duodenal mucosa

Converts trypsinogen into trypsin

Question 5

Trypsin function

Answer 5

Conversion of pro-proteases and some pro-lipases into active enzymes

Question 6

Difference of inflammation between acute and chronic pancreatitis

Answer 6

Question 7

Causes of acute pancreatitis

Answer 7

G – gallstones
E – ethanol (alcohol)
T – trauma
S – steroids
M – mumps and other viruses (EBV, CMV)
A – auto-immune (Polyarteritis nodosa, SLE)
S – scorpion/snake bite
H – hypercalcaemia, hypertriglyceridaemia, hypothermia
E – ERCP
D – drugs (SAND: steroids and sulphonamides, azothioprine, NSAIDS,
diuretics [loop/thiazide])

Question 8

Describe the pathogenesis of acute pancreatitis?

Answer 8

↑ permeability of pancreatic duct epithelium (Alcohol, acetylsalicylic acid, histamine)
Acinar cell enzymes diffuse into periductal interstitial tissue

Alcohol ppts proteins in ducts → ↑ upstream pressure

Pancreatic enzymes activated intracellularly
proenzymes & lysosomal proteases incorporated into same vesicles → trypsin activated

Question 9

What are the 3 types of acute pancreatitis

Answer 9

Oedematous pancreatitis

Haemorrhagic pancreatitis

Necrotic pancreatitis
(+/- superseding infection > infected necrosis)

Question 10

Give the signs of acute pancreatitis

Answer 10

Haemodynamic instability (tachycardic, hypotensive)
Peritonism in upper abdomen/generalised
Grey-Turner’s sign (bruising in flanks)
Cullen’s sign (bruising around umbilicus)

(Grey Turner’s & Cullen’s signs seen in haemorrhagic pancreatitis)

Question 11

Give the symptoms of acute pancreatitis

Answer 11

Epigastric pain radiating to back
often eased by sitting forward

N&V (vomiting +++)

Fevers

Question 12

What differential diagnoses are causative of acute pancreatitis

Answer 12

Gallstone disease & associated complications (e.g. biliary colic & acute cholecystitis)

Peptic ulcer disease/perforation

Leaking/ruptured AAA

Question 13

Outline the investigations into acute pancreatitis and what they’re each used for

Answer 13

Blood tests
Amylase/lipase
other causes of ↑ amylase include:
Parotitis
renal failure

X rays
Erect CXR
AXR (sentinal loop, GS)

USS
look for GSs as cause for pancreatitis

CT abdomen
patients not settling with conservative management & only 48-72 hrs after symptom onset

MRCP
If GS pancreatitis suspected with abnormal LFTs (CBD stone)

ERCP
To remove CBD GS

Question 14

What criteria is used to assess the severity of pancreatitis

Answer 14

Modified glasgow/ransons criteria
P – PO2 <8KPa
A – age >55yrs
N – WCC >15
C – calcium <2mmol/L
R – renal: urea >16mmol/L
E – enzymes: AST >200iu/L, LDH >600iu/L
A – Albumin <32g/L
S – sugar >10mmol/L

Score of >3 indicates severe pancreatitis

Question 15

Apart from glasgow/ranson criteria what can you use to predict severity of pancreatitis

Answer 15

CRP is an independent predictor of severity
>200 suggests severe pancreatitis

Question 16

Outline the local complications of acute pancreatitis

Answer 16

Pancreatic necrosis +/- infection (infected necrosis)
Pancreatic abscess
Pancreatic pseudocyst
Haemorrhage: due to bleeding from eroded vessels
Small vessels > haemorrhagic pancreatitis (Cullen’s/Grey Turner’s sign)
Large vessels (e.g. Splenic artery)
> life threatening bleed (unless forms pseudoaneurysm)
Thrombosis of splenic vein, SMV, portal vein (in order of frequency)
> ascites
> small bowel venous congestion/ischaemia
Chronic pancreatitis/pancreatic insufficiency (if recurrent attacks)

Question 17

Outline the systemic complications of acute pancreatitis?

Answer 17

Hypocalcaemia
lipase → FFAs → chelate Ca2+ salts → ↓ serum levels (saponification)

Hyperglycaemia (diabetes if significant beta cell damage)

SIRS (Systemic Inflammatory Response Syndrome)
ARF (Acute Renal Failure)
ARDS (Adult Respiratory Distress Syndrome)
DIC (Disseminated Intravascular Coagulation)
MOF (Multi Organ Failure) & death

Question 17

How do you manage acute infected necrotic pancreatitis

Answer 17

Antibiotics + Percutaneous Drainage

Question 18

What is a pancreatic pseudocyst

Answer 18

peri-pancreatic fluid collection
↑ [pancreatic enzymes] within a fibrous capsule
presents >6 weeks after pancreatitis

Question 19

What conditions do you need to drain a pancreatic pseudocyst under?

Answer 19

Pseudocyst symptomatic (pain)
Pseudocyst causing compression of surrounding structures e.g. CBD (obstructive jaundice), duodenum (high SBO)
Pseudocyst infected (abscess)

Question 20

What 3 methods are there of managing a pancreatic pseudocyst?

Answer 20

Percutaneously under radiological guidance (CT)
Endoscopically - EUS puncturing posterior wall of stomach & inserting stent
Surgically via laparoscopic/open:
pseudocystgastrostomy (cyst opened into stomach)
pseudocystjejunostomy

Question 21

Outline the endocrine and exocrine functions of the pancreas

Answer 21

Endocrine - 2%
Islets of Langerhans
Secrete hormones into blood - Insulin & Glucagon (also Somatostatin and Pancreatic Polypeptide)

Exocrine - 98%
Secretes pancreatic juice into duodenum via MPD/sphincter of Oddi/ampulla
Digestive function (Pancreas Lecture)

Question 22

What occurs in chronic pancreatitis?

Answer 22

Destroys endocrine & exocrine tissue → fibrosis of pancreas
IDDM & steatorrhea

Question 23

How can you manage chronic pancreatitis?

Answer 23

Endoscopically
Surgically - resection/drainage