Pancreatitis

Question 1

Features of acute pancreatitis

Answer 1

• normally pancreatic enzymes are stored within secretory granules as zymogens
• sudden escape of active lytic pancreatic enzymes into the glandular parenchyma - enzymic destruction (autodigestion)
• triggered by inappropriate activation of trypsinogen, proenzymes etc

Question 2

Causes of acute pancreatitis

Answer 2

1. Gallstones - biliary obstruction
2. Ethanol - alcohol has a direct toxic effect
3. Trauma
4. Steroids
5. Mumps, infections, malignancy
6. Acute ischemia - shock, thrombosis, vasculitis
7. Surgery
8. Hyperlipidemia, hypercalcemia, metabolic disorders
9. ERCP
10. Drugs (others eg furosemide, azathioprine)
11. Hereditary

Question 3

Pathogenesis of acute pancreatitis

Answer 3

1. Initiating event
   - duct obstruction - interstitial edema - impaired blood flow - ischemia
   - accumulation of lipases - local fat necrosis
   - acinar cell injury (alcohol, drugs, trauma, ischemia, infection) - release of intracellular proenzymes & lysosomal hydrolases - activates proenzymes
2. Further acinar cell injury - activates enzymes, leading to
   - interstitial inflammation & edema
   - proteolysis (proteases)
   - fat necrosis (lipases, phospholipases)
   - hemorrhage (elastases)

Question 4

Gross morphology of acute pancreatitis

Answer 4

• hemorrhagic & necrotic
• fat necrosis of adipose tissue - chalky white deposits - TGs converted into calcium soap
• if severe - pancreas hemorrhagic mass
• ‘chicken broth’ peritoneal fluid (serous, slightly turbid brown tinged fluid)

Question 5

Lab findings of acute pancreatitis

Answer 5

1. Raised bilirubin
   - edema - obstruction
2. Raised serum amylase & lipase
   - parenchymal destruction - release of enzymes
3. Glycosuria
   - destruction of pancreas - affects endocrine function (islets) & insulin secretion
4. Hypocalcemia
   - poor prognostic sign
   - increased enzyme release into blood esp lipase - disseminate - fat necrosis - calcium soap - increased calcium taken out from blood & deposited - low calcium levels - tetany (spasms)

Question 6

Effects & complications of acute pancreatitis (4)

Answer 6

1. Systemic organ failure - shock, ARDS, acute renal failure
2. Pancreatic abscess
3. Pancreatic pseudocyst - no epithelial lining, just a focus of necrotic material walled off by fibrous/gran tissue
4. Duodenal obstruction

Question 7

Features of chronic pancreatitis

Answer 7

• inflammation of the pancreas with irreversible destruction of exocrine parenchyma, fibrosis
• destruction of endocrine parenchyma in late stages
• associated with prolonged obstruction of pancreatic duct, autoimmune injury, hereditary pancreatitis

Question 8

Morphology of chronic pancreatitis

Answer 8

• atrophy & dropout of acini - loss of parenchymal cells
• dilated pancreatic ducts w protein plugs
• interlobular fibrosis & inflammatory infiltrate
• calcifications
• pseudocysts