pancreatitis
TRANSCRIPT
UNIVERSITY OF THE GAMBIAUNIVERSITY OF THE GAMBIA
SCHOOL OF MEDICINE & ALLIED HEALTH SCHOOL OF MEDICINE & ALLIED HEALTH SCIENCESSCIENCES
ACADEMIC YEAR 2007-2008ACADEMIC YEAR 2007-2008
MEDICAL PROGRAMME4th YEAR SECOND SEMESTER
MEDICINE I
COURSE 2007 - 2008
Dr Ygber Luis Gonzalez de la CruzDr Ygber Luis Gonzalez de la Cruz
Consultant phycisian Consultant phycisian
R.V.T.HR.V.T.H
Visiting Lecturer Visiting Lecturer
PancreatitisPancreatitis
Acute PancreatitisAcute Pancreatitis
Is a clinical syndrome defined by a discrete Is a clinical syndrome defined by a discrete episode of abdominal pain and elevations in episode of abdominal pain and elevations in serum enzyme levelsserum enzyme levels
Inflammation of the pancreas with varying Inflammation of the pancreas with varying amounts of injury to adjacent and distant amounts of injury to adjacent and distant organsorgans
more than 80% of the cases are related to more than 80% of the cases are related to biliary stones or alcohol usebiliary stones or alcohol use
The criteria for diagnosing Pancreatitis The criteria for diagnosing Pancreatitis areabdominal pain, fever, and jaundice, along areabdominal pain, fever, and jaundice, along with physical findingswith physical findings
Etiologic factorsEtiologic factors
Acute Pancreatitis
Interstitial Pancreatiti
s
Necrotizing
Pancreatitis
PATHOLOGYPATHOLOGY
InterstitialInterstitial
1.1. The gland is edematous, but its The gland is edematous, but its gross architecture is preservedgross architecture is preserved
2.2. Parenchymal inflammatory cells are Parenchymal inflammatory cells are present present
3.3. Reduced enzyme secretionReduced enzyme secretion
4.4. Partial cell necrosis may allow the Partial cell necrosis may allow the acinus to regenerate rapidly after acinus to regenerate rapidly after injury.injury.
Necrotizing PancreatitisNecrotizing Pancreatitis
Marked tissue necrosis and Marked tissue necrosis and hemorrhagehemorrhage
Surrounding areas of fat necrosis Surrounding areas of fat necrosis Large hematomas often are located Large hematomas often are located
in the retroperitoneal spacein the retroperitoneal space Vascular inflammation and Vascular inflammation and
thrombosis are common.thrombosis are common.
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Three major pathological processes Three major pathological processes within the acinar cellwithin the acinar cell
1.1. Inactive digestive zymogens are Inactive digestive zymogens are converted into active enzymesconverted into active enzymes
2.2. Pancreatic exocrine secretion is Pancreatic exocrine secretion is inhibitedinhibited
3.3. The pancreas generates pro-The pancreas generates pro-inflammatory mediatorsinflammatory mediators
Activation of Pancreatic Activation of Pancreatic ZymogensZymogens
May be the first step in a process May be the first step in a process that leads to pancreatic auto-that leads to pancreatic auto-digestiondigestion
Potential consequences are Potential consequences are
1.1. damaging local effectsdamaging local effects
2.2. Attack on other tissuesAttack on other tissues
3.3. Promotion or activation of additional Promotion or activation of additional pathways leading to tissue injurypathways leading to tissue injury
Inhibition of SecretionInhibition of Secretion
Retention of active enzymes within Retention of active enzymes within the acinar cell instead of their the acinar cell instead of their secretion into the pancreatic ductsecretion into the pancreatic duct
DIAGNOSISDIAGNOSIS
Presence of severe abdominal painPresence of severe abdominal pain Biochemical evidence of pancreatic Biochemical evidence of pancreatic
injuryinjury
SymptomsSymptoms
PainPain
1.1. Occurs in 95% of patientsOccurs in 95% of patients
2.2. Often located in the epigastric and Often located in the epigastric and umbilical regionumbilical region
3.3. Deep, visceral pain is among the Deep, visceral pain is among the most severe describedmost severe described
4.4. Nausea and vomiting are present in Nausea and vomiting are present in 85% 85%
SignsSigns
Low-grade fevers are reported in 60% of Low-grade fevers are reported in 60% of patientspatients
Tachycardia and hypotension are found in Tachycardia and hypotension are found in up to 40% of patientsup to 40% of patients
Abdominal tenderness and guardingAbdominal tenderness and guarding Bowel sounds are decreased or absentBowel sounds are decreased or absent Pleural effusionsPleural effusions Mild jaundiceMild jaundice Dark discoloration in the back, flank, or the Dark discoloration in the back, flank, or the
para-umbilical regionpara-umbilical region
Grey Turner’s sign in acute pancreatitis
Markers of Pancreatic Markers of Pancreatic InjuryInjury
A number of factors influence the A number of factors influence the level of serum markers of level of serum markers of PancreatitisPancreatitis
1.1. Serum levels of pancreatic enzymes Serum levels of pancreatic enzymes are the sum of tissue production, are the sum of tissue production, release into the blood, and release into the blood, and clearanceclearance
2.2. In patients with renal failure, the In patients with renal failure, the serum amylase may increaseserum amylase may increase
Measured enzyme activities may be Measured enzyme activities may be influenced by a number of “serum influenced by a number of “serum factors” as hyperlipidemiafactors” as hyperlipidemia
Enzymes may be produced from non-Enzymes may be produced from non-pancreatic tissuespancreatic tissues
Standard enzyme assays, such as Standard enzyme assays, such as amylase and lipase, provide no amylase and lipase, provide no information on the severity of the information on the severity of the pancreatitispancreatitis
Markers of Pancreatic Markers of Pancreatic InjuryInjury
AmylaseAmylase LipaseLipase Urinary enzymes (urinary Urinary enzymes (urinary
trypsinogen 2)trypsinogen 2) Trypsinogen activation peptide Trypsinogen activation peptide
Inflammatory MarkersInflammatory Markers
Inflammatory cells release Inflammatory cells release neutrophil-specific elastaseneutrophil-specific elastase
Interleukin-6 (IL-6)Interleukin-6 (IL-6) C-reactive proteinC-reactive protein
Markers of Biliary Tract Markers of Biliary Tract InvolvementInvolvement
alanine aminotransferase (ALT)alanine aminotransferase (ALT) Ratio of lipase to amylaseratio of Ratio of lipase to amylaseratio of
lipase to amylase in alcoholiclipase to amylase in alcoholic Serum bilirubin level over 3Serum bilirubin level over 3
ImagingImaging
Abdominal Radiographs to exclude Abdominal Radiographs to exclude non-pancreatic diseasesnon-pancreatic diseases
Radiographic findingsRadiographic findings
1.1. Pleural effusionsPleural effusions
2.2. Intestinal gas patterns may Intestinal gas patterns may demonstrate an ileus patterndemonstrate an ileus pattern
3.3. Isolated dilated loop of small bowel Isolated dilated loop of small bowel overlying the pancreasoverlying the pancreas
4.4. Colon cutoff signColon cutoff sign
5.5. Loss of the psoas marginsLoss of the psoas margins
6.6. Pancreatic calcification or calcified Pancreatic calcification or calcified gallstonesgallstones
SonographySonography
1.1. appears hyp-oechoicappears hyp-oechoic Computed TomographyComputed Tomography
1.1. Pancreatic enlargementPancreatic enlargement
2.2. Inhomogeneity of the pancreatic Inhomogeneity of the pancreatic parenchymaparenchyma
3.3. Fluid infiltrating the peri-pancreatic Fluid infiltrating the peri-pancreatic fat fat
Endoscopic CholangiopancreatographyEndoscopic Cholangiopancreatography
LOCAL COMPLICATIONSLOCAL COMPLICATIONS
Acute Fluid CollectionsAcute Fluid Collections Necrosis and Infected NecrosisNecrosis and Infected Necrosis PseudocystsPseudocysts Pancreatic AbscessesPancreatic Abscesses Ascites and FistulaeAscites and Fistulae Vascular and Splenic ComplicationsVascular and Splenic Complications Gastrointestinal ObstructionGastrointestinal Obstruction Gastrointestinal ObstructionGastrointestinal Obstruction