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