Pancreatic Disorders Overview

Pancreatic Disorders Overview

• The pancreas is a dual-function gland, acting as both an endocrine and exocrine gland
• The exocrine portion of the pancreas produces digestive enzymes crucial for protein breakdown in the small intestine
• The endocrine component of the pancreas makes insulin, a key hormone regulating blood sugar levels (99% of pancreas is exocrine and 1% is endocrine)
• Insulin facilitates glucose uptake by cells, preventing blood sugar from spiking

Acute Pancreatitis

• Inflammation of the pancreas is known as pancreatitis
• Common causes include chronic alcohol use and gallstones
• Plays a role in diabetes mellitus
• Pancreatic cancer may follow chronic pancreatitis or arise from other causes
• Often detected at an advanced stage, impacting prognosis due to potential spread to other body areas
• Accounts for 3% of all cases requiring hospital admission due to abdominal pain
• Majority (80%) cases show favorable outcomes
• Severe form causes approximately 20% of deaths, often within the first week, mostly due to multi-organ failure

Causes of Acute Pancreatitis

• Common (90%): Gallstones, alcohol
• Rare: Idiopathic, post-ERCP, post-surgical (abdominal, cardiopulmonary bypass), trauma, drug side effects (various), metabolic problems, infections (mumps, Coxsackie virus), hereditary disorders, organ transplantation, severe hypothermia, petrochemical exposure

Acute Pancreatitis - Pathophysiology

• Traditional theories include toxic-metabolic or oxidative stress hypotheses where normal zymogen processing/release is disrupted by a stressor.
• Ductal obstruction is also proposed, as a mechanical problem caused by plugs or stones affecting the integrity of acinar cells (frequent in cases involving alcohol and tropical disease).

Acute Pancreatitis - Prognosis

• Glasgow criteria help assess prognosis based on indicators like age, blood oxygen levels, blood cell count, albumin, calcium, glucose, urea, enzymes, and lactate dehydrogenase.
• Higher number of criteria met indicates a more severe case.

Acute Pancreatitis - Clinical Features

• Severe, constant upper abdominal pain
• Nausea, vomiting
• Quiet/absent bowel sounds
• Oliguria (low urine output)
• Hypovolemic shock
• Discoloration of flanks (Grey Turner's sign) or periumbilical region (Cullen's sign) (suggests severe haemorrhaging)

Acute Pancreatitis - Complications

• Systemic inflammatory response syndrome
• Hypoxia
• Hyperglycemia
• Hypocalcemia
• Reduced serum albumin
• Pancreatic necrosis
• Abscess
• Pseudocyst
• Pancreatic ascites or pleural effusion
• Gastrointestinal issues (bleeding, erosion, thrombosis)

Acute Pancreatitis - Investigations

• Elevated serum amylase or lipase
• Ultrasound
• CT scans
• Plain X-rays (for ruling out other problems like perforation or obstruction and identifying pulmonary complications)

Chronic Pancreatitis

• Chronic inflammatory disorder
• Fibrosis and destruction of exocrine pancreatic tissue
• Leads to loss of exocrine/endocrine functions—increased risk of diabetes mellitus in advanced cases
• Recurrent acute pancreatitis or persistent pain characteristics, showing patterns of inflammatory and fibrosing conditions

Chronic Pancreatitis - Classification

• Toxic-metabolic (alcohol, smoking, hypercalcemia)
• Idiopathic
• Genetic (autosomal dominant/recessive, modifier genes)
• Autoimmune (isolated or with other conditions)
• Recurrent/severe acute pancreatitis
• Obstructive (pancreas divisum, sphincter issue)

Chronic Pancreatitis - Clinical Presentation

• Pain
• Weight loss and malnutrition
• Pancreatic insufficiency (endocrine & exocrine)
  • Endocrine: Pancreatic diabetes (type 3c), global loss of insulin/glucagon, paradoxical peripheral enhancement and reduced hepatic response to insulin, brittle diabetes
  • Exocrine: Diarrhoea, steatorrhea

Chronic Pancreatitis - Diagnosis

• Suspected based on clinical history and imaging studies
• Lab tests: serum amylase or lipase (elevation), elevated liver function tests (bilirubin/alkaline phosphatase may indicate bile duct obstruction)
• Imaging: ultrasound, CT, abdominal X-rays, MRCP, endoscopic ultrasound
• Collection of pure pancreatic juice (after secretin injection, gold standard but invasive)
• Pancreolauryl test, fecal pancreatic elastase tests

Chronic Pancreatitis - Autoimmune Type

• AIP (autoimmune pancreatitis)
• Mimics cancer but responds to corticosteroids
• Abdominal pain, weight loss/obstructive jaundice without acute attacks of pancreatitis, high serum IgG or IgG4 levels, presence of other autoantibodies
• Imaging shows a diffusely enlarged pancreas, narrowing of the pancreatic duct, lower bile duct stricturing