Pancreatitis PDF - Lecture Notes

Lecture Material is adapted from © 2017 Wolters Kluwer Health, Lippincott Williams & Wilkins Applied Pathophysiology: A Conceptual Approach to the Mechanisms of Disease Chapter 3: Inflammation and Tissue Repair Module 4: Clinical Models Dr. Romeo Batacan Jr. MPAT12001 Medical Pathophysiology Lec...

Lecture Material is adapted from © 2017 Wolters Kluwer Health, Lippincott Williams & Wilkins Applied Pathophysiology: A Conceptual Approach to the Mechanisms of Disease Chapter 3: Inflammation and Tissue Repair Module 4: Clinical Models Dr. Romeo Batacan Jr. MPAT12001 Medical Pathophysiology Lecture Series Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins  Pancreatitis Clinical Pathophysiology Diagnosis Treatment manifestations Pathophysiology of Acute Pancreatitis Acute pancreatitis (sudden inflammation of the pancreas): injury of 1. acinar cells 2. zymogen 3. pancreatic duct 4. protective digestive feedback mechanism of exocrine pancreas Cause: 1. Excessive alcohol consumption 2. Gallstones 3. Idiopathic (unknown) Alcohol is a major cause of pancreatic autodigestion by triggering: Intracellular accumulation of digestive enzymes https://www.pancreasfoundation.org/patient- information/acute-pancreatitis/acute-pancreatitis- diagnosis-and-treatment/ Premature enzyme activation and release Increased permeability of ductules and easy passage of enzymes to the parenchyma Increased protein content of pancreatic secretions and creation of protein plugs  Pathophysiology of Acute Pancreatitis Craft AJ, Gordon C, Tiziani A. Understanding pathophysiology. 1st ed. Chatswood, Mosby; 2011 Clinical Manifestations of AcutePancreatitis http://www.mayoclinic.org/diseases- conditions/pancreatitis/symptoms-causes/dxc-20252598 Related to the inflammatory response occurring in the pancreas pain digestive signs and symptoms inflammation Manifestations include: Upper abdominal pain of sudden onset (often referred to as epigastric pain) growing in intensity leading to a dull, steady ache often radiating to the back Nausea Vomiting Anorexia Diarrhea Marieb EN, Hoehn KN. Human Anatomy & Physiology. 9th ed. Boston, Pearson Education; 2013 Diagnostic Criteria of AcutePancreatitis Patient history Physical examination Laboratory testing for inflammation Blood count (WBC numbers increased) ESR (increased) Indicates the presence of inflammation CRP (increased) Specific laboratory test Serum amylase and lipase: elevated in acute pancreatitis both are digestive enzymes that are excessively released with inflammation of the pancreas Serum alkaline phosphatase, total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT): liver enzymes elevated in cases of pancreatitis caused by gallstones Imaging studies: ultrasound, CT, MRI – to identify location and cause of pancreatic injury Treatment of Acute Pancreatitis Aims: 1. to eliminate the cause of pancreatic injury 2. stop autodigestion 3. care for the symptoms 4. prevent systemic complications IV hydration in the first 24 hours NPO (nil-per-os: nothing by mouth) – to decrease secretion and rest gland Pain management (analgesics) Mild pancreatitis No nausea/vomiting: oral feeding Severe pancreatitis Requires ICU care Possibility of shock, renal failure, multiple organ failure Successful treatment: No pain Able to take adequate nutrition No complications Chronic Pancreatitis Ongoing inflammatory process of the pancreas Irreversible cellular changes Exocrine and endocrine tissue is replaced Irreversible tissue changes by scar tissue due to chronic inflammation and fibroblast proliferation Differs from acute pancreatitis Duration Irreversibility of lost functions: 1. Impact on exocrine functions of the pancreas 2. Impact on the endocrine functions in advanced cases: loss of islet cell function – insulin dependent diabetes Cause 1. 60-70% chronic alcohol abuse 2. 10%~ autoimmune or hereditary 3. 20~ idiopathic, results of recurrent acute pancreatitis Pathophysiology of Chronic Pancreatitis Alcohol Alcohol triggers (as described in acute pancreatitis) Enzyme activation and release Autodigestion Pancreatic ducts become obstructed Obstruction leads to ischemia of cells Acinar cells become atrophic and fibrotic Resulting in loss of function Chronic alcohol abuse leads oxidative stress (liver metabolise alcohol, ROS are formed naturally during the process) Promoting further cellular injury, organ damage Pathophysiology of Chronic Pancreatitis Autoimmune conditions: Aetiology is unknown High level of autoantibodies against the pancreas Diffuse enlargement of pancreas Narrowing of ducts Other autoimmune disorders Renal tubular acidosis (disrupt metabolic processes) Cystic fibrosis (leads to chronic pancreatic insufficiency and inflammation) Recurrent acute pancreatitis Promote state of fibrosis and necrosis  Clinical Manifestations of Chronic Pancreatitis development of disease: several months to years before the onset of symptoms severe intermittent episodes of abdominal pain (mid or upper right-sided, radiating to the back) lasting several hours unpredictable intervals as a result of damage to the digestive functions of the exocrine pancreas after 90% of the pancreas has been destroyed diarrhea steatorrhea (fatty stools) weight loss Diagnostic Criteria of Chronic Pancreatitis Gold standard: Endoscopic retrograde cholangiopancreatography (ERCP) stomach and duodenum are visualized through an endoscope radiographic contrast dye is injected into the ducts of the biliary tree and pancreas obstructed pancreatic pathways can be seen on radiographs Serum amylase and lipase levels: may be elevated during exacerbations of disease over time normal to low Fibrotic changes in pancreas Loss of exocrine function Enzymes can no longer be concentrated Direct aspiration of pancreatic duct or duodenum test levels of bicarbonate and enzymes A: Normal biliary and pancreatic ducts during an ERCP; B: ERCP image expensive and invasive http://www.hopkinsmedicine.org/gastroenterology_hepatology/clinical_services/advanced_endosc opy/endoscopic_retrograde_cholangiopancreatography.html  Marieb EN, Hoehn KN. Human Anatomy & Physiology. 9th ed. Boston, Pearson Education; 2013 Endoscopic retrograde cholangiopancreatography (ERCP) illustrates moderate dilation of the main pancreatic duct and ectasia (dilation) of the secondary ducts associated with moderately advanced chronic pancreatitis. Arrows indicate intraductal pancreatic stones. Treatment of Chronic Pancreatitis 1. Based on the cause Risk factor for pancreatic cancer 2. Focused on healing Includes: Pain management Behavior modification to promote a healthy lifestyle: alcohol cessation, smoking cessation, exercise, quality nutrition (fat-free) Surgical intervention to correct: cyst (due to walled off pancreatic juice, necrotic debris), abscess obstruction, fistula formation (due to fibrosis, strictures) partial gland resection