Acute and Chronic Pancreatitis

Acute and Chronic Pancreatitis By Dr. Zahoor1ObjectivesWe will study 1. Pancreas normal structure and function 2. Acute Pancreatitis pathogenesis, presentation, investigation and treatment 3. Chronic Pancreatitis pathogenesis, presentation, investigation and treatment 2PancreasStructure and FunctionPancreas lies retroperitoneally across the posterior abdominal wall from the second part of duodenum to the spleenPancreatic head is encircled by the duodenum and tail is in contact with spleenPancreas has exocrine cells 98% and endocrine cells 2% 34

Pancreas Anatomy Structure and FunctionsPancreasThe main pancreatic duct joins the common bile duct to enter the duodenum as a single duct at the ampulla of valter

What is the importance?Gall stones or cholecystitis can cause pancreatitis 56

Clinical presentation of Gallstones PancreasExocrine Function of PancreasThe pancreas Acinar cells produce digestive enzymes amylase, lipase, colipase and proteases Trypsinogen and Chymotrypsinogen

7PancreasEndocrine Function of PancreasHormone producing cells are islets of langerhans secrete hormone There are five types of islets cells 1. Beta cells secrete insulin 2. Alpha cells secrete glucogan 3. D Cells secrete Somatostatin 4. PP cells produce pancreatic polypeptide 5. Entrochromaffin cells produce serotonin 8PancreatitisPancreatitis is divided into 1. Acute Pancreatitis 2. Chronic Pancreatitis

We will discuss each one 9Acute PancreatitisIt is acute inflammation of pancreas, which occurs in previously normal pancreas and returns to normal after resolution.10

Causes of Acute PancreatitisPathogenesis of Acute PancreatitisIt is due to activation of digestive enzyme Trypsinogen to Trypsin within pancreas, may be caused by rise in intracellular Ca2+ which may trigger it May be due to impairment of Trypsin degradation Activated enzyme Trypsin causes cellular nacrosis

11Pathogenesis of Acute PancreatitisGall stones cause pancreatitis by blocking pancreatic drainage at the level of ampulla Alcohol interferes with Ca2+ homeostasis in pancreatic Acinar cells 12Clinical Features of Acute PancreatitisPain in epigastric region accompanied by nausea and vomiting. Pain radiates to the back.Inflammation spreads throughout the peritoneal cavity. Involvement of retro peritoneum leads to back pain.

13Clinical Features of Acute PancreatitisPatient may give history of gall stones or alcohol intake In severe cases, there may be hypotension, tachycardia, and oligurea

14Clinical Features of Acute PancreatitisAbdominal examination - May show tenderness and guarding and reduced or absent bowel sounds

Specific clinical signs in severe necrotizingPancreatitisCullen signs periumblical bruisingGreyturners sign flank bruising

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Greyturners signDiagnosis of Acute Pancreatitis Blood testSerum amylase increased three times more than normal within 24 hours of onset of pain Amylase falls back to normal in 3-5 days Serum Lipase increased

Urine amylase

Do other base line investigations - Blood count, urea and electrolyte, blood glucose, liver biochemistry, plasma calcium, arterial blood gases - They help in assessing the severity of the attack18Diagnosis of Acute Pancreatitis RadiologyErect X-ray abdomen to exclude gastroduodenal perforation Supine abdominal film may show gall stones or pancreatic calcification Abdominal Ultrasound - To look for gall stones in common bile duct, dilated intrahepatic duct, also for pancreatic swelling, nacrosis, and peripancreatic fluid collection 19Radiology (cont)Contrast enhanced CT scan Should be performed after 72 hours to see for pancreatic necrosis CT can detect fluid collection, abcess formation and pseudocyst developmentMRI and MRCP (Magnetic Resonance cholangiopancreatography) for pancreatic duct and Biliary treeEndoscopic retrograde cholangiopancreatography (ERCP) used as treatment to remove the duct stones in gall stone related pancreatitis 20Pancreatitis Assessment of Disease Severity 21

ACUTE PANCREATITIS GLASGOW CRITERIAP - PaO2 < 8kPaA - Age > 55 yearsN - Neutrophalia WBC > 15 109 /lC - Calcium < 2 mmol/lR - Renal function urea > 16 mmol/lE - Enzyme LDH > 600 iu/l, AST > 200 iu/lA - Albumin < 32g/lS - Sugar blood glucose > 10 mmol/lIf patient score 3 or more, it indicates severe pancreatitis and patient should be transferred to ITU22PancreatitisAssessment of Disease Severity Majority of cases of pancreatitis are mild and run short self limiting course But about 25% cases run complicated course and 10% may be life threatening Increased CRP > 200mg/L in first four days signifies severity 2324

Abdominal CT showing swollen pancreas25

CT Abdomen showing pancreatic pseudocyst (Ps cyst)TreatmentIV fluids Nasogastric suction prevents abdominal distension and vomitus and decreases risk of pneumonia Blood gases will guide for O2 administrationAntibiotic Cefuroxime (reduces incidence of pancreatic nacrosis)Analgesia Pethidine or Tramadol (Avoid morphine as it causes contraction of sphincter of ODDI) 2627

Long term outcomeMild and moderate cases of pancreatitis usually make full recoverySevere acute pancreatitis may cause pancreatic insufficiency. Both exocrine (malabsorption) and endocrine (diabetes).

28CHRONIC PANCREATITIS29Chronic PancreatitisIn developed countries, cause of chronic pancreatitis is alcohol in 60-80% cases. Other causes can be metabolic, genetic, autoimmune

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Causes of Chronic PancreatitisChronic PancreatitisPathogenesis Increased activated trypsin or impaired clearance of trypsin Increased trypsin leads to precipitation of protein within the pancreatic duct lumen in the form of plugs and causes duct obstructionIncrease alcohol causes chronic pancreatitis by impairing Ca2+ regulation which promotes Trypsinogen activation to trypsin 31Chronic PancreatitisGenetic aspect of chronic pancreatitisGenetic factors may be responsible for trypsin activations e.g. cystic fibrosis CFTR (cystic fibrosis transmembrane conductance regulator) in apical surface of Acinar cells Auto immune chronic pancreatitis (ACP) There is increased IgG4 level, this process is not dependent on trypsin 32Chronic PancreatitisClinical features Pain epigastric region, radiates to the back Anorexia and weight loss Exocrine and endocrine insufficiency may develop i.e. malabsorption or diabetes may be presenting feature 33InvestigationSerum amylase and lipase may be increased Faecal elastase abnormal (decreased) in majority of cases of chronic pancreatitisTransabdominal ultrasound scan Contrast enhanced spiral CT-scan - provides more assessment for calcification in dilated pancreatic duct 3435

Contrast CT showing multiple calcification in pancreasInvestigationMRI and MRCP (magnetic resonance cholangiopancreatography) Endoscopic ultrasounds for assessing complication including pseudocyst formation Diagnostic ERCP (endoscopic retrograde cholangiopancreatography) it has been replaced by MRCP 36Treatment of Chronic PancreatitisChronic pancreatitis if alcohol related then long term abstinence is advised For abdominal pain - Opiate Tramadol - NASAID (Non steroidal anti-inflammatory drugs) - For chronic pain, amitryptyline (tricyclic antidepressants) - Stent of pancreatic duct to maintain duct patency 37Treatment of Chronic PancreatitisFor Steatorrhea - Pancreatic enzymes - H2 receptor antagonist or proton pump inhibitors to neutralize acidity in duodenum

Diabetes due to pancreatic disease may need insulin 38Complications of Chronic PancreatitisPancreatic pseudocyst (fluid collection surrounded by granulation tissue) If pseudocyst is < 6cm in diameter, spontaneous resolution may occur Pseudocyst can be drained endoscopically, using endoscopic ultrasound 39Complications of Chronic PancreatitisOther complication of chronic pancreatitis - Ascites - Pleural effusion (rare) increased amylase in pleural fluid will confirm the etiology - Increased risk of cancer in chronic pancreatitis

40Additional Information Clinical Syndromes - pancreasInsulinoma Gastrinoma VIPoma GlucagonomasSomatostatinomas 41Insulinomas Insulinomas are pancreatic cell tumor, derived from beta cells that secret insulin Classic presentation is fasting hypoglycemia Other presenting feature may be sweating, palpitation, weakness Diagnosis is confirmed by demonstration of hypoglycemia with normal or elevated insulin level42Gastrinoma There is hyper secretion of gastric acid secondary to ectopic gastrin secretion within endocrine pancreas Zollinger - Ellison SyndromePatient has recurrent severe duodenal ulcerationDiagnosis is confirmed by elevated gastrin levelHigh dose proton pump inhibitors are used to suppress the symptoms 43VIPoma Endocrine pancreatic tumor producing VIP (Vasoactive Intestinal Polypeptide)This causes severe secretary diarrhea due to stimulation of Adenyl cyclase Verner -Morrison Syndrome (clinical syndrome causing profuse watery diarrhea, hypokalemia and metabolic acidosis)

44GlucagonomasGlucagonomas are -cell tumors responsible for migratory necroletic dermatitis, weight loss, diabetes mellitus, deep vein thrombosis, anemia and hypoalbumiaemia Diagnosis is made by measuring pancreatic glucogan in the serum

45Somatostatinomas Somatostatinomas are rare malignant D cell tumors of the pancreasThey cause diabetes mellitus, gall stones, diarrhea, Steatorrhea They can be diagnosed by high serum somatostatin level46THANK YOU47