Internal Diseases and Therapy · MU Sofia

105. Acute and chronic pancreatitis

Explains how the pancreas's digestive enzymes are activated too early in acute pancreatitis, with alcohol and gallstones given as main causes and a list of other aetiologies, including a mnemonic. Covers clinical signs, including Cullen's sign shown in a picture, diagnostic tests, complications and supportive treatment. Then describes chronic pancreatitis as fibrosis and calcification following repeated acute episodes, with its imaging diagnosis, complications and treatment.

Inside: 1 section · 2 labelled pictures · 15 flashcards · 3 min

Topic 106 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 1 section, about 481 words (3 min of reading), with 15 flashcards.

In this note

  1. Acute and chronic pancreatitis

Acute and chronic pancreatitis

Acute pancreatitis

  • The exocrine part of the pancreas secretes digestive enzymes into the duodenum that break down carbohydrates, lipids and proteins. As these are found in the pancreas itself, the pancreas secretes inactive forms, which are then activated by proteases in the duodenum.
  • If these enzymes activate too early, they can cause acute pancreatitis. One such example is the enzyme Trypsinogen.
  • Etiology:
  • Alcohol induced
  • Alcohol increases trypsinogen secretion but decreases fluid and bicarbonate in the pancreatic ducts. This thickens the pancreatic juices, and makes them very viscous.
  • The viscous pancreatic fluid can form a plug in the pancreatic duct, causing backing up of the juices.
  • This can cause the inactive Trypsinogen to fuse with lysosomes, converting it to Trypsin and activating it.
  • Trypsin, now active then begins autodigestion of the pancreas
  • Gallstones
  • Gallstones can get lodged in the sphincter of Oddi (where both the common bile duct and pancreatic duct come together to excrete into the duodenum). This blockage once again causes clogging of the pancreatic duct and therefore a build up of pancreatic juices.
  • From here the pathogenesis is the same as the alcohol induced form.
  • Other causes are Idiopathic, trauma (puncture), steroids, mumps autoimmune disease, scorpion sting, hypercalcemia, endoscopic retrograde cholangiopancreatography and drugs (I GET SMASHED). Additionally, Cystic Fibrosis can cause acute pancreatitis, due to the fact it makes pancreatic secretions thicker.
  • Eventually, acute pancreatitis can lead to pancreatic tissue destruction, triggering an inflammatory response, and liquefactive hemorrhagic necrosis.
  • Clinical signs
  • Nausea
  • Vomiting
  • Pain & tenderness (steady, persists for days, in epigastric region, often radiates to back)
  • Hypocalcemia
  • Bruising around belly button and flank
  • Diagnosis can be through labs (increased amylase and lipase serum) and CT or MRI imaging
  • Although note, other causes of increased amylase and lipase include intestinal ischemia, bowel obstruction, cholecystitis and choledocholithiasis
  • Complications include pancreatic pseudocyst which itself can become an abscess, rupture and others. Additionally, bleeding, disseminated intravascular coagulation and acute respiratory distress syndrome can all occur.
  • Treatment is general supportive care that allows patient to recover within days. Pain control and antiemetics with regular hydration.

Cullen's sign in acute pancreatitis: a bluish-purple ecchymosis in the periumbilical abdominal wall.

Image: “Cullen's sign” by Herbert L. Fred, MD and Hendrik A. van Dijk, CC BY 2.0, via Wikimedia Commons.

Chronic Pancreatitis

  • Often due to repeated bouts of acute pancreatitis

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