WEEK 5 - Pancreatitis

Located posterior to the stomach between the duodenum on the right and the spleen on the left

• Head - tucked into the curve of the duodenum • Neck - 2cm long, overlies the superior mesenteric artery • Body - passes over the aorta and L2 • Tail - touches the spleen

• Endocrine portion - produces hormones 2. Exocrine portion - produces digestive enzymes and alkaline fluid

• Alpha - secrete glucagon for increasing BGLs • Beta - secrete insulin for decreasing BGLs • Delta - secrete somatostatin and gastrin • F - secrete pancreatic polypeptide, for suppression of appetite in response to meal ingestion

Lie between Acinar cells, produce and secrete hormones

Adjacent to blood vessels to allow hormones to be secreted directly into circulation

Acinar cells, secrete digestive enzymes: • Proteases, for breakdown of proteins • Amylase, for breakdown of carbohydrates • Lipase, for breakdown of fat into FFAs Ductal cells, secrete: - Alkaline fluid, for neutralising chyme and for fat digestion and absorption, released in response to secretin

• By secreting proteases in their inactive forms (zymogens) • Trypsin inhibitor - prevents early activation of proteases while in the pancreas • Alkaline fluids - flush enzymes into the duodenum

I - Idiopathic G - Gallstones E - Ethanol/alcohol T - Trauma S - Steroids M - Mumps/viruses A - Autoimmune S - Scorpion stings H - Hypertriglyceridaemia/ hypercalcaemia E - Endoscopic retrograde cholangiopancreatography D - Drugs

Unknown Theory = injury to acinar cells = early activation of proenzymes causing autodigestion of the pancreas

• Acinar cell injury • Acute inflammatory response • Systemic complications

• Biliary tract obstruction = increases intraductal pressure, pancreatic juices back up and leak into interstitial tissue • Lipase causes fat breakdown = injury causes inflammatory response • Oedema = impairs blood flow = ischaemia • Proenzyme activation due to defective intracellular transport = pancreatic autodigestion

• Injury to acinar cells and pancreatic tissue destruction = release of proinflammatory cytokines = inflammatory response • Inflammation leads to vascular changes and cellular events

• Alcohol • Trauma • Viruses • Drugs

• Vasoconstriction due to histamine release • Vasodilation = increases hydrostatic pressure = pushes fluid into interstitial tissue • Increased vascular permeability = pushes exudate into interstitial tissue • Increased blood viscosity

• Chemotaxis - movement of leukocytes towards the site of inflammation down a chemical gradient • Phagocytosis - leukocytes engulf and destroy dead cells • Activation of plasma protein systems

• Margination - movement of leukocytes from central axial column to the periphery • Rolling - Leukocytes move along the epithelial surface • Activation - Of adhesion molecules (selectins and integrins) on the surface of leukocytes • Adhesion - Leukocytes stick to the endothelial wall • Diapedesis - Movement of leukocytes from the endothelial wall to the interstitial tissue through gap junctions

• Shock • Cardiac - myocardial depression, decreased TPR, hypotension • Lungs - PO, ARDS • Renal - pre-renal failure, acute tubular necrosis • Sepsis • Disseminated intravascular coagulation - use of all clotting factors so pt continues to bleed • MODS

Fluid resuscitation Vasopressors to vasoconstrict

• Epigastric pain - central and upper abdo • N and V • Abdo distension and tenderness • Fever • Leukocytosis • Steatorrhea - excessive undigested fat in faeces due to lack of lipase • Transient hyperglycaemia - damaged alpha cells = release of glucagon = increased BGLs • Hypotension • Tachycardia • Hypoxaemia • Elevated urea and creatinine

• Elevated serum amylase • Elevated serum lipase • Elevated urine amylase and serum CRP • Radioactive imaging

Does not exist

• Fluid resuscitation + colloids - prevent hypovolaemia, increase TPR • Pain management - opioids, PCA • Nutrition - TPN for vomiting, NGT favourable, intake vs output charts • ABs - only if there is an infection • Surgery - pancreatic resection or removal of gallstones

Chronic alcohol abuse