The Digestive System|
Synonyms : Acute Pancreatitis
Pancreatitis refers to
inflammation and damage of the pancreatic tissue that is usually classified
into acute and chronic. Acute and chronic forms are distinguished from each
other on the basis of structural (pathologic) criteria. In acute pancreatitis
the gland is normal before the attack and can return to normal after
resolution of the attack, whereas in chronic pancreatitis the gland is
abnormal before or after attack, or both. This classification scheme does not
depend on how rapidly symptoms appear or resolve, or on the severity of the
symptoms (what would be expected from the terms acute and chronic). Thus, it
may be impossible to distinguish an exacerbation of chronic pancreatitis from
an attack of acute pancreatitis on clinical grounds alone.
is an acute condition resulting from the activation
of the digestive proenzymes in the pancreatic duct system or even in the
pancreatic glandular cells. The release of enzymes leads to necrosis
of the pancreatic tissue and adjacent structures. About 50% of cases are
associated with biliary disease (acute pancreatitis develops in 5% of all
patients with gallstones) and about 20% with alcoholism while in rest no cause
can be identified (idiopathic). However, it is controversial whether alcohol
can cause acute pancreatitis in a normal pancreas. Most episodes of
alcohol-associated pancreatitis occur in patients who have abused alcohol for
many years. Thus, chronic pancreatitis is probably present at the time acute
painful episodes begin.
Risk factors for acute pancreatitis:
(probably in the setting of mild chronic pancreatitis) by causing oxidative
stress with free radical formation
causing temporary impaction in the sphincter of Oddi before passing into
obstructive factors (duodenal diverticulum, stenosis of the papilla of Vater,
carcinoma in the head of the pancreas)
precise mechanism how pancreatic proenzymes are activated is not well
understood and it can probably vary in different patients. It is believed that
increased pressure in the pancreatic duct system may be the first event. The
pathologic changes of acute pancreatitis strongly suggest autodigestion
of the pancreatic tissue by inappropriately activated pancreatic enzymes. The tissue lesions appear to be the consequence
of proteolysis, lipolysis, and damage of blood vessels. Normally, pancreatic
enzymes are present in the cells in the proenzyme form
and have to be activated, which occurs in the intestines under influence
of enzyme enterokinase. Under normal circumstances pancreatic proenzymes and
lysosomal enzymes are separated in pancreatic cells. It is possible that
direct contact between these two is responsible for the activation of
pancreatic proenzymes which then start to digest and damage pancreatic tissue.
Activation of trypsin from trypsinogen is believed to be one of the initiating
events. The activated enzymes so generated cause disintegration of fat cells
and damage to the elastic fibres of blood vessels, which can explain fat
necrosis (chalky-white patches scattered throughout the abdominal cavity
and seen during surgery) and rupture of blood vessels with resulting haemorrhage.
on after the removal of necrotic tissue by inflammatory cells, a pancreatic
pseudocyst (pseudocysts have no epithelial lining in contrast to ‘real?
cysts) might be formed from collection of pancreatic secretions walled of by
granulation tissue, and with communication with pancreatic duct system. If
infection with bacteria occurs, pseudocyst can be transformed into pancreatic
Providing the patient survives the attack of acute pancreatitis all of the listed histologic changes in the pancreatis tissue are almost fully reversible with no residual damage left.
Clinical features: < BACK TO TOP >
is usually sudden onset with severe pain in the epigastrium occurring within
12-24 hours following a large meal or alcohol bout.
pain is usually persistent (may last for few hours or even several days) and
radiates through to the back, and may be described as the most severe pain
report that sitting up and leaning forward may reduce the pain, but coughing,
sneezing, deep breathing and sudden movements may aggravate it (stretching of
and vomiting are common.
severe cases patient’s condition worsens with increased respiratory rate
(tachypnoea), dyspnoea (breathlessness) and hypoxaemia (low saturation of
blood with oxygen) due to the damage of the lungs by enzymes (phospholipase A2
can also degrade surfactant in the alveoli) and toxic material that get
absorbed in blood (ARDS - adult respiratory distress syndrome); there can be
fever and hypotension.
pancreatitis may be mistaken for acute cholecystitis, cholangitis, perforated
peptic ulcer, myocardial infarction, bowel infarction or even appendicitis.
develops 1-2 weeks after the onset of pancreatitis and presents with
persistent abdominal pain, nausea, vomiting and weight loss.
In case of pancreatic abscess, patient’s condition deteriorates (3-5 weeks after the onset of acute pancreatitis) with severe abdominal pain, fever and weight loss.
Diagnosis: < BACK TO TOP >
examination reveals epigastric tenderness with or without rigidity
amylase activity is elevated first day of the disease and after that starts
to fall due to renal clearance (amylase is a pancreatic enzyme which is
released into the circulation in pancreatic damage). Persistently elevated
amylase suggests the development of pseudocyst or pancreatic abscess.
which are even more specific for pancreas are serum lipase and pancreatic
isoamylase (a form of amylase found only in the pancreas, sometimes referred
to as amylase-P).
test shows leukocytosis and raised ESR rate, serum calcium level can fall due
to formation of calcium soaps in the pancreas and peritoneal cavity.
Ultrasound scanning and computed tomography are the most important in the diagnosis of the condition, especially to detect the development of pseudocyst, abscess or haemorrhage.
Management < BACK TO TOP >
fluid replacement and relief of pain are important (pethidine [Pethidine] by
intramuscular injections; morphine can cause constriction of the sphincter of
Oddi and is better avoided).
monitoring of the respiratory function is carried out and oxygen is given if
of oral feeding (intravenous feeding instead) with naso-gastric intubation
and suction to prevent overaccumulation of fluid in the stomach and
intestines due to reflex atony (ileus) of the gut. Ileus is always found in
the acute phase and suction should be continued until gastrointestinal
motility has returned. Suction of the gastric content can also help relieve
is an option in case of pancreatic abscess or cholecystitis of the
resection of the pancreas may be carried out when necrosis is very marked but
the mortality rate is high; clinical trials did not manage to demonstrate
that this improves the outcome.
usually subside spontaneously in 4-6 weeks but if they fail to do so,
surgical resection in treatment of choice.
Prognosis depends upon the severity of the attack. Overall, the mortality is 10-20%, and death is caused by multiorgan failure, shock, secondary abdominal infection or the adult respiratory distress syndrome.
Prognosis < BACK TO TOP >
Nutrition < BACK TO TOP >
Nutrition that alleviate or prevent Pancreatitis :-
Herbs < BACK TO TOP >
Herbs that alleviate or prevent Pancreatitis :-
(source : -)
15 May 2009
19 June 2005
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