PancreatitisPancreatitis

Dr. Gehan Mohamed Dr. Abdelaty ShawkyDr. Gehan Mohamed Dr. Abdelaty Shawky

Learning objectivesLearning objectives

• Identify different types of pancreatitis.• List various causes of pancreatitis as biliary stone,

alcohol and the mechanism of their action.• Understand how to diagnose a case of pancreatitis

by the help of clinical presentation ,histopathologic changes and imaging studies and differentiate it from other causes of acute abdomen.

• Know the serious complications of pancreatitis.

PancreatitisPancreatitis• It may be:1. Acute inflammation: occurs suddenly and

lasting for a few days. Usually heals by regeneration without any functional or anatomic changes.

2. Chronic inflammation: occurs gradually with recurrent attacks . Heals by fibrosis that result in endocrine and exocrine insufficiency.

* Pathogenesis of pancreatitis:

• It occurs when pancreatic enzymes (especially trypsin that digest food) are activated in the pancreas instead of the small intestine so it autodigest the pancreas and autodigest the pancreas and surrounding tissue

* Causes of pancreatitis:(1) Chronic alcoholism.(2) gallstones.(3) Some medications such as diuretics, the

chemotherapeutic agents, steroid use .(4) trauma.(5) autoimmune disease.(6) Infectious causes. Coxsackie virus, Cytomegalovirus,

Hepatitis B virus. Salmonella, Aspergillus, Toxoplasma

* Mechanism of pancreatitis caused by Biliary Tract Stones :

The stone might have caused outflow obstruction from a common biliopancreatic channel at the ampulla of vater toward the intestine allowing so bile reflux into the pancreatic duct with activation of the pancreatic enzymes leading to digestion of the pancreas.

Biliary Tract Stones

Mechanism of pancreatitis caused by Abuse of Ethanol :

1. Ethanol act directly on pancreatic acinar cells to cause injury .2. It promotes secretion of pancreatic juice that is rich in proteolytic enzyme content but low in enzyme inhibitors.3. Secretion of an enzyme-rich fluid could also lead to protein precipitation and the formation of intraductal plugs.

* Diagnosis of pancreatitis:

1. Clinical picture

2. Laboratory Finding

3. Histopathologic changes

1. Clinical picture:• severe upper abdominal pain radiating to the back.• nausea, and vomiting.• Blood pressure may be elevated by pain or

decreased due to dehydration or internal bleeding. • The abdomen is usually tender.• Fever or jaundice may be present.• Unexplained weight loss may occur from a lack of

pancreatic enzymes hindering digestion.• Fatty stools (steatorrhea).

(2). Laboratory Finding:-Elevation of white count- 20,000-50,000.

- Elevated serum lipase and amylase(5 to 40 times)

(lipase is generally considered a better indicator).

- Abnormal low serum Ca due to Binding of Ca in areas of fat

necrosis.

- Abdominal ultrasound is generally performed first, for

detecting gallstones, diagnosing alcoholic fatty liver (combined

with history of alcohol consumption).

3. Histopathologic changes:A. In mild acute pancreatitis: changes frequently include interstitial edema and infiltration by inflammatory cells with relatively little necrosis.B. In severe acute pancreatitis: extensive necrosis, thrombosis of intrapancreatic vessels, vascular disruption, and intraparenchymal hemorrhage can be seen. C. In chronic pancreatitis: there is both loss of pancreatic acini, islets of langerhans and fibrosis.

Gross pathology of acute pancreatitis

Chronic pancreatitis

Normal histology of pancreas

Microscopic picture of acute pancreatitis

Microscopic picture of acute pancreatitis showing necrosis , inflammatory cells.

Microscopic picture of acute pancreatitis showing necrosis , inflammatory cells.

Microscopic picture of chronic pancreatitis characterized by loss of some pancreatic acini and replaced by fibrosis(arrow)

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* Complications of pancreatitis:1. Shock.2. Pancreatic abscess due to acute necrotizing pancreatitis 3. Development of pancreatic pseudocysts which is collections of pancreatic secretions that have been walled off by scar tissue. These may cause pain, become infected, rupture and bleed.4. Chronic pancreatitis can lead to diabetes mellitus or pancreatic cancer.