PANCREATITIS

STRUCTURE
 Elongated and tapered organ
 Pale grey gland weighing about 60gms, 12-15cms long
 Situated in Epigastric and left hypochondriac regions of the abdominal cavity.
 It’s part of your digestive system and your endocrine system. Your pancreas is
a dual organ — like a factory with two production lines. It makes:
 Enzymes to help with digestion (exocrine system).
 Hormones to control the amount of sugar in your bloodstream (endocrine
system).
PARTS OF PANCREAS:
• Head: The wider part of your pancreas that sits in the curve of your
duodenum.
• Neck: The short part of your pancreas extending from the head.
• Body: The middle part of your pancreas between the head and neck, which
extends upward.
• Tail: The thinnest part of your pancreas, located near your spleen.
 FUNCTIONS OF PANCREAS

• The exocrine function is performed by the acini cells of the pancreas.

• The bulk of the pancreas is composed of "exocrine" cells that produce enzymes to help with the digestion of food.
• These exocrine cells release their enzymes into a series of progressively larger tubes (called ducts) that eventually join
together to form the main pancreatic duct.
• The main pancreatic duct runs the length of the pancreas and drains the fluid produced by the exocrine cells into the
duodenum, the first part of the small bowel.
• The common bile duct originates in the liver and the gallbladder and produces another important digestive juice called BILE.
• The pancreatic juices and bile that are released into the duodenum help the body to digest fats, carbohydrates, and proteins.
PANCREATITIS

Pancreatitis is the inflammation of the pancreas and is

characterized by edema, cellular exudate, and fat
necrosis.
The disease can range from mild and self-limiting to
severe, with autodigestion of the gland and
peripancreatic tissues, necrosis, and hemorrhage of
pancreatic tissue.
Pancreatitis is classified as either acute or chronic. Both
acute and chronic pancreatitis can cause pancreas to
produce fewer of the enzymes that are needed to
breakdown and process nutrients.
This can lead to malnutrition, diarrhea and weight loss
inspite of eating normally. The latter with pancreatic
destruction so extensive that exocrine and endocrine
functions are severely diminished, and maldigestion and
diabetes may result.
 ETIOLOGY SYMPTOMS:
• Symptoms may worsen with the
Conditions that lead to ingestion of food. Clinical
pancreatitis are presentation also may include
 Alcoholism, • Indigestion,
• Fever
 Gallstones • Yellowing of the skin
 Abdominal surgery • Nausea
• Vomiting
 certain medications, • Abdominal distension, and
 cigarette smoking steatorrhea.
• Severe cases are complicated by
 trauma
hypertension, oliguria, and dyspnea.
 hypercalcaemia due to • There is extensive destruction of
overactive parathyroid pancreatic tissue with subsequent
gland, fibrosis, enzyme production is
 hypertriglyceridemia diminished, and serum amylase and
lipase may appear normal.
 infection • However, absence of enzymes to aid
 and pancreatitis can also in the digestion of food leads to
occur due to family history. steatorrhea and malabsorption.
 ACUTE PANCREATITIS
• Acute pancreatitis is defined as a discrete episode of
cellular injury and inflammation in the pancreas.
PATHOPHYSIOLOGY
• usually with symptoms of abdominal pain, nausea, and
vomiting, and typically accompanied by elevations in
serum levels of amylase or lipase and by radiographic
evidence of pancreatic inflammation, edema, or
necrosis.
• With repeated episodes, there is a shift from acute
inflammation, necrosis, and apoptosis to the chronic
inflammation and fibrosis that is characteristic
of chronic pancreatitis.
• In some patients, it may be difficult to distinguish acute
pancreatitis from a flare of chronic pancreatitis.
 ACUTE PANCREATITIS
CAUSES:
 Alcoholism and biliary tract disease
 Acute pancreatitis may also be due to trauma, gallstones, virus infections, tumors, nutritional deficiency
 hypertriglyceridemia
 hypercalcemia
 certain vascular diseases and a number of metabolic diseases.
SYMPTOMS:
 May range from a mild inflammatory reaction to severe illness.
 The most predominant symptom is severe abdominal pain radiating to the back and is aggravated by eating.
 Epigastric tenderness
 Distention
 constipation, nausea and vomiting occur.
 Increased pressure in the ducts causes the activated pancreatic enzymes to escape into the interstitial tissues, leading to elevations
in serum amylase and lipase.
 Other clinical findings include hyperlipidemia and hypocalcemia.
 Alteration of structure or function of the pancreas or adjacent organs may be demonstrated radiographically.
 ACUTE PANCREAT I T IS ( H ISTO RY TAK ING AND PH YSISCA L EXAM INAT IO N):

HISTORY TAKING
1. ABDOMINAL PAIN- REMEMBER “SOCRATES”
• SITE- Diffuse ,upper abdominal pain
• ONSET-sudden
• CHARACTER- Pain
• RADIATION-Radiates to the back
• ASSOCIATED FACTOR-nausea, vomiting, dyspnea
• TIMING-pain escalates in intensity and peaks within 10-20 mins of onset
• AGGRAVATING AND RELEVING FACTOR-By breathing with increased
chest expansion and relieved by leaning forward
• SEVERITY- depending on pain severity, patient may present in shock.
2. HISTORY OF UNDERLYING CAUSE- “I GET SMASHED”
3.HISTORY OF COMPLICATIONS:
SYSTEMIC: ARDS, Renal failure, shock, Arrythmias
METABOLIC: Hypocalcemia, hyperglycemia, Encephalopathy
LOCAL: Mostly develop silently, Pancreatic abscess-high grade fever, Pancreatic
effusion, Pseudocyst
 DIAGNOSIS:
BLOOD TESTS. following key tests:
a) Serum Amylase and Lipase
Amylase: This enzyme is often elevated in acute pancreatitis, though its levels may not always correlate with the severity of the
disease. Elevated amylase levels are seen in the first 24-48 hours.
Lipase: More specific to the pancreas than amylase, lipase levels tend to rise and remain elevated longer than amylase in acute
pancreatitis (up to 5-7 days). A lipase level more than three times the normal value is suggestive of acute pancreatitis.
b) Liver Enzymes (AST, ALT, ALP)If gallstones are the underlying cause of pancreatitis, liver enzymes such as AST, ALT, and
alkaline phosphatase (ALP) may be elevated, indicating potential bile duct obstruction or liver involvement.
c) Blood Glucose: Elevated blood glucose levels can be seen in severe pancreatitis due to impaired insulin production by the
damaged pancreas.
d) White Blood Cell Count (WBC) :An elevated WBC count can indicate an inflammatory response or infection associated with
pancreatitis.
e) Triglycerides and Calcium
Triglycerides: Elevated triglyceride levels (greater than 1000 mg/dL) are one of the causes of acute pancreatitis.
Calcium: Hypocalcemia (low calcium levels) may occur in severe cases of pancreatitis, often due to the deposition of calcium salts
in areas of pancreatic necrosis.
f) C-Reactive Protein (CRP) : CRP is an inflammatory marker that may be elevated in acute pancreatitis. It is sometimes used to
assess the severity of the disease and predict complications.
3. Imaging Tests OTHER TESTS
a) Abdominal Ultrasound a) Endoscopic Retrograde
b) Computed Tomography (CT) Scan Cholangiopancreatography (ERCP)
•ERCP is a specialized procedure used to visualize
highly sensitive for detecting complications such as: the bile and pancreatic ducts and is primarily used if
• Pancreatic necrosis (tissue death) there is suspicion of a biliary obstruction (due to
• Pseudocysts gallstones or strictures) as the cause of acute
pancreatitis.
• Pancreatic abscess
•It allows for therapeutic interventions, such as the
• Infected pancreatic tissue removal of gallstones or the placement of a stent in
The contrast-enhanced CT is especially useful in identifying areas of necrosis, which the bile duct, which can relieve the obstruction.
can influence treatment decisions. •Note: ERCP is not routinely performed in all cases
CT severity index (CTSI): This scoring system uses CT imaging to assess the severity of acute pancreatitis, as it is invasive and can
of acute pancreatitis by evaluating pancreatic inflammation, necrosis, and sometimes cause complications like inducing
complications. pancreatitis.
c) Magnetic Resonance Imaging (MRI)
b) MRCP (Magnetic Resonance
• MRCP (Magnetic Resonance Cholangiopancreatography): A specialized MRI
technique used to visualize the bile and pancreatic ducts. It is particularly helpful inCholangiopancreatography)
identifying ductal obstruction caused by gallstones or other blockages. •MRCP is a non-invasive technique used to evaluate
the bile and pancreatic ducts, similar to ERCP but
d) Endoscopic Ultrasound (EUS)
without the need for endoscopy or radiation.
• EUS is a highly sensitive test used for evaluating the pancreas and bile ducts. It is •It is especially useful for diagnosing bile duct
particularly useful when the cause of pancreatitis is unclear, such as when evaluating obstructions or structural abnormalities in the
for small gallstones, ductal abnormalities, or pancreatic masses.
ducts.
• EUS-guided fine-needle aspiration (FNA) can also be used to biopsy pancreatic
tissue if a mass or pancreatic cancer is suspected.
SEVERITY SCORING SYSTEMS:
once acute pancreatitis is diagnosed, several scoring systems
may be used to assess the severity and predict the risk of
complications. These include:
1. RANSON CRITERIA: A set of 11 clinical and
laboratory parameters that predict the severity and prognosis
of acute pancreatitis.
Parameters include age, white blood cell count, glucose
level, AST levels, and others measured at presentation and
after 48 hours.
2. APACHE II (Acute Physiology and Chronic Health
Evaluation II): A scoring system that assesses the severity
of the disease based on various clinical and laboratory
parameters. Higher scores correlate with more severe
pancreatitis and a higher risk of complications.
3. BISAP (Bedside Index for Severity in Acute
Pancreatitis): A simplified scoring system used to predict
the severity of acute pancreatitis using five clinical variables:
blood urea nitrogen (BUN), impaired mental status, systemic
inflammatory response syndrome (SIRS), age, and pleural
effusion.
 TREATMENT:
1. Supportive Care Intravenous (IV) Fluids: Lactated Ringer’s or normal saline are commonly used to replenish
fluids. Fluids are administered through an IV to prevent hypovolemia (low blood volume) and maintain adequate
perfusion to vital organs.
2. Electrolyte Management
3. Pain Management: Common pain management options include - Opioids (e.g., morphine) for severe pain.
Non-opioid analgesics (e.g., acetaminophen or ibuprofen) may be used for milder pain.
Avoiding NSAIDs in the early phase due to potential gastrointestinal side effects.
4. Fasting (NPO - Nil Per Os): Gradual reintroduction of oral intake begins when the pain subsides, often starting
with clear liquids and progressing to solid foods.
5. Antibiotics are not routinely given in acute pancreatitis unless there is a suspected infection (e.g., infected
pancreatic necrosis or abscess).
• If an infection is identified, broad-spectrum antibiotics (such as carbapenems, quinolones, or third-generation
cephalosporins) are used to treat the infection.
6. Pancreatic Enzyme Replacement
7. Monitoring and Support- vitals and laboratory tests
8. Prevention of Recurrence- Lifestyle changes, follow ups.
 TYPES OF SURGICAL PROCEDURES IN ACUTE PANCREATITIS
1. Cholecystectomy (Gallbladder Removal):
If gallstones are the cause of acute pancreatitis, the gallbladder is often removed after the acute episode has subsided (usually after 4-6
weeks) to prevent further attacks.
2. Pancreatic Necrosectomy:
This procedure involves removing the necrotic (dead) tissue from the pancreas. It may be done if there is infected pancreatic necrosis,
and it can be done via open surgery, laparoscopy, or minimally invasive techniques.
Necrosectomy helps reduce infection, prevent sepsis, and promote recovery.
3. Drainage of Pancreatic Pseudocyst:
If a pseudocyst (a fluid-filled sac) develops and does not resolve on its own, or if it becomes infected or large, it may need to be drained.
This can be done either through:
1. Surgical drainage (direct removal of the cyst).
2. Endoscopic drainage (less invasive, using a camera to insert a drainage tube into the cyst).
3. Percutaneous drainage (using a needle through the skin to drain the cyst).
4. Surgical Drainage of Abscesses: abscesses (collections of infected fluid)
5. ERCP (Endoscopic Retrograde Cholangiopancreatography):
While ERCP is not a traditional surgical procedure, it can be used to remove gallstones from the bile duct or to place a stent in the bile or
pancreatic duct to relieve obstructions. It is often performed before surgery if there is a biliary obstruction.
6. Pancreatic Duct Surgery:
In rare cases, when there is a blockage or damage to the pancreatic duct, surgery may be done to remove the obstruction or reconstruct
the duct.
 NUTRITIONAL MANAGEMENT IN ACUTE PANCREATITIS:
Objectives:
* The basis for nutrition therapy is to put the pancreas at rest.
* To meet the metabolic and nutritional needs of the patient.
* To replete nutritional requirements without stimulating the pancreas.

Energy And Protein: Patients with severe acute pancreatitis are hypermetabolic which may be further complicated
by sepsis or multi-organ failure.
 energy requirements in severe acute pancreatitis are 15-20 kcal/kg body weight/day with a total protein intake
of 1.2 - 1.5 g/kg body weight/day or 15-20 percent of total energy.
 If multi-organ failure syndrome occurs, then energy and protein needs have to be modified.
 NUTRIT ION A L M ANAGEM ENT IN ACUTE PANCREATI T I S:

FATS: Severe hyperlipidemia occurs in patients with acute pancreatitis, the mechanism for which is not very clear. Low fat
diet.
ROUTE OF SUPPORT: Earlier, TPN was considered the gold standard in the management of severe pancreatitis to give
'pancreatic rest’.
 However, at present it is recommended that if the bowel is functioning, enteral nutrition is more advantageous.
 It is much less expensive than TPN, maintains gastrointestinal integrity and gut mucosal barriers.
 It also prevents sepsis and multi system organ failure.
 In mild pancreatitis, patients should be on intravenous (IV) fluids till the pain is controlled. Oral feeding can
commence thereafter.
 The patient should be given small amounts of carbohydrate- protein diet and gradually increased over 3-6 days with
careful supplementation of fat. After 7 days, a normal diet can be given.
 In severe acute pancreatitis, enteral feeding (nasojejunal or nasogastric) must be started as early as possible.
 Semi elemental diets at 1 kcal/ml may be started.
 TPN is used when enteral feeds aggravate pain, ascites etc. Lipid emulsions can be used safely if the serum triglyceride
levels remain below 400 mg/dl.
 Once the condition improves, the patient can be shifted to enteral and the oral feeds.
 CHRONIC PANCREATITIS
• Chronic pancreatitis is characterized by its progressive fibrotic nature. This disease may be described as relapsing, recurrent,
or continuous in nature.
PATHOPHYSIOLOGY OF CHRONIC PANCREATITIS
Inflammation and Fibrosis
(destruction of both exocrine (digestive enzyme-producing) and endocrine (insulin-producing) tissue.)

Ductal Obstruction
(The inflammation causes ductal strictures or calcifications that obstruct the pancreatic ducts, impairing the flow of
digestive enzymes. )

Acinar Cell Damage

(This impairs exocrine function, leading to malabsorption, steatorrhea (fatty stools), and weight loss.)

Endocrine Dysfunction
Destruction of the islets of Langerhans (insulin-producing cells) leads to endocrine dysfunction Chronic

Pain
The pain is often related to increased pressure within the duct and irritation of surrounding tissues.

Altered Pancreatic Enzyme Secretion

(Reduced enzyme secretion)
 CHRONIC PANCREATITIS
CAUSES :
 The etiology of chronic pancreatitis is similar to acute pancreatitis, however there is progressive deterioration.
 As in acute pancreatitis, alcoholism is the most common cause of attacks. Alcohol indirectly stimulates pancreatic
secretions, and may also obstruct pancreatic outflow.
 Obstructions of the ducts lead to chronic changes, including destruction of the islets of Langerhans in some patients,
fibrosis, pseudocyst, and pancreatic calcification.
 When enzyme secretion is only 10 percent of normal, impaired digestion leads to steatorrhea, and deficiency of the B-
complex and fat soluble vitamins.

SYMPTOMS:
 Recurrent attacks of burning Epigastric pain, especially after meals containing alcohol and fat.
 Other symptoms include flatulence, anorexia, weight loss, nausea and vomiting.
 Both diabetes and steatorrhea occurs with calcified pancreatitis.
 Weight loss may also be caused by avoidance of food, as pain is frequently exacerbated after eating.

TREATMENT: Conservative management is used unless the patient has unremitting pain or complications necessitating
partial or complete pancreatectomy. Medications to alleviate pain and to inhibit pancreatic secretion are used.
 CHRONIC PANCREATITIS
NUTRITIONAL MANAGEMENT:
The aim of the dietary treatment is to minimize gastric secretion because of its stimulating effect on secretion output.
ENERGY AND PROTEIN: Chronic pancreatitis causes hypermetabolism.
 The nutrition therapy of such patients should be of high calorie (35 kcal/kg) high protein (1.0 to 1.5 g/kg) and rich in
carbohydrates with moderate amounts of fats in order to minimize symptoms of underlying disease.
 The intake of carbohydrates should be monitored when it is evident that diabetes is present.
FAT: Normally vegetable fats are better tolerated than animal fats. Medium chain triglycerides may be used to increase fat
absorption because they need minimal digestion and do not require lipase, colipase and bile salts.
 Medium chain triglycerides have a lower energy density than long chain triglycerides and quite foul tasting.
 Associated adverse effects can include cramps, nausea and diarrhea.
 MCT's should be increased slowly according to the tolerance of the patient.
FIBER: Oral nutrition therapy should be low in fiber because fiber may absorb pancreatic enzymes and delay the absorption of
nutrients.
VITAMINS AND MINERALS: Fat soluble vitamins (A, D, E and K), vitamin B12 and micronutrients including antioxidants
should be replaced as clinically indicated. Calcium and vitamin D supplements within the physiologic dosage range are
recommended for vitamin D deficiency even in the face of pancreatic calcifications.
ROUTE OF SUPPORT: Elemental formulas or enteral formulas consisting of pre-digested products and low fat content are
beneficial for patients with chronic pancreatitis. These products generally cannot be consumed because of their taste.
 This is a lifelong condition which has to be managed symptomatically.
 Patients may also be prescribed oral pancreas enzymes in a pill form, to aid in the digestion of food. This is known as PANCREAS
ENZYME REPLACEMENT THERAPY, or PERT. The Pancreatic replacement therapy is given with meals.
 Lipase supplements reduce steatorrhea in chronic pancreatitis patients.
 Nutrition therapy has always been considered part of the treatment of chronic pancreatitis because of the frequent malnutrition
associated with the disease.
 Jejunal feeding improves weight, reduces narcotic use and improves patient's quality of life.
• SURGICAL TREATMENT:, pancreas has been extensively damaged, it may be necessary to remove the entire pancreas (TOTAL
PANCREATECTOMY).
• Complications associated with pancreatectomy include is delayed gastric emptying, where the food does not pass quickly enough
into the intestine.
• Pancreatectomy can be very effective in treating pain, but won't be able to produce the insulin that's needed by the body. To
overcome this problem, a technique called AUTOLOGOUS PANCREATIC ISLET CELL TRANSPLANTATION (APICT) is
sometimes used.
• Pancreatic islet auto transplantation is performed after total pancreatectomy in patients with severe and chronic, or long-lasting,
pancreatitis that cannot be managed by other treatments. After pancreatectomy, islets are extracted and purified from the pancreas.
The islets then are infused through a catheter into the liver. The goal is to give the body enough healthy islets to make insulin.
• Pancreatic jejunostomy (Puestow procedure) or Whipple procedure (pancreaticoduodenectomy) may be indicated in cases of
severe pain or complications such as pancreatic pseudocysts or tumors.
• A person who receives a pancreatic islet cell transplant should follow a meal plan designed for a person with diabetes. To keep
pancreas healthy, high cholesterol, high calcium diets and excess consumption of alcohol should be avoided.
• Diet and lifestyle changes is the essential remedy to keep the pancreas healthy.