Numan AS Daud

The pancreas is a large gland located behind the

stomach and next to the duodenum

The pancreas has two primary functions:

1. To secrete powerful digestive enzymes into the
small
intestine to aid the digestion of
carbohydrates, proteins, and fat.
2. To release the hormones insulin and glucagon
into the bloodstream. These hormones are involved
in blood metabolism, regulating how the body
stores and uses for energy.

Pancreatitis is a disease in which the pancreas becomes

inflamed,which requires immediate medical attention and
hospitalization during an attack that has multiple causes
and symptoms
Pancreatic damage occurs when the digestive enzymes are
activated before they are secreted into the duodenum and
begin attacking the pancreas.
It occurs when pancreatic enzymes (especially trypsin) that
digest food are activated in the pancreas instead of the
small intestine.
It may be acutebeginning suddenly and lasting a few
days, or chronicoccurring over many years
There are two forms of pancreatitis: acute and chronic

Eighty percent of pancreatitis is caused by

alcohol and gallstones.
Gallstones are the single most common
etiology of acute pancreatitis.[1]
Alcohol is the single most common etiology
of chronic pancreatitis

Some medications are commonly associated with

pancreatitis, most commonly corticosteroids such as
prednisolone, but also including the HIV drugs didanosine
and pentamidine, diuretics, the anticonvulsant valproic
acid, the chemotherapeutic agents
Lasparaginase and azathioprine, estrogen by way of
increased blood triglycerides,[7] cholesterol-lowering
statins and the antihyperglycemic agent sitagliptin.[8]
There is an inherited form that results in the activation of
trypsinogen within the pancreas, leading to autodigestion.
Involved genes may include Trypsin 1, which codes for
trypsinogen, SPINK1, which codes for a trypsin inhibitor, or
cystic fibrosis transmembrane conductance regulator.[9]

Other common causes include trauma, mumps,

autoimmune disease, high blood calcium, high blood
triglycerides, hypothermia, and endoscopic retrograde
cholangiopancreatography (ERCP).

Pregnancy can be a cause, possibly by increasing blood

triglycerides.

Diabetes mellitus type 2 is associated with a 2.8-fold

higher risk.[10]

Less common causes include pancreatic cancer, pancreatic

duct stones,[11] vasculitis (inflammation of the small blood
vessels in the pancreas), coxsackievirus infection, and
porphyriaparticularly acute intermittent porphyria and
erythropoietic protoporphyria.

A number of infectious agents have been

recognized as causes of pancreatitis
including:[12]
Viruses

Coxsackie virus
Cytomegalovirus
Hepatitis B
Herpes simplex virus
Mumps
Varicella-zoster virus

Bacteria

Fungi

Parasites

Legionella
Leptospira
Mycoplasma
Salmonella

Aspergillus
Ascaris
Cryptosporidium
Toxoplasma

Acute pancreatitis is a sudden inflammation that

occurs over a short period of time.
In the majority of cases, acute pancreatitis is
caused by gallstones or heavy alcohol use.
Other causes include medications, infections,
trauma, metabolic disorders, and surgery.

In about 10% to 15% of people with acute

pancreatitis, the cause is unknown.

The severity of acute pancreatitis may range from mild

abdominal discomfort to a severe, life-threatening illness.
However, the majority of people with acute pancreatitis
(more than 80%) recover completely after receiving the
appropriate treatment.

In very severe cases, acute pancreatitis can result in

bleeding into the gland, serious tissue damage, infection,
and cyst formation.
Severe pancreatitis can also create conditions which can
harm other vital organs such as the heart, lungs, and
kidneys.

Symptoms of acute pancreatitis:

Upper abdominal pain that radiates into the back.

Patients may describe this as a "boring sensation"
that may be aggravated by eating, especially foods
high in fat.

Swollen and tender abdomen

Nausea and vomiting

Fever

Increased heart rate

Grey Turner sign

Cullens sign

Chronic pancreatitis occurs most commonly after an

episode of acute pancreatitis and is the result of ongoing
inflammation of the pancreas.
In about 45% of people, chronic pancreatitis is caused by
prolonged alcohol use.

Other causes include gallstones, hereditary disorders of

the pancreas, cystic fibrosis, high triglycerides, and certain
medicines.
Damage to the pancreas from excessive alcohol use may
not cause symptoms for many years, but then the person
may suddenly develop severe pancreatitis symptoms,
including severe pain and loss of pancreatic function,
resulting in digestion and blood sugar abnormalities.

Symptoms of chronic pancreatitis:

The symptoms of chronic pancreatitis are similar to those of

acute pancreatitis.
Patients frequently experience constant pain in the upper
abdomen that radiates to the back.
In some patients, the pain may be disabling.
Other symptoms may include weight loss caused by poor
absorption (malabsorption) of food.
This malabsorption occurs because the gland is not secreting
enough enzymes to break down the food normally.
Also, diabetes may develop if the insulin-producing cells of the
pancreas become damaged.

Diagnosing pancreatitis requires two of the following:

Characteristic abdominal pain

Blood amylase or lipase will be 4-6 times higher than the
normal variations, (dependent on the laboratory that is
testing the blood)
Abdominal ultrasound is generally performed first, which
is advantageous for the diagnosis of the causes of the
pancreas, for example, detecting gallstones, diagnosing
alcoholic fatty liver (combined with history of alcohol
consumption). They are both the main causes of
pancreatitis. Abdominal ultrasound also shows an
inflamed pancreas clearly. It is convenient, simple, noninvasive, and inexpensive.
Characteristic CT scan

Amylase or lipase is frequently part of the

diagnosis; lipase is generally considered a
better indicator.
Cholecystitis, perforated peptic ulcer, bowel
infarction, and diabetic ketoacidosis can
mimic pancreatitis by causing similar
abdominal pain and elevated enzymes.

The diagnosis can be confirmed by

ultrasound and/or CT.

The treatment of pancreatitis is supportive

and depends on severity.
Morphine generally is suitable for pain
control.
The treatment that is received for acute
pancreatitis will depend on mild form of the
condition (no complications), or the severe
form (serious complications)

Mild acute pancreatitis

The treatment of mild acute pancreatitis is successfully carried
out by admission to a general hospital ward.

Eating should not be allowed until pancreatic inflammation has

resolved, which usually takes around five days
Because pancreatitis can cause lung damage and affect normal
lung function, oxygen is usually delivered through breathing
tubes that are connected via the nose.
Dehydration may result during an episode of acute pancreatitis,
so fluids will be provided intravenously.
The pain associated with even mild cases of acute pancreatitis
can be severe, so it may require quite a strong, opiate-based
painkiller.

Severe acute pancreatitis

They will need to be admitted to a high dependency unit or

intensive care unit
The drop in fluid levels can lead to a reduction in the volume of
blood within the body, which is known as hypovolemic shock.
Hypovolemic shock can be life-threatening as it can very quickly
starve the body of the oxygen-rich blood that it needs to survive.
Fluids will be pumped intravenously.
Oxygen will be supplied through tubes attached to the nose and
ventilation equipment may be used to assist with breathing.
Feeding tubes may be used to provide nutrients, while painkillers
can help to relieve the pain.

As with mild acute pancreatitis, it will be necessary to treat the underlying cause.

If the cause is gallstones, it is likely that an ERCP procedure or removal of your

gallbladder will be recommended.

If the cause is alcohol use, stopping drinking and receiving treatment for alcohol
dependency will be recommended (as discussed above).

Oral intake, especially fats, is generally restricted at first. Fluids and electrolytes
are replaced intravenously.

Nutritional support should be initiated via tube feeding to surpass the portion of
the digestive tract most effected by secreted pancreatic enzymes. [25]

The underlying cause should also be treated

The patient is monitored for complications.

Severe acute pancreatitis has high mortality

rates, especially where necrosis of the
pancreas has occurred.
Several scoring systems are used to predict
the severity of an attack of pancreatitis
(APACHE II, Ranson, and Glasgow)

Early complications include shock, infection, systemic

inflammatory response syndrome, low blood calcium, high
blood glucose, and dehydration.
Blood loss, dehydration, and fluid leaking into the
abdominal cavity (ascites) can lead to kidney failure.

Respiratory complications are often severe. Pleural

effusion is usually present. Shallow breathing from pain
can lead to lung collapse. Pancreatic enzymes may attack
the lungs, causing inflammation.
Severe inflammation can lead to intra-abdominal
hypertension and abdominal compartment syndrome,
further impairing renal and respiratory function and
potentially requiring management with an open abdomen
(laparostomy) to relieve the pressure.

Late complications include recurrent pancreatitis

and the development of pancreatic pseudocysts
collections of pancreatic secretions that have
been walled off by scar tissue.
These may cause pain, become infected, rupture
and bleed, block the bile duct and cause
jaundice, or migrate around the abdomen.
Acute necrotizing pancreatitis can lead to a
pancreatic abscess, a collection of pus caused by
necrosis, liquefaction, and infection.