Pancreatitis

[Alterations in Metabolic and Endocrine Functions]

PANCREATITIS Predisposing factors:

Precipitating factors: - Alcohol abuse - Drugs (antihypertensives, diuretics, antimicrobials, immunosuppresives, oral contraceptives) - Biliary obstruction - Hypercalcemia - Hypertriglyceridemia - Abdominal trauma - Tumors - Ischemia

- Genetic/ Family History - Anatomical variants

Damage to pancreatic cells Elastase Inflammation of the parenchyma

Necrosis of blood vessels and ductal fibers

Edema of the pancreas and pancreatic duct Hemorrhage Activation of pancreatic enzymes inside pancreas

Acute Pancreatitis

Phospholipase A

Autodigestion of the pancreas

Fat necrosis Cell membrane

Further inflammation of pancreas

Lipase

Fat Necrosis

Obstruction to the flow of pancreatic enzyme

Chronic Pancreatitis

Kalikrein

Edema Vascular permeability Smooth muscle contraction Vasodilation

Hypoperfusion

Peripancreatic exudation or pancreatic ductal leakage

Necrosis

Pseudocyst

Invasion of bacteria Infected necrotic pancreas or abscess

Compresses nearby organs

Constant pain or deep ache in the abdomen which felt in the back

Realease of toxic metabolites into peritoneal space Ruptured due to trauma to the sac Realease of toxic metabolites into blood Hemorrhage Death

SOURCES:

Shock Pulmonary Insufficiency Acute renal failure Dissemenated Intravascular Coagulation

Hypovolemia

Fisher, T. & Raton, B. (2015, March 16). MedlinePlus: Pancreatic Pseudocyst. Retrieved March 20, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000272.htm. Freedman, S. (2013, October). The Merck Manual: Acute Pancreatitis. Retrieved March 2015, from

1

[Alterations in Metabolic and Endocrine Functions] http://www.merckmanuals.com/professional/gastrointestinal_disorders/pancreatitis/acute_pancreatitis.html. Gardner, T. (2014, December 8). Medscape: Acute Pancreatitis. Retrieved March 2015, from http://emedicine.medscape.com/article/181364-overview. Pancreatitis. (2015). In Encyclopædia Britannica. Retrieved from http://www.britannica.com/EBchecked/topic/441022/pancreatitis.

PANCREATITIS

Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas.[1] There are two forms of pancreatitis: acute and chronic. Acute pancreatitis. Acute pancreatitis is a sudden inflammation that lasts for a short time. It may range from mild discomfort to a severe, life-threatening illness. Most people with acute pancreatitis recover completely after getting the right treatment. In severe cases, acute pancreatitis can result in bleeding into the gland, serious tissue damage, infection, and cyst formation. Severe pancreatitis can also harm other vital organs such as the heart, lungs, and kidneys.[2] Chronic pancreatitis. Chronic pancreatitis is long-lasting inflammation of the pancreas. It most often happens after an episode of acute pancreatitis. Heavy alcohol drinking is another big cause. Damage to the pancreas from heavy alcohol use may not cause symptoms for many years, but then the person may suddenly develop severe pancreatitis symptoms.[3] ETIOLOGY Acute pancreatitis has many causes, such as alcohol abuse, cholelithiasis, abdominal trauma, virus infection, drugs, and metabolic factors. The mechanisms by which these conditions trigger pancreatic inflammation have not been identified.[4] Acute pancreatitis is thought to result from inappropriate intrapancreatic activation of proteases, which causes autodigestion of the pancreas. Exactly how this occurs is unknown.

[5]

It is thought that

alcohol-induced pancreatitis may include a physiochemical alteration of protein that results in plugs that

1

Pancreatitis. (2015). In Encyclopædia Britannica. Retrieved from http://www.britannica.com/EBchecked/topic/441022/pancreatitis..

2

Freedman, S. (2013, October). The Merck Manual: Acute Pancreatitis. Retrieved March 2015, from http://www.merckmanuals.com/professional/gastrointestinal_disorders/pancreatitis/acute_pancreatitis.html.

3

Lewis, S. and et.al. Medical Surgical Nursing: Assessment and Management of Clinical Problems. Singapore: Mosby Elsevier Inc. .

2

[Alterations in Metabolic and Endocrine Functions] (2008). 4

Gardner, T. (2014, December 8). Medscape: Acute Pancreatitis. Retrieved March 2015, from http://emedicine.medscape.com/article/181364-overview.

block the small pancreatic ductules. Biliary pancreatitis occurs when edema or an obstruction blocks the ampulla of Vater, resulting in reflux of bile into pancreatic ducts or direct injury to the acinar cells. Other causes include the following: 

Hyperlipidemia, which may occur secondary to nephritis, castration, or exogenous estrogen administration, or as hereditary hyperlipidemia



Hypercalcemia arising as a result of hyperparathyroidism



Cholecystitis and cholelithiasis



Familial cases with no definite mechanism defined



Pancreatic tumor



Pancreatic trauma or pancreatic duct obstruction, such as penetrating or blunt external trauma, intraoperative manipulation, or ampullar manipulation, and pancreatic ductal overdistention during endoscopic retrograde cholangiopancreatography (ERCP)



Pancreatic ischemia during episodes of hypotensive shock, cardiopulmonary bypass, visceral atheroembolism, or vasculitis



Drugs; although azathioprine and estrogens have been directly linked with the disease, many other drugs are believed to have an association (e.g., antibiotics, anticonvulsants, thiazide diuretics, sulfonamides, valproic acid)



Other general causes, such as pancreatic duct obstruction, obesity, duodenal obstruction, viral infection (e.g., mumps), carcinoma, scorpion venom, ERCP, peritoneal dialysis, and factors still to be determined.[1]

PATHOPHYSIOLOGY Pancreatitis occurs when digestive enzymes produced in your pancreas become activated while inside the pancreas, causing damage to the organ.[2] During normal digestion, the inactivated pancreatic enzymes move through ducts in your pancreas and travel to the small intestine, where the enzymes become activated and help with digestion.[3]

1

Pancreatitis. (2015). In Encyclopædia Britannica. Retrieved from http://www.britannica.com/EBchecked/topic/441022/pancreatitis.

3

[Alterations in Metabolic and Endocrine Functions] 2

Udan, J. (2002). Medical Surgical: Concepts and Clinical Application (First Edition). Philippines: Guiani Prints House.

3

Ibid

In pancreatitis, the enzymes become activated while still in the pancreas. This causes the pancreas to undergo the process of inflammation. It is thought that alcohol increases the production of digestive enzymes in the pancreas and/or increases the sensitivity to the hormone cholecystokinin (CKK). CCK stimulates the production of pancreatic enzymes. Other and most common pathologic mechanism is autodigestion of the pancreas that may lead to further damage to thepancreas. One possible cause is the reflux of the bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. This causes the enzymes to irritate the cells of your pancreas, causing inflammation and the signs and symptoms associated with pancreatitis.[1] Regardless of the etiology, pancreatic enzymes (including trypsin, phospholipase A2, and elastase) become activated within the gland itself. The enzymes can damage tissue and activate the complement system and the inflammatory cascade, producing cytokines. This process causes inflammation, edema, and sometimes necrosis. In mild pancreatitis, inflammation is confined to the pancreas. In severe pancreatitis, there is significant inflammation, with necrosis and hemorrhage of the gland and a systemic inflammatory response. After 5 to 7 days, necrotic pancreatic tissue may become infected by enteric bacteria.[2] Activated enzymes and cytokines that enter the peritoneal cavity cause a chemical burn and third spacing of fluid; those that enter the systemic circulation cause a systemic inflammatory response that can result in acute respiratory distress syndrome and renal failure. The systemic effects are mainly the result of increased capillary permeability and decreased vascular tone, which result from the released cytokines and chemokines. Phospholipase A2 is thought to injure alveolar membranes of the lungs.[3] In about 40% of patients, collections of enzyme-rich pancreatic fluid and tissue debris form in and around the pancreas. In about half, the collections resolve spontaneously. In others, the collections become infected or form pseudocysts. Pseudocysts have a fibrous capsule without an epithelial lining. Pseudocysts may hemorrhage, rupture, or become infected.[4]

1

Pancreatitis. (2015). In Encyclopædia Britannica. Retrieved from http://www.britannica.com/EBchecked/topic/441022/pancreatitis..

2

Freedman, S. (2013, October). The Merck Manual: Acute Pancreatitis. Retrieved March 2015, from http://www.merckmanuals.com/professional/gastrointestinal_disorders/pancreatitis/acute_pancreatitis.html.

3

Gardner, T. (2014, December 8). Medscape: Acute Pancreatitis. Retrieved March 2015, from http://emedicine.medscape.com/article/181364-overview.

4

[Alterations in Metabolic and Endocrine Functions] 4

Fisher, T. & Raton, B. (2015, March 16). MedlinePlus: Pancreatic Pseudocyst. Retrieved March 20, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000272.htm.

With repeated bouts of acute pancreatitis, damage to the pancreas can occur and lead to chronic pancreatitis. Scar tissue may form in the pancreas, causing loss of function. A poorly functioning pancreas can cause digestion problems and diabetes.[1]

CLINICAL MANIFESTATION Signs and symptoms of pancreatitis may vary, depending on which type you experience. Acute pancreatitis signs and symptoms include: 

Upper abdominal pain



Abdominal pain that radiates to your back Abdominal pain that feels worse after eating



Nausea



Vomiting



Tenderness when touching the abdomen

Chronic pancreatitis signs and symptoms include: 

Upper abdominal pain



Losing weight without trying



Oily, smelly stools (steatorrhea)

The following uncommon physical findings are associated with severe necrotizing pancreatitis: 

Cullen sign (bluish discoloration around the umbilicus resulting from hemoperitoneum)



Grey-Turner sign (reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes); more commonly patients may have a ruddy erythema in the flanks secondary to extravasated pancreatic exudate.



Erythematous skin nodules, usually no longer than 1 cm and typically located on extensor skin surfaces; polyarthritis.[2]

Complications Pancreatitis can cause serious complications, including: 

Infection. Acute pancreatitis can make your pancreas vulnerable to bacteria and infection. Pancreatic infections are serious and require intensive treatment, such as surgery to remove the infected tissue. [3]



Pseudocyst. Acute pancreatitis can cause fluid and debris to collect in cyst-like pockets in your pancreas. A large pseudocyst that ruptures can cause complications such as internal bleeding and infection.[4]

1

Gardner, T. (2015, April 1). Medscape: Acute Pancreatitis. Retrieved April 15, 2015, from http://emedicine.medscape.com/article/181364-

5

[Alterations in Metabolic and Endocrine Functions] overview. 2

Ibid

3

Ibid

4

Fisher, T. & Raton, B. (2015, March 16). MedlinePlus: Pancreatic Pseudocyst. Retrieved March 20, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000272.htm.



Breathing problems. Acute pancreatitis can cause chemical changes in your body that affect your lung function, causing the level of oxygen in your blood to fall to dangerously low levels.[1]



Diabetes. Damage to insulin-producing cells in your pancreas from chronic pancreatitis can lead to diabetes, a disease that affects the way your body uses blood sugar.[2]



Kidney failure. Acute pancreatitis may cause kidney failure, which can be treated with dialysis if the kidney failure is severe and persistent.[3]



Malnutrition. Both acute and chronic pancreatitis can cause your pancreas to produce fewer of the enzymes that are needed to break down and process nutrients from the food you eat. This can lead to malnutrition, diarrhea and weight loss, even though you may be eating the same foods or the same amount of food.[4]



Pancreatic cancer. Long-standing inflammation in your pancreas caused by chronic pancreatitis is a risk factor for developing pancreatic cancer.[5]

Jaclyn Mae T. Alviola MSN Student

1

Freedman, S. (2013, October). The Merck Manual: Acute Pancreatitis. Retrieved March 2015, from http://www.merckmanuals.com/professional/gastrointestinal_disorders/pancreatitis/acute_pancreatitis.html.

6

[Alterations in Metabolic and Endocrine Functions] 2

Ibid

3

Ibid

4

Gardner, T. (2014, December 8). Medscape: Acute Pancreatitis. Retrieved March 2015, from http://emedicine.medscape.com/article/181364-overview.

5

Ibid

7