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Acute and chronic pancreatitis

Pancreatitis (acute and chronic) is a serious disease characterized by inflammation of the pancreas. 
The pancreas is a large gland located behind the stomach and duodenum (the first part of the small intestine).

 

Pathophysiology (development) of pancreatitis

During the normal digestion process, the pancreatic enzymes in inactive form are released into the small intestine through the pancreatic duct. 
They become active in the duodenum. 
In the case of pancreatitis, the enzymes are activated within the pancreas and begin to digest the pancreatic tissues. 
This process is known as self-digestion and can cause inflammation of the pancreas and necrosis (cell death).

Under normal conditions, the pancreas has the following defenses:

  • In the pancreas, the enzymes are contained within the organelles and are inactive;
  • In the organ and blood there are some inhibitors, for example:
    • The trypsin inhibitor,
    • α1-antitripsina,
    • α2-macroglobulina.
  • Continuous pancreatic flow prevents stasis that can cause enzymatic activation,
  • The sphincter of Oddi prevents the reflux of juices in the pancreas.

In the duodenal papilla, the pancreatic duct is located near (sometimes attached) to the common bile duct. 
Thus, pancreatic juices mingle with bile in the duodenum. 
Pancreatic juice has an alkaline pH (7.9-8.6) and is composed of:

  • Water and electrolytes (97%),
  • Bicarbonate, is the main dissolved element and increases the pH,
  • Protein: digestive enzymes (3%).

This is necessary to reduce the acidity of foods that have been digested in the stomach, where the environment is very acidic. 
The alkaline duodenal pH is an ideal environment for enzymatic activity.

Protein component

Proteolytic enzymes
  • Trypsin,
  • Quimotripsina
  • Elastase
  • Carbepteptidase A e B
Glycolytic enzymes α-amylase
Lipolytic enzymes Pancreatic lipase

 

Normally, enzymes are activated in the passage from the pancreas to the duodenum. However when the pancreas is inflamed, the enzymes are activated in the tissue itself of the pancreas.

Instead of breaking down the lipids in the duodenum, the lipase attacks the pancreatic tissue.

The same goes for the other enzymes.

 

Hypocalcemia and pancreatitis

Some of the hydrogen and calcium is bound to albumin in the bloodstream. 
People with pancreatitis suffer from vomiting and this can cause alkalosis (increased blood pH). 
The body reacts with the release of hydrogen ions from the albumin to recover the correct pH level in the blood. 
Thus, there is a greater amount of free albumin that can be bound to calcium. 
In this way, free calcium in the blood is reduced.

Proteolytic enzymes (which break down proteins) can cause destruction of circulating parathyroid hormones , and the parathyroid gland may not produce enough amounts of hormones. 
These are considered the main causes of persistent hypocalcemia in acute pancreatitis. (7)

 


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Pancreatitis can be of two types: acute and chronic.

  • In acute pancreatitis, sudden inflammation of the pancreas occurs due to the activation of pancreatic enzymes within the organ;
  • In chronic inflammation is observed at relapse (relapse) and fibrosis of organs (specific tissue replacement by fibrous connective tissue).

The chronic pancreatitis is divided into :

  1. Alcohol,
  2. Non alcoholic,
  3. Linked to anatomical changes.

Among non-alcoholic pancreatitis are the following types:

  1. Tropical,
  2. Hereditary
  3. Metabolic,
  4. Autoimmune Chronic (PCA) is an inflammatory disease that occurs because the body’s immune system mistakenly attacks the pancreas.

Acute pancreatitis can be of two types (1):

  • Edematous pancreatitis (mild form)
    It is the mildest and most frequent type, characterized by inflammation and sometimes a small area of ​​lipid necrosis (focal). The organ gets bigger and the release of enzymes does not cause major changes.
  • Acute hemorrhagic necrotic pancreatitis (severe form)
    Acute hemorrhagic necrotizing pancreatitis. 
    It is a serious and deadly disease. 
    There are important anatomical changes and the mortality is up to 60-70% of patients. It can also cause a failure of other organs.

Signs of acute hemorrhagic pancreatitis include:

  • Vomiting
  • Heart disease
  • Cardiovascular shock
  • Acute pancreatic necrosis, or destruction of islets of langerhans in the pancreas

 

Causes of pancreatitis

The 2 main causes of pancreatitis, ie the formation of gallstones (2) and alcoholism (3) represent 80% of the cases. 
The alcoholism caused by pancreatitis occurs due to alcohol consumption for long. 
The alcohol:

  • It stimulates the production of enzymes that digest proteins,
  • It reduces the secretion of bicarbonate,
  • It causes the reduction of the inhibitors of the pancreatic enzyme.

The formation of gallstones in the gallbladder can cause blockage in the pancreatic duct and the accumulation of digestive juices inside the pancreas. 
Obstruction of the bile ducts beyond the conjunction of the common bile duct and the pancreatic duct causes reflux of bile into the pancreatic ducts. 
Bile attacks the lipids of cell membranes causing lesions. 
The smoke is one of the risk factors , so you need to quit smoking .

Other causes:

 

Pancreatitis can develop for different reasons depending on whether it is acute or chronic.

Acute pancreatitis
The main causes of acute pancreatitis are:

  1. Gallstones,
  2. Diseases of the gallbladder,
  3. Alcoholism.

Other causes include:

  • diagnostic examination or surgical intervention in the bile duct;
  • Traumatic lesions that cause damage to the pancreatic or biliary ducts;
  • Abnormal structure of the pancreas;
  • Genetic factors;
  • Hypertriglyceridemia (elevated blood lipid levels);
  • Some medications like cortisone , thiazide diuretics, valproic acid, salicylates and estrogen can cause pancreatitis;
  • Some bacterial or viral infections such as mumps, Mycoplasma pneumoniaand coxsackie B virus;
  • Poisons: scorpion, anticholinesterase pesticides;
  • Idiopathic cause (reason is unknown).

Generally, in children (9), acute pancreatitis is caused by:

  • Cystic fibrosis ,
  • Mumps or other infections,
  • Trauma abdominal,
  • Reye Syndrome,
  • Kawasaki disease,
  • Juvenile rheumatoid arthritis ,
  • Lupus,
  • because,
  • Henoch-Schönlein purpura,
  • Anorexia nervosa,
  • Food allergy ,
  • Inflammatory bowel disease
  • Hypercalcemia,
  • Diabetes,
  • Deficiency of α1 antitrypsin,
  • Malnutrition,
  • Deficiency of vitamins A and D,
  • Hemolytic-uremic syndrome.

Chronic pancreatitis
More often than not, chronic pancreatitis is caused by alcohol abuse for a long time. 
Some other diseases can lead to chronic pancreatitis, such as:

  • Stenosis (narrowing) or obstruction of the pancreatic duct due to trauma,
  • The formation of pseudocysts,
  • Hyperparathyroidism,
  • Hypercalcemia (may promote the formation of calcifications ),
  • Hyperlipidemia,
  • Malnutrition,
  • Autoimmune diseases,
  • A genetic (hereditary) disease,

In some cases it is idiopathic (cause unknown).

 


Symptoms of pancreatitis

Acute pancreatitis
The most frequent symptoms of acute pancreatitis are:

The abdominal pain is between the navel and ribs. 
The back pain can be felt in a horizontal band just below the shoulder blades.

Frequency of symptoms

Abdominal pain 95%
Vomiting 60%
Paralytic ileus * 50%
Abdomen not palpable 
(because of pain)
40%
Fever 60%
Jaundice ** 10-15%
Palpable mass 10%
Shock and hypotension 30%
Necrose Adiposa / Tromboflebite <1%

* Blockage of intestinal contents progression

** In case of edema (swelling) of the head of the pancreas, compression of the common bile duct may occur. The consequence is jaundice.

Chronic Pancreatitis
Many symptoms of chronic pancreatitis are similar to those of acute pancreatitis, but others may appear when persistent pancreatic inflammation worsens over time. 
Symptoms of chronic pancreatitis include:

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