|
Back to Topics<<<< It is the acute inflammation of the pancreas, it can vary from mild parenchymal oedema to severe haemorrhagic destruction with loss of pancreatic viability, gangrene and subsequent necrosis. ETIOLOGY: There are many causes of pancreatitis. In 90% of cases, the cause is related to the excessive alcohol in take or biliary tract disease. Autodigestion: It is the most commonly believed phenomenon in which there is acute necrosis of the tissue of pancreas by its own proteolytic enzymes, trypsin. Usually the trypsinogen is secreted in an inert form and it is converted to its activated form (trypsin) in duodenum by enterokinase but if the activation of trypsinogen to trpysin occurs with in the pancreas, it causes acute inflammation of the pancreatic tissue. This can happen by many reasons like regurgitation of bile when the pancreatic duct and accessory duct open into duodenum through the common channel or when there is an obstruction to the outflow of pancreatic juices like by the impact of stones in the sphincter of Oddi etc. The other causes are:
1. The pancreas In mild form the pancreas shows a generalized (rarely localized) oedema. In severe form it is grossly haemorrhagic and necrotic. Suppuration may follow subsequently. 2. Haemorrhage The haemorrhage, which occurs in the gland itself, spreads to its vicinity. The peritoneal cavity, specially the lesser sac contains a blood stained sacs. Occasionally there may be haemorrhage at distal sites e.g. abdominal wall. The haemorrhage is believed to occur as a result of degenerative changes, brought about in the walls of blood vessels, by the liberated pancreatic enzymes. 3. Fat necrosis This is cause by lipase escaping from the pancreas. The lipase splits the fat into glycerol and fatty acids. The fatty acids combine with calcium to form soaps. The soaps is represented in the area of fat necrosis, which are dull, opaque, yellowish white, raised areas suggestive of drops of wax. The sites of these deposits are as follows:
Gallstones, infected by and chronic cholecystitis are commonly associated. The liver function is often depressed. Histological forms:
Ecchymosis and pigmentation of the skin may be seen within 24 hrs of the initial attack due to the spread of blood and pancreatic ferments from retroperitoneal tissue o the subcutaneous fat and skin. Typically there are two sites:
Blood count: Blood count shows high leucocytosis Blood chemistry: Serum calcium: Usually the level of the calcium decrease as the calcium is involved in the soap formation. The fall is generally in about a week. A level below 7mg/100ml indicates a grave prognosis (normal level of calcium in the blood is 10mg/100ml). Serum bilirubin: The level of the serum bilirubin is increased even if there is no evidence of jaundice. Blood sugars: Blood sugars are elevated sometimes. Serum fibrinogen: The level of the serum fibrinogen is increased in the first week and is of prognostic value. Methaemalbumin: The presence of methaemalbumin in blood indicates a bad prognosis as it is suggestive of haemorrhagic necrosis. Enzyme Studies: Amylase: the normal level of amylase in the serum is about 80-150 Somogyi units. If it is present in more than 500 units then it is suspicious, but if it is present above 1000 units then it is suggestive. It usually rises with an hour of onset and then gradually falls down over the next few days. Urinary diastase (amylase): Normally diastatic index is about 150 units. It starts rising after 12 hrs of initial attack and remains elevated for days. So this test is of value in the diagnosis in the later stages. Other investigating methods are: X-Ray: “Cut off sign” is present as gas filled solitary loop consisting of duodenum and proximal jejunum. It may also reveal any of the presence of gall stones. The absence of subdiaphragmatic gas shadow excludes the peptic perforation. Ultrasound CT-scans MRI TREATMENT: Therapeutic:
Surgical treatment includes opening of the bursa omentalis and incorting drainage tube. In necroting pancreatitis, distal or proximal resection of the pancreas is indicated. Distal pancreatectomy is done if head of pancreas is normal; and Pancreatoduodenectomy is performed if the head of the pancreas is mainly involved Longitudinal Pancreatojejunostomy is carried out if the pancreatic duct is grossly dilated. COMPLICATIONS:
Kerte’s sign: If the patient feels pain at one point (mid epigastric point) Meyor and Rupsen: If we palpate the junction of 11th and 12th rib with vertebrae patient feels pain Grey Turner and Cullen’s sign: Subcutaneous hemorrhages rise in the upper left quadrant and around the umbilicus This article has been written by Dr. M. Javed Abbas. If you have any comments please do not hesitate to sign my Guest Book. 00:55 06/02/2003 |