PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB BACHELOR MEDICINE AND SURGERY (MBBS) UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

1. PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB
BACHELOR MEDICINE AND SURGERY (MBBS)
UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN
MD-2508 (DIGESTIVE SYSTEM)
PROBLEM BASED LEARNING (PBL)
ACUTE
PANCREATITIS

2. TRIGGER 1
• Man
• 44 Y/O
• 160 pound (72 kg)
• Suffer epigastric pain (last 3 hour), radiate to
back

3. • Anatomical organ related
• Differential diagnose related

4. TRIGGER 2 (History)
• Already vomited clear material three times
• Alcoholic
• Likes fatty meal & has elevate fat in blood

5. TRIGGERS 3 (physical examination)
• Pulse 110/min
• Bp: 120/70 mmHg (normal)
• Esp. rate: 16/min (normal)
• temp: 38.3 C
• Exm abdomen
• Distension epigastrium, bowel sound are hypoactive,
percussion tenderness, involuntary guarding, referred
tenderness
• No diabetes, htn
• Sister had gallbladder removed

6. d/word
• percussion tenderness: Pain feel at area of
percussion
• involuntary guarding: abdominal muscle
spasm, caused by retroperitoneal
inflammation
• referred tenderness: Called reflex pain, pain
at other site

7. Trigger 4 (investigation)
• X-ray : dilated transvers colon with no-free air
• Hemoglobin: 15 g/dl
• Wbc: 15,000/ ul
• Serum amylase: 2,000 units/l (high)
• Acute pancreatitis

8. • Site of tenderness
• Onset of tenderness (when)
• Associating factor (symptom)
• Duration of pain (how long)
• Does it radiate to other part
• Characteristic of pain (crushing, burning,
palpate)
• What make pain worst
• How patient react to relieve the pain

9. ABDOMINAL REGION

10. TRANSPYLORIC PLANE : An upper
transverse line also known as Addison's
Plane, located halfway between the
jugular notch and the upper border of
the pubic symphysis. The plane in most
cases cuts through the pylorus of the
stomach, the tips of the ninth costal
cartilages and the lower border of the
first lumbar vertebra.
TRANSTUBECULAR PLANE : passing
through the iliac tubercles; behind, its
plane cuts the body of the fifth lumbar
vertebra.

11. Abdomen
Regions
Organs
Right
Hypochondriu
m
Liver, Gallbladder, Right Kidney, Small Intestine
Left
Hypochondriu
m
Spleen, Colon, Left Kidney, Pancreas
Epigastrium Stomach, Liver, Pancreas, Duodenum, Spleen,
Adrenal Glands
Right Lumber
Region
Gallbladder, Liver, Right Colon
Left Lumber
Region
Descending Colon, Left Kidney
Umbilical
Region
Umbilicus, Jejunum, Ileum, Duodenum
Right Iliac
Fossa
Appendix, Cecum
Left Iliac Fossa Descending Colon, Sigmoid Colon
Hypogastrium Urinary Bladder, Sigmoid Colon, Female
Reproductive Organs

12. What is Abdominal Pain?
• the term abdominal pain generally is used to
describe :
– pain originating from organs within the abdominal
cavity.
– Organs of the abdomen include the stomach, small
intestine, colon, liver, gallbladder, spleen, and
pancreas.
– Abdominal pain can range in intensity from a mild
stomach ache to severe acute pain.
– The pain is often nonspecific and can be caused by a
variety of conditions.

13. What Causes Abdominal Pain?
• Inflammation (appendicitis, diverticulitis, colitis),
• Stretching or distention of an organ (obstruction
of the intestine, blockage of a bile duct by
gallstones, swelling of the liver with hepatitis)
• Loss of the supply of blood to an organ (ischemic
colitis).
• Constipation
• Diarrhoea
• Acid reflux

16. Pancreas: type of cell and
secretion

17. THE PANCREAS
• Combination of two glands
a. Exocrine pancreas
o Secrete substances into the intestine
o enzymes
b. Endocrine pancreas
o Secrete substances into the bloodstream
o hormones

19. The exocrine pancreas
• It has 2 types of cells:
–Acinar cells :
• Produce digestive
enzymes:
–Protease, amylase,
lipase and peptidases
–Duct cells :
• Alkaline Fluids
–Bicarbonate ions
–Water

20. The endocrine pancreas
• Part of pancreas that made up endocrine
function is Islets of Langerhans
• 4 main types of cells:
– α alpha cells : Glucagon
– β beta cells : Insulin
– Δ delta cells : Somatostatin
– PP cells (γ (gamma) cells) : Pancretic polypeptide
• The islets of Langerhans play an imperative role
in glucose metabolism and regulation of blood
glucose concentration

23.  GALLSTONES
Hard pieces of stone-like
Produced in the gallbladder
Block the bile duct
Stopping pancreatic enzymes from traveling to the small intestine
Forcing them back into the pancreas
It begin to irritate the cells of the pancreas
Causing the inflammation

24. ALCOHOLISM
 How alcohol actually triggers the inflammation in the pancreas
is not clear.
 The molecules in alcohol interfere with the cells of the
pancreas.
 Causing the enzymes to start digesting it.
 Stopping them working properly.

25.  INJURY TO PANCREAS
 Car accident or bad fall leading to abdominal trauma.
 accidental damage during a procedure to remove gallstones or examine
the pancreas
 AUTOIMMUNE DISEASE
 own immune system attacks healthy cell
 Associated with lupus or Sjogren's syndrome
 INFECTION
 Viral – mumps virus , HIV
 IDIOPATHIC
 Idiopathic pancreatitis
 No obvious cause was identified

26. Pathophysiology of Acute
Pancreatitis

27. Pathogenesis of acute pancreatitis
Interstitial oedema
Impaired blood flow
Ischaemia
Acinar cell injury
Interstitial inflammation
oedema
Gallstone
Chronic alcoholism
Release of intracellular
proenzymes and
lysosomal hydrolases
Activation of enzymes
ACTIVATED ENZYMES
Delivery of proenzymes to
lysosomal compartment
Intracellular activation of
enzymes
Proteolysis
(proteases)
Fat necrosis
(lipase, phospholipase)
Haemorrhage
(elastase)
Alcohol, drugs
trauma, ischaemia,
viruses
Metabolic injury
(experimental)
Alcohol, duct obstruction
DUCT OBSTRUCTION ACINAR CELL INJURY DEFECTIVE INTRACELLULAR
TRANSPORT

29. pathogenesis

30. progression

31. Acute Pancreatitis; Haemorrhage and necrosis

32. Normal pancreas
Acute pancreatitis

33. MARIA

34. INTRODUCTION OF VOMITTING
• Known as emesis / throwing up
• Involuntary, forceful expulsion of the contents of
one's stomach through the mouth and sometimes
the nose.
• Not same as regurgitation.
MARIA

35. WHAT CAN YOU EXPECT FROM THE
VOMITUS?
QUANTITY COLOUR
CONTENTS
ONSET &
DURATION
MARIA

36. •Large amount.
•Small amount.
MARIA

37. GREEN/DARK
YELLOW
FRESH
BRIGHT RED
BROWNISH -
RED
FROTHY PINK
COLOUR
COFFEE-
GROUND

38. GREEN/DARK
YELLOW
FRESH BRIGHT
RED
BROWNISH
RED
FROTHY PINK COFFEE
GROUND
MARIA

39. MARIA

40. Undigested
food
Blood
Bile Fecal
MARIA

41. 4.Onset and duration
MARIA

42. AMYLASE

43. • enzyme
• begins the chemical process of digestion
• catalyses the hydrolysis starch—sugars
• 3 type-α-Amylase, β-Amylase, γ-Amylase
• Pancreas, salivary gland -alpha amylase
• hydrolyse dietary starch -
disaccharides ,trisaccharides converted by other
enzymes to glucose -energy
• Foods large amounts of starch, little sugar,
( rice,potatoes) -slightly sweet taste as chewed- amylase
degrades starch – sugar
• producing salivary amylase-gene AMY1,-originated in
pancreas
amylase

44. The normal range is 23
to 85 units per liter
(U/L). Some
laboratories give a
range of 40 to 140 U/L
pancreas damage @
inflamed-amylase in
blood
urine
By blood@urine sample
Some can affect
amount of detectable
amylase
Amylase
blood test

45. • Some medications that could heighten the amount of
amylase in the blood include:
• asparaginase
• aspirin
• birth control pills
• cholinergic medications
• ethacrynic acid
• methyldopa
• opiates (codeine, meperidine, morphine)
• thiazide diuretics (chlorothiazide, hydrochlorothiazide,
indapamide, metolazone)

46. Indication of high amylase count
• Acute or chronic pancreatitis: enzymes - help break down food in
intestines -malfunction - begin breaking down the tissues of the
pancreas. Acute pancreatitis - sudden - not last long, chronic
pancreatitis does improve , worsens over time.
• Cholecystitis: inflammation of the gallbladder. Cholecystitis is
usually caused by gallstones. Gallstones are deposits of hardened
cholesterol or other substances that can form in the gallbladder,
and cause blockages. This condition can also sometimes be caused
by tumors.
• Macroamylasemia: the presence of macroamylase in the blood.
This is an abnormal compound of the enzyme and a protein.
• Gastroenteritis: inflammation of the gastrointestinal tract.

47. • Tubal pregnancy: the fertilized egg (embryo) is
in one of the fallopian tubes (tubes that
connect the ovaries to the uterus) instead of
in the uterus. This is also called an ectopic
pregnancy, which is a pregnancy that takes
place outside the uterus.
• Other conditions: can also cause elevated
amylase counts, including salivary gland
infections, or intestinal blockages.

48. Indications of low count of amylase
• preeclampsia: a condition in pregnant
women, also called toxemia of pregnancy.
Signs of this condition also include high blood
pressure.
• damaged pancreas
• kidney disease

49. FAT METABOLISM

50. • The body has limited supply of glucose.
• 3 sources of fatty acid for energy metabolism
- dietry tryacylglycerol
- tryacylglycerol that synthesize in liver
- tryacylglycerol stored in adipocytes
• When foods enter the stomach, it will breakdown
into components such as carbohydrates, proteins
and fats.
• Dietry tryacylglycerol comes from the fat in the foods
we eat and the process of breakdown start to occurs
in small intestine not in the stomach.

51. In the small intestine,
bile salt from the gall
bladder will emulsify the
realtively insoluble
dietry fat to form
micelles.

52. The micelles have non-polar
core and surrounded by bile
salts.
R-group are non-polar and
so they point towards the
centre of the micelles.

53. After that, as micelles moving
downwards the small
intestine, pancreatic lipase will
degrades the triacylglycerol
into fatty acids and glycerol.

54. Then, the 3 Fatty acids and 1
glycerol packaged with
apoprotein and cholesterol
into blood-soluble-complex
called chylomicrons.

55. The chylomicrons will
cross blood vessel
membrane and move
into blood stream.
From here on, the
chylomicrons will have 2
possible pathways:
-Stored in adipocytes
-Move to muscle cells

56. For fat storage in adipocytes,
the triacylglycerol is cleaved
on the wall of blood vessel
by lipoprotein lipase into
fatty acid and glycerol.
Then it will move to
adipocyte cells and stored as
fat droplets.

57. However, if the person
exercise or do hard
chorus after that, the
fat then will be utilized
by muscle cells as
energy through beta-
oxidation
to form carbon dioxide
and ATP.

58. Up to this point we have
described dietry fatty acid
pathway either stored in
the adipocytes or
immediately utilized.

59. During strenous exercise,
muscle use up the small
amount of the body’s stored
glycogen. So, in order to
compensate that insufficient
energy, the energy that
stored as fat droplets in
adipocytes is released.

60. Epinephrin or glucagon leaves
bloodstream and binds to
adipocytes receptor.
This will allow adenylate cyclase
to convert ATP into cAMP.
Then, cAMP will bind to protein
kinase and activates it.

61. Activated protein kinase will
Proceeds to bind to
triacylglycerol lipase and
activating it.
Once activated, the
triacylglycerol lipase is able
to break triacylglycerol into
fatty acid and glycerol.

62. Then fatty acid molecules are
pick up by the protein albumin
in the blood stream.
Serum albumin travels through
the blood vessels and release
the fatty acid molecules into
myocytes.

63. Finally, the fatty acid will
undergo beta-oxidation to
produce carbon dioxide and ATP

64. Complication of Pancreatitis.

65. Early
complications
infections
Malnutrition
Abdominal swelling
Systemic inflammatory response
High blood glucose
Severe respiratory failure
Late
complications
Recurrent pancreatitis
Pancreatitic pseudocyst
Acute necrotizing pancreatitis

66. Early complications
Infection.
• make pancreas vulnerable to bacteria and infection  inflammations 
interruption to blood supply  necrosis
• require intensive treatment, such as surgery to remove the infected tissue.
Diabetes.
• Damage to insulin-producing cells in pancreas
• from chronic pancreatitis can lead to diabetes
• affects the way our body uses blood sugar.
Kidney failure
• can be treated with dialysis if the kidney failure is severe and persistent.
Malnutrition.
• Both acute and chronic pancreatitis can cause pancreas to produce fewer of the
enzymes that are needed to break down and process nutrients from the food
• lead to malnutrition, diarrhea and weight loss, even though patient may be eating
the same foods or the same amount of food..

67. Pleural effusion pain
Shallow
breathing
Breathing
problems.
Lung collapse
Severe
respiratory
complications

68. Pancreatic enzymes may
attack the lungs
inflammation
Severe inflammation
lead to intra-abdominal
hypertension
and abdominal
compartment syndrome
impaired renal and
respiratory function

69. Late complications
Recurrent pancreatitis
• Pancrease permanently damaged & chronic pancreatitis develops
Pseudocyst.
• fluid and debris to collect in cyst-like pockets in pancreas and walled off by scar tissue
• may cause pain, become infected, rupture and bleed
• May cause bloating, indigestion and a dull abdominal pain
Acute necrotizing pancreatitis
• pancreatic abscess (a collection of pus caused by necrosis, liquefaction and infection)
• Hypovolemic shock (ascites  decreasing the blood volume & BP)
• Prone to infection  bacteremia  multiple organ failure
Pancreatic cancer.
• Long-standing inflammation in pancreas caused by chronic pancreatitis is a risk factor
for developing pancreatic cancer

70. Treatment and management of acute
pancreatitis

71. Aim of treatment
1. Focus on relieving the symptoms
2. Preventing further complication
3. Support body functions

72. Treatment & management
• Determine and treat etiology (avoid alcohol)
• No solid food should be taken by mouth for a
few days (bowel rest)
• Adopt a liquid diet consisting of foods like
soups. These simple foods may allow the
inflammation process to get better.
• Administration of pain killer
• IV replacement of fluids
• If the attack lasts longer than a few days,
nutritional supplements are administered
through an IV line.

73. Treatment & management
• Nasogastric (NG) tube. The thin, flexible plastic tube
is inserted through the nose and down into the
stomach to suck out the stomach juices. This suction
of the stomach juices rests the intestine further,
helping the pancreas recover
• By giving antiemetic
• Prevent infection by antibiotic
• Indication to surgery if pancreatitis not respond to
treatment

74. INVESTIGATION OF ACUTE
PANCREATITIS

75. PANCREATIC ENZYME
• Amylase
- after 2 to 12 hours
- 23-85 U/L (normal range)
- Most accurate diagnosed when at least twice
of normal range

76. • Lipase
– 4 to 8
– 0-160 U/L (normal range)
– Increased sensitivity in alcohol-induced
pancreatitis
– more specific and sensitive than amylase for
detecting acute pancreatitis

77. Complete blood count (CBC) and
hematocrit;
• Normal hematocrit value
Male: 38.8-50.0 percent
Female: 34.9-44.5 percent
• To evaluate RBC count
• To evaluate WBC count

78. Trypsinogen activation peptide
• Within a few hours
• Early marker for acute pancreatitis and close
correlation to severity

79. Blood glucose test
• Pancreas released insulin to handle level of
blood glucose
• In pancreatitis,
- pancreas may does not make enough insulin
- The insulin does not work properly
• Using fasting blood glucose level
• Normal value (3.9 to 5.5 mmol/L)

80. Why do abdominal X-ray?
• Acute pancreatitis
- low sensitivity
- localised ileus (blockage of intestine)
- colon cut-off sign ( dilated colon to colon
with no air seen beyond the splenic flexure.
This is due to extension of inflammation along
mesocolon)
- pleural effusion

81. • Chronic pancreatitis
- calcification