2. • Pancreatitis is inflammation of the pancreas.
• The pancreas is a large gland behind
the stomach, close to the first part of
the small intestine, called the duodenum.
• The pancreas has two main functions—to
make insulin and to make digestive juices, or
enzymes, to help you digest food.
• These enzymes digest food in the intestine.
• Pancreatitis occurs when the enzymes damage
the pancreas, which causes inflammation.
3. • There are four types of pancreatitis, according to
the classification :
• I. Acute pancreatitis — a single episode of
pancreatitis in a previously normal gland.
• II. Acute relapsing pancreatitis— recurrent
attacks of acute pancreatitis with normalcy in the
intervals between attacks and without
permanent functional damage of the pancreas.
• III. Chronic pancreatitis — irreversible destruction
of pancreatic function with constant pain.
• IV Chronic relapsing pancreatitis— recurrent
attacks of pain with frequent pain-intervals with
progressive functional damage of the pancreas.
4. ACUTE AND ACUTE RELAPSING
PANCREATITIS
'Acute pancreatitis’ means acute inflammation
superimposed on a normal gland and when
such several episodes occur ‘acute relapsing
pancreatitis’ is said to exist.
5. Pathogenesis
1 GALLSTONES AND CHOLEDOCHOLITHIASIS:
Gallstones and alcohol are the two major
conditions which can give aetiological
explanation of no less than nearly 90% of
cases of acute pancreatitis.
6. • The mechanism by which gallstones result
pancreatitis is not very clearly known,
• (a) For quite a long time common channel
theory ’ has given much importance in which
bile reflux into the pancreatic duct as the two
ducts join together to form the common
channel before they open into the duodenum.
• But unfortunately bidirectional reflux i.e bile
flowing into the pancreatic duct and
pancreatic juice into the bile duct has been
observed in humans without pancreatitis.
7. • Active perfusion of normal bile into pancreatic
duct at normal pressure does not cause
pancreatitis.
• Moreover pressure in the pancreatic duct
system is consistently higher than that in the
bile duct system and that is why one cannot
expect that bile will perfuse the pancreatic
ducts.
8. • (b) Transient obstruction of the pancreatic duct by
gallstones can result in pancreatitis.
• Transampullary migration of biliary calculi
appears to be well established as an important
cause of acute and acute relapsing pancreatitis.
• Several studies have indicated tha
choledocholithiasis can lead to the development
of acute pancreatitis even in the absence of a
common biliary-pancreatic channel.
• Presumably the presence of an ampullary stone
or oedema at the papilla can obstruct pancreatic
duct outflow and thus results increase in pressure
within the pancreatic duct system.
9. 2. ALCOHOL
• The exact mechanism is also not known how
alcohol can induce pancreatitis,
• (a) A direct toxic effect of alcohol on the
pancreatic parenchyma has been postulated
but could not find a solid base,
• (b) With prolonged alcohol intake protein is
precipitated in pancreatic juice within the
ductuless leading to ductular obstruction and
increased pressure within the ductules,
10. • (c) Duodenal inflammation induced by alcohol
may produce some degree of duct
obstruction,
• (d) Persistent vomiting may cause
regurgitation of duodenal contents into the
pancreatic ducts
• Two mechanisms seen to give reasonable
explanation how alcohol may cause acute
pancreatitis.
11. • (e) alcohol stimulates pancreatic secretion by
way of acid-induced secretion release,
• (f) Alcohol increases sphincteric tone at the
ampullary region.
• So alcohol increases secretion against an
unyielding sphincter.
• This seems to be the most reasonable
explanation of how alcohol causes acute
pancreatitis.
12. 3. OBSTRUCTION
• It is obvious that some sort of obstruction of
the pancreatic duct is required to produce
acute pancreatitis.
• But deliberate ligation of the major pancreatic
duct in the treatment of chronic relapsing
pancreatitis has not caused acute disease
• So duct obstruction must be associated with
stimulation of pancreatic secretion.
13. • Closed-loop duodenal obstruction with biliary
exclusion is followed by fulminating type of
acute pancreatitis.
• Obstructed duodenum may elaborate factors
that may provoke pancreatic inflammation
14. 4. METABOLIC FACTORS.
• (a) Hyperlipidaemia has got some relation with
acute pancreatitis.
• Some patients with a genetic predisposition to
hyperlipidaemia and pancreatitis are often
diagnosed in childhood.
• Second variety of hyperlipidaemia which causes
pancreatitis is often diagnosed as idiopathic
variety.
• Dietary-induced hypertriglyceridaemia may cause
attacks of acute pancreatitis alcoholic patients.
• It seems that conversion of triglycerides to toxic
free acids within the pancreatic parenchyma by
pancreatic lipase may be the cause of pancreatitis
in hyperlipidaemia.
15. • (b) Hypercalcaemia and pancreatitis are often
associated with.
• Hyperparathyroidism may reveal itself by
repeated attacks of acute pancreatitis.
• Precipitation of calcium phosphate in the
pancreatic duct will lead to obstruction along
with increased pancreatic secretion to cause
pancreatitis.
• (c) Haemochromatosis has been thought to
produce pancreatic fibrosis and atrophy due to
irritating property of deposited iron in the
pancreas.
16. 5. VASCULAR FACTORS
• Pancreatitis may be induced by injection of
microspheres of various sizes into the
pancreaticoduodenal arteries in animals.
• These particles occlude the terminal arterial
supply and produce local ischaemia.
• Sometimes in older patients who have
widespread vascular obstruction from
atherosclerosis and patients who have undergone
cardiopulmonary bypass are sometimes seen
with severe haemorrhagic pancreatitis.
17. 6. POSTOPERATIVE PANCREATITIS
• Following certain intra-abdominal operations
pancreatitis may occur. These operations are
mainly on the stomach or on the biliary tract.
• After partial gastrectomy afferent loop
obstruction may cause pancreatitis.
• After common bile duct exploration, specially
if a long-armed T-tube has been placed
through the sphincter of Oddi pancreatitis
may follow.
18. 7. MISCELLANEOUS
• Certain toxins such as methyl alcohol, zinc
oxide, cholinesterase inhibitors have been
known to produce pancreatitis by pancreatic
injury.
• A few viral diseases e.g. mumps, echovirus
infection, coxsackie virus infections,
mononucleosis have been incriminated to
cause pancreatitis.
19. • A few drugs e.g. corticosteroids, phenformim.
azathioprin, chlorothiazide, frusemide etc. have
been held responsible to cause pancreatitis.
• A certain investigative procedures particularly
ERCP may cause pancreatitis.
• Trauma. scorpion sting, porphyria, shock,
vasculitis are a few factors which have some
direct relation with pancreatitis.
• Autodigestion by activated intrapancreatic
enzymes may lead to such pancreatitis.
