Acute Pancreatitis, Chronic Pancreatitis, Psuedocyst, Adenocarcinoma

There are two main pathologies related to the pancreas: Acute pancreatitis and Chronic Pancreatitis. In this video we will go over the underlying pathophysiology and pathogenesis of those diseases in preparation for USMLE Step 1

Acute Pancreatitis
Reversible destruction due to activation of inappropriate activation of enzyme that leads to autodigestion.
Causes: GET SMASHED
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hypercalcemia/Hypertriglyceridemia, ERCP, Drugs.
Gallstones and Ethanol (Alcohol) are responsible for 80% of acute pancreatitis.
Gallstones can cause acute pancreatitis by blocking the pancreatic duct and reflux of bile.
Alcohol causes acute pancreatitis by increasing permeability of the membrane to the enzymes. Enzymes go into intersitium and degrades the interstitium. Alcohol changes shapes of the protein which causes it to deposit and evenutally leads to pancreatitis.
On CT the pancreas will be dilated and edematous.
The main enzyme that is activated is trypsin which goes on to activate the other enzymes such as lipase, kalliekrin and other enzymes .Phosphlipase will break down fat which will lead to calcium sequestration that can cause hypocalcemia. It also breaks down lung surfanctant which can lead to ARDS which leads to hypoxia.
Elastase and Complement factors affects vessels which increases bleeding and hemorrhage. Elastase also affects islets cells.
Prothrombin factors - thrombosis and ischemia and pain in extremities
Kallikrein is activated by trysin that can lead to DIC.
CLinical signs of acute pancreatitis
The main clinical sign is abdominal pain that radiates to the back. Anorexia, weight loss and vomiting.
Lab - increase amylase and lipase,

Chronic Pancreatitis
This is irreverisble destruction leading to fibrosis and destruction of pancreas.
Caused by ALcohol and obstruction, recurrent attacks of acute pancreatitis.
Alcohol changes the quality of the pancreatic juice. This leads to decrease water and HCO3. Citrate and lithostatin and these prevent calcium from precipitating. Calcium deposition causes blockage of the duct.
Obstruction by Cystic Fibrosis shows distention of the pancreatic duct. Eventually you will get atrophy stenosis and fibrosis.

Clinical symptoms of Chronic pancreatitis.
Pain, Malabsorption (unable to breakdown food). Eventually can cause Diabetes Mellitus. Thrombosis due to activation of prothrombin by trypsin. Jaundice and Diarrhea due to psuedocyst.

PSUEDOCYST
no epithelial lining, Hemorrhagic material that is localized.

ADENOCARCINOMA
Primarily from the head of the pancreas. Tumor markers CA19-9.
Causes Tobacco (not alcohol), Chronic pancreatitis can also lead to adenocarcinoma. Age greater than 50 years old and it is common amongst Jews and Africans.

CLINICAL
Abdominal pain radiating to back similar to acute pancreatitis. Malabsorption which leads to steatorrhea, weight loss.
Trousseau's Sign - migratory thrombophlebitis which is redness/tenderness extremities.
Courvoisier's sign - Obstructive jaundice with non-tender palpable gallbladder
Treatment for pancreatic adenocarcinoma includes chemotherapy, radiation and whipple procedure

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