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Two causes of acute pancreatitis
What is peritonitis?
peritonitis is the inflammation of the peritoneum which is the lining of the abdomen
Three stages of alcohol-related liver disease?
Alcoholic fatty liver disease
Alcoholic hepatitis
Cirrhosis
Two causes of chronic pancreatitis
symptoms and signs of peritonitis
Symptoms:
Signs:
how does alcohol use cause liver cirrhosis?
Prolonged alcohol misuse causes liver cell (hepatocyte) damage and necrosis and this leads to liver cirrhosis
what happens in secondary peritonitis?
gastrointestinal (oesophagus, stomach, pancreas, hepatobiliary, small or large intestine) perforations which leads to the contents spilling out into a normally sterile area and this leads to infections
Signs and symptoms of acute pancreatitis
Symptoms:
– Acute abdominal pain
– Central, severe & often radiates to back
– Vomiting
– History of Alcohol excess, gallstones & certain drugs
Signs:
– Guarding and tenderness in upper abdomen
how does alcohol cause anaemia?
Chronic alcohol use can result in vitamin B deficiencies and folate deficiency which can result in macrocytic anaemia.
heavy alcohol consumption can cause generalized suppression of blood cell production and the production of structurally abnormal blood cell precursors that cannot mature into functional cells
Three social implications of alcohol use
· Family effects - 5 million families deal with problem drinker, arguments, violence, debt, relationship problems
· Death
· Crime and disorder
· Domestic violence - Involved in 73% of cases
· Poor productivity at work
· Absences/sick leave from work
Function of pancreas
Exocrine
• Powerful digestive enzymes (Trypsin, lipases & amylase) released into the small intestine to aid the digestion of carbohydrates, proteins & fat
Endocrine
• Insulin & glucagon for glucose regulation
What happens in acute pancreatitis caused by gall stones
Common bacteria that cause peritonitis
gram-negative (e.g. Escherichia coli and Klebsiella pneumoniae) and anaerobic bacteria. The actual pathogens differ depending on the organ affected. gram-positive organisms observed with upper GI perforations
How does alcohol use cause coagulation problems?
alcohol can interfere with the coagulation processes at several levels, causing, for example, abnormally low platelet numbers in the blood (i.e., thrombocytopenia), impaired platelet function (reduced platelet clumping etc), and diminished fibrinolysis
What happens in acute pancreatitis caused by alcohol?
What happens in chronic pancreatitis?
how does alcohol use cause portal hypertension?
When the liver is very scarred, it's harder for blood to move through it.
This leads to an increase in the pressure of blood around the intestines- portal hypertension
How does alcohol use cause varices?
The blood find a new way to return to the heart from the liver. It does this by using smaller blood vessels.
But these vessels are not designed to carry the weight of blood, so they can become stretched out and weakened. These weakened blood vessels are known as varices.
What happens in spontaneous bacterial peritonitis?
- It is usually a complication of liver or kidney failure, resulting in fluid buildup in the abdominal cavity (ascites).
- Spontaneous bacterial peritonitis is the development of an infection of the ascites fluid in the peritoneum
A 56-year-old male presents to his GP with severe acute onset abdominal pain that radiates to his back. He is a smoker and has a past medical history of heavy alcohol use, osteoarthritis, asthma. His current medications include a salbutamol and a corticosteroid inhaler. On examination, his body mass index is 35kg/m².
Which of the following factors is the most likely cause of the presentation?
Walter presents acutely to the hospital with severe epigastric pain that is radiating to the back, nausea and vomiting. Upon questioning, he has suffered from several episodes of biliary colic in the past. A blood test reveals a lipase level of 1000U/L.
What is the pathophysiology of the condition affecting Walter?
A. An enormous release of pancreatic enzymes triggers a negative feedback mechanism, causes the pancreatic glands to stop producing pancreatic enzymes
B. Pancreatic enzymes released as a result of inflammation autodigest the liver and biliary tree tissue
C. Pancreatic enzymes released as a result of inflammation autodigest the pancreatic tissue
D. The pancreatic enzymes produced are defective and unable to aid in food digestion
E. An accumulation of pancreatic enzymes causes blockage of the pancreatic ducts and pain
C. Pancreatic enzymes released as a result of inflammation autodigest the pancreatic tissue
Inflammation of the pancreas in acute pancreatitis causes pancreatic enzymes to be released and activated, and digest the pancreatic tissue. This process is called autodigestion.
You are on a general surgical receiving ward when a 75-year-old woman is admitted from the emergency department with severe, sudden onset abdominal pain which radiates to her back.
The patient reports she is normally fit and well, although has been badly affected by rheumatoid arthritis over the last few years, but this is improving with treatment. She does not drink alcohol and has previously undergone an open cholecystectomy, although this was so long ago she cannot remember exactly when it happened.
Blood tests were taken in the emergency department:
Given the likely diagnosis, what is the most likely causative factor leading to this patient’s presentation?
A. Azathioprine
B. Ethanol
C. Gall stones obstructing the common bile duct
D. Recent trauma
E. Sodium valproate
A. Azathioprine
It is important to note that both presentation and blood tests here indicate a likely diagnosis of acute pancreatitis. Once this has been established, we need to remember that the most common causes of this condition by far are gallstones and ethanol, both of which can be ruled out via history taking. Note that although after cholecystectomy it is possible to have retained stones in the common bile duct, this is rare and becomes less likely with the significant time since the operation.
azathioprine, an immunosuppressive medication used in the treatment of rheumatoid arthritis and known to have a side effect of acute pancreatitis. This makes it the most likely causative factor in this case.
A 65-year-old man presents with severe upper abdominal pain, fever, and vomiting. He is diagnosed with acute pancreatitis. Which of the following liver function tests is raised disproportionately in pancreatitis?
A. Unconjugated bilirubin
B. Alanine aminotransferase (ALT)
C. Alkaline phosphatase (ALP)
D. Amylase
E. Gamma glutamyltransferase (GGT)
D. Amylase
Amylase is produced in the pancreas and is used to digest carbohydrates. It is released into the blood in large quantities in pancreatic disease.
Alanine aminotransferase (ALT) is a relatively liver-specific cytoplasmic enzyme and is raised in hepatic injury.
A 45-year-old female with a history of sickle cell disease presents to the emergency department with severe epigastric pain that radiates to her back. The patient appears clinically jaundiced. She reports drinking one small glass of red wine a week but no other alcohol consumption. A diagnosis of acute pancreatitis is made.
What is the most likely cause of acute pancreatitis in this patient?
A. Alcohol
B. Autoimmune
C. Gallstones
D. Steroids
E. Trauma
C. Gallstones
Gallstones and heavy alcohol use are the most common causes of pancreatitis
You are on a post-take ward round with your consultant and review a 48-year-old man who was admitted with sudden severe abdominal pain, confusion and pyrexia. He has a background of alcoholic cirrhosis and known ascites which is normally asymptomatic. An ascitic tap was done overnight which showed a neutrophil count of 375/mm³ and was sent for urgent microscopy & culture.
What organism is most likely to grow from the ascitic tap?
E. coli
Staphylococcus aureus
Klebsiella
Streptococcus
Enterococcus
E. coli
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli