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Acute pancreatitis

Acute pancreatitis is the sudden inflammation of the pancreas… [which] occurs when there is abnormal activation of the digestive enzymes within the pancreas.

Emmanuel Enabuele

I was presiding in a seminar on fake drugs organised by the Health Writers Association of Nigeria. One of the presenters is the head of a psychiatric hospital. I had asked her about the most commonly abused substance in our environment. Her answer was very simple and straightforward: alcohol. It wasn’t even hard substances, like morphine and cocaine. At the time of this seminar Tramadol was not even trending.

The import of this is that sizeable populations of our citizenry, especially the middle class are consuming quite a quantity of alcohol beverages. It is not surprising that one of the common complaints in our environment is upper abdominal pain, which, erroneously, in most cases are referred to ‘Ulcer.’

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I had a friend who was married for 16 years without a child. To be able to cope with this, his wife resorted to excessive alcohol consumption. On average she was hospitalised at least twice a month for severe upper abdominal pains. Along the line, she developed type ll diabetes mellitus and burned out.

During one of the visits to the hospital, before she passed on, a smart House Officer decided to check her serum LIPASE and found that it was abnormally high. There was no puzzle here. Excessive alcohol intake had led to inflammation of the PANCREAS and death of Islets of Langerhans cells, which produce insulin resulting in diabetes. The illness by then was end stage and there was little anyone could do, but some lessons had been learnt.

The pancreas is a glandular organ that is located in the left upper part of the abdomen behind the stomach between the first parts of the small intestine known as the duodenum and extends to the spleen. It has both endocrine and exocrine functions. As an endocrine organ it synthesises and secrets hormones like insulin and glucagon, which regulate blood sugar levels and somatstatin that regulates the beta and alpha cells that produce these hormones. Delta cells produce somatostatin. The pancreas exocrine function includes the production of pancreatic juice, which is emptied into the duodenum through the pancreatic ducts as it joins the common bile duct. This fluid contains enzymes that help breakdown carbohydrate, proteins and lipids in the intestine. It is alkaline in nature, which helps to neutralise the acid secreted by the stomach in the chyme.

Acute pancreatitis is the sudden inflammation of the pancreas. The symptoms of acute pancreatitis can be mild or severe. The inflammation of pancreas occurs when there is abnormal activation of the digestive enzymes within the pancreas. Trypsinogen is an enzyme precursor or a proenzyme that is converted to the active form, trypsin. During pancreatitis, trypsinogen gets into contact with cathepsn, a lysosomal enzyme inside the cell, which helps in degrading proteins. Trypsin then leads to further activation of other molecules of trypsinogen. The activation of this enzyme and its biological effect leads to inflammation of the pancreas with oedema, vascular injury and cell death.

In life, there are two types of cell death: Necrosis the uncontrolled death of cells that can be massive and aptosis, which is regulated cell death. This process is continuous throughout life and is controlled by a set of enzymes known as caspase. The balance between necrosis and aptosis is maintained by the presence of this enzyme. However, this enzyme can be depleted in chronic alcohol intake resulting in necrosis and aggravation of symptoms in pancreatitis. There are basically two types of acute pancreatitis: mild and severe. In mild cases, there is just inflammation and oedema of the organ, while in severe cases there are cell death or necrosis and the involvement of nearby organs like the liver, gall bladder and the duodenum.

The symptoms and signs of acute pancreatitis can vary depending on the severity of the lesion. Common symptoms include severe upper abdominal pains that radiates to the back in majority of cases, loss of appetite, nausea and vomiting. There is always an associated fever with shivering. There could be difficulty with breathing, rapid heartbeat with drop in blood pressure and shock. Irritation of the diaphragm could lead to hiccup and the covering of the abdominal internal organs known as the peritoneum may be involved in the inflammatory process, a condition known as peritonitis. In all, simple abdominal pains may be the sole presenting symptom.

Talking of clinical signs in our environment, the one commonly noticed but unfortunately may not be associated with pancreatitis is of the lungs. Most signs elicited in patients with pancreatitis come from pressing the various areas of the abdomen and chest proximally related to the deep-seated pancreas. These would include Korte’s sign, Kemenchick’s sign and Mayo-Robson sign. Clinical signs as a result of bleeding seen under the skin like Cullen’s and Gray Turner’s are not easily visible in the dark skinned.

The diagnosis of acute pancreatitis is from a good history and clinical findings. In a reasonable number of cases experienced clinicians can detect severe pancreatitis but Computerized Tomography (CT) would be required to differentiate mild acute pancreatitis from sever necrotic pancreatitis. In practice, a combination of abdominal CT and abdominal ultrasound together are considered the gold standard for the evaluation of acute pancreatitis. The caveat here is that the imaging can be deferred for a day or two to allow necrosis to be complete and resuscitates the patient. Without which the result may be misleading.

Even though CT is the gold standard, Magnetic Resonance Imaging MRI has gradually gained popularity as a valuable tool for visualising the pancreas, pancreatic fluid collection and dead tissue debris. There is other usefulness of MRI especially when gallstones may be involved. Here an endoscopic study can also be done. Blood tests are important for the identification of collateral organ failures and to be able to predict the eventual outcome of the ailment. It also will give an indication of how well the patient has been resuscitated. The blood tests carried out include full blood count, liver function test, renal function test, serum calcium estimation, serum amylase and lipase and so on. In practice, in a resource constrained environment the caregiver is likely to prefer serum lipase as against amylase.

In making a diagnosis, the interpretation of the findings in the tests is better left in the hands of an experienced clinician. A simple urinalysis with evidence of glycosuria in a previously non-diabetic patient may be a very useful guide towards figuring out the severity of the lesion. This automatically should suggest the screening for Diabetes Mellitus, which in massive necrosis of pancreatic tissue is the norm. Not that in the presence of glycosuria, polyuria may be absent.

• To be continued

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