Pancreatitis: Pathology review

While in the Emergency Department, two individuals came in with severe epigastric pain. Michael who is 45, complains of pain that radiates to his back, vomiting, and nausea.

All of these symptoms appeared after he came home from partying at the bar a few hours ago.

On the clinical examination, there’s epigastric tenderness without guarding or rebound, decreased bowel sounds, and purple discoloration around the periumbilical region. He also tends to bend over to relieve the pain.

Anna, who is 29 years old, on the other hand, says the pain started abruptly and that it doesn’t radiate anywhere. She also noticed it gets worse after her meals. On examination, she presents with epigastric pain, scleral icterus, and fever.

Both were admitted and started on IV fluids.

Blood tests were ordered, which revealed lipase and amylase levels that were 3 times more than normal.

Ok, so from what we can gather, both people have acute pancreatitis.

Let’s begin with a bit of physiology. The pancreas is located in the epigastric region, behind the stomach, and it is mostly a retroperitoneal organ.

It has both endocrine functions, by releasing hormones like insulin and glucagon, and exocrine functions by secreting enzymes needed for food digestion.

The exocrine pancreas releases digestive enzymes through smaller ducts which drain in the main pancreatic duct.

The main pancreatic duct, which travels through the length of the pancreas, joins the common bile duct at the ampulla of Vater and drains into the duodenum.

Now, the main pancreatic enzymes include pancreatic amylase which breaks down carbohydrates; trypsin and chymotrypsin, which break down proteins; and lipase which breaks down lipids.

To protect the pancreas from destroying itself, the acinar cells of the pancreas manufacture zymogen, or the inactive form, of trypsin, called trypsinogen.

When this zymogen is released into the small intestine, it is cleaved by enteropeptidase enzymes found in the duodenum.