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The pancreatic enzymes

Pancreatitis is basically the autodigestion of the pancreas by the pancreatic enzymes caused by obstruction of pancreatic ducts (e.g. edema, tumor, inflammation, and gallstones) and other causes. But before anything else, let’s review the different types of pancreatic enzymes and their main role in our system.

pancreatitis-pathophysiology diagram
Photo credit: medicinenet.com

Our pancreas is located in our abdominal cavity. This amazing organ produces two types of hormones: endocrine and exocrine functioning hormones.

Endocrine:

The pancreatic islets or famously known as islets of Langerhans produces:

  1. Alpha Cells (glucagon)-stimulates the liver to break down stored glycogen to glucose (hyperglycemic agent)
  2. Beta Cells (insulin)-is responsible for lowering blood sugar (hypoglycemic agent)
  3. Somatostatin- regulates glucagon and insulin

Exocrine:

The pancreas also produces “pancreatic juice” that is responsible for breaking down the food entering the small intestines. This pancreatic juice is enzyme rich and it contains:

  1. Amylase- responsible for digestion of starch or carbohydrates
  2. Lipase- responsible for fat digestion
  3. Trypsin, chymotrypsin, and others- responsible for protein digestion. Trypsin is also the enzyme that causes autodigestion.

What’s Pancreatitis?

Pancreatitis can be classified in two forms: acute and chronic.

Acute pancreatitis has also two types:

  1. Edematous (interstitial)

This type of pancreatitis causes fluid accumulation and as a result hypovolemia can result due to severe third spacing of fluid.

  1. Necrotizing (hemorrhagic)

This type of pancreatitis occur when there is premature activation of pancreatic enzymes. There are several explanation for this type of pancreatitis. Obstruction, disruption, or inflammation of the pancreatic duct can cause the enzymes to back up and spill into the pancreas. This is what we call autodigestion or dyschylia “digestion of fat and tissue in and around the pancreas”. These eventually causes cell death and tissue damage in the retroperitoneum and omentum.

Complications of Hemorrhagic Pancreatitis:

  1. Hemorrhage
  2. SIRS
  3. Sepsis
  4. Multiple Organ Failure
  5. Respiratory Distress
  6. DIC
  7. Cardiogenic shock
  8. Hypovolemia
  9. Acute liver failure
  10. Acute renal failure

Pancreatitis Pathophysiology and Schematic Diagram

What are the signs and symptoms of acute pancreatitis?

  • Severe abdominal pain: Left Upper Quadrant that radiates to the back
  • Cullen’s sign: discoloration of the abdomen and periumbilical area, suggest that there is massive bleeding
  • Grey Turner’s sign: blush discoloration of the flanks, also suggest bleeding

Chronic Pancreatitis

This is an inflammatory disorder characterized by progressive destruction of the pancreas with scar tissue replacing the pancreatic tissue.

What are the signs and symptoms of chronic pancreatitis?

  • Persistent pain
  • Steatorrhea
  • Jaundice
  • Left upper quadrant mass

What are the usual causes of pancreatitis?

  • Alcoholism- alcohol itself is a “downer” or depressant that may cause spasm in the sphincter of Oddi.
  • Obstruction
  • Abdominal trauma
  • Drug toxicity: e.g. corticosteroids, estrogen, thiazides cyclosporine
  • Infection
  • Shock

What are the laboratory/diagnostic tests for pancreatitis?

  1. Elevated serum amylase and lipase (confirmatory test)
  2. Elevated WBCs
  3. Elevated bilirubin
  4. Elevated urinary amylase levels
  5. Elevated glucose
  6. Hypocalcemia
  7. ECG readings: long ST segment
  8. Endoscopic retrograde cholangiopancreatography: shows calcifications and strictures
  9. CT scan: shows enlargement of the pancreas
                                    Normal Laboratory ResultsFindings in patients with pancreatitis
Lab TestsConventionalSI Units
Serum Amylase4-25 units/mL4-25 arb. unitElevated
Serum Lipase2 units/mL or lessUp to 2 arb. unitElevated
WBCS4,300-10,800/mm34.2-10.8×109/LElevated
Bilirubin Up to 1.0 mg/100 mLUp to 17 µmol/LElevated
Urinary Amylase24-76 units/ml24-76 arb. unitElevated
Serum Glucose70-110 mg/100 mL3.9-5.6 mmol/LElevated
Urinary GlucoseNegativeNegativePresent
Calcium8.5-10.5 mg/100 mL2.1-2.6 mmol/LDecreased

Normal range of each test vary depending on the range/standard/computation followed by the laboratory.

Nurses should educate their patient that though pancreatitis is a deadly disease, it is highly preventable. As nurses, what are the nursing health teaching we can give to our patients?

  1. Avoid too much alcohol consumption. Alcoholism is one of the major cause of this disease.
  2. Eat a balanced-diet. Avoid eating fatty and high-carbohydrate meal.
  3. Maintain a healthy weight. Check your BMI and lose some pounds if you are overweight.
  4. If you think you have most of the risk factors of this disease, have a lifestyle change.

References:

  • Guyton, A. & Hall, J. (2006). Textbook of Medical Physiology. 11th edition.
  • Myers, E. (2006). RNotes: Nurse’s Clinical Pocket Guide. F. A. Davis Company. Philadelphia. 2nd edition.
  • Schilling McCann, J. (2007). Lippincott manual of nursing practice series: Pathophysiology. Lippincot Williams & Wilkins, Philadelphia.
  • Silvestri, L. (2008). Comprehensive Review for the NCLEX-RN Examination. Saunders Elsevier. 4th edition.
  • Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins. 12th edition
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Rina Malones is currently working as a critical care/acute stroke nurse. Besides from blogging, she's also studying International Health at University of the Philippines Open University.