3.  Digestive (exocrine) ◦ Produces enzymes and proezymes that break down carbohydrates, fats, proteins and acids in the dudenum (proealstase, chymotrypsynogen, trypsynogens, Alfa-amylase, Sterol esterase, Lipase, DNase, RNase.

4.  Hormonal (endocrine) secretes: ◦ Insulin and glucagon – which regulate the level of glucose in the blood ◦ Somatostatin – which prevents the relese of the other two hormones

5.  Synthesis of enzymes as inactive precursors  Segregation of enzymes in membrane bound compartments  Enterokinase only found in duodenal mucosal cells.

6.  An acute inflammatory process of the pancreas  Degree of inflammation varies from mild to edema to severe necrosis  Most common in middle-age

7.  Primary etiologic factors are ◦ Biliary tract disease ◦ Alcohol abuse ◦ Trauma ◦ Infection ◦ Drugs ◦ Postoperative ◦ Unknown

8.  Trypsinogen ◦ Normally released into the small intestine, where it is activated to trypsin ◦ In AP activated trypsin is present or released in pancreas thus auto digestion of pancreas

9.  Abdominal pain is predominant symptom ◦ Pain located in LUQ ◦ Pain may be in the midepigastrium ◦ Commonly radiates to the back ◦ Sudden onset ◦ Severe, deep, piercing, steady ◦ Aggravated by eating ◦ Not relived by vomiting

10.  Physical examination frequently reveals: ◦ Low-grade fever ◦ tachycardia and hypotension ◦ Hypovolemia secondary to exudation of blood and plasma proteins to retroperitoneal space. ◦ Pulmonary findings (most frequently left sided) ◦ Bowel sounds are usually diminished or absent ◦ A faint blue discoloration around umbilicus (Cullen’s sign) or green-brown discoloration of the flanks (Turner’s sign.

12.  The diagnosis of acute pancreatitis is usually established by the detection of an increased level of serum amylase or lipase  Values threefold or more above normal virtually clinch the diagnosis  There appears to be no definite correlation between the severity of pancreatitis and the degree of serum lipase or amylase elevations.

13.  Renal insufficiency  Salivary gland lesions  „Tumor” hyperamylasemia ◦ Carcinoma of the lung ◦ Carcinoma of the esophagus ◦ Breast carcinoma, ovarian carcinoma

14.  Perforated or penetrating peptic ulcer  Intestinal obstruction or infarction  Ruptured ectopic pregnancy  Peritonitis  Aortic anurysm  Chronic liver disease  Postoperative hyperamylasemia

15.  The diagnosis of AP requires two of the following: ◦ Typical abdominal pain ◦ Threefold or greater elevation in serum amylase and/or lipase level

16.  Perforated viscus – especially peptic ulcer  Acute cholecystitis and biliary colic  Acute intestinal obstruction  Mesenteric vascular occlusion  Renal colic  Myocardial infarction  Dissecting aortic aneurysm  Connective tissue disorders with vasculitis  Pneumonia  Diabetic ketoacidosis

17.  The initial assessment of severity in acute pancreatitis is critical for the appropriate managment of patients.  The criteria for severity in acute pancreatitis was defined as organ failure of at least one organ system (defined as a systolic blood pressure 2.0 mg/dL after rehydratation, and gastrointestinal bleeding > 500 mL/24 hours) and the presenece of a local complication such as necrosis, pseudocyst, and absces

18.  Early predictors of severity at 48 hours included ≥ Ranson’s sign and APACHE II score ≥8.  Traditional severity indices such as APACHE II and Ranson’s criteria have not been clinical useful – require collection of large amount of clinical and laboratory data over time, and do not have acceptable positive and negative predictive value for severity.

19.  Simplified scoring system for the early prediction of mortality.  System referred to as the Bedside Index of Severity in Acute Pacreatitis (BISAP)  Five clinical and laboratory parameters obtained within the first 24 hours of hospitalization

20.  BUN > 25  Impaired mental status  SIRS  Age > 60  Pleural effusion on radiography Presence of three or more of these factors was associated with increased risk for mortality.

21.  Alcoholism is the most common cause of clinically apperent chronic pancreatitis  Prolonged consuption of socially acceptable amount of alcohol is compatible with development of chronic panreatitis

22.  Diffuse calcification noted on plan film radiography  Abdominal ultrasonography  CT scaning  MRCP  Endoscopy ultrasonography

24.  Pancreatic enzymes  Menagment of pain  Endoscopic treatment ◦ Sphincterotomy ◦ Stenting ◦ Stone extraction ◦ Dreinage of pseudocyst  Surgical procedures

26.  Associated with poor prognosis  At the time of diagnosis 85-90% of patients have inoperable or metastatic disease  Only 20% 5-year survival rate when the tumor is detected at an early stage and when complete surgical resection is accomplished

27.  Cigarette smoking  Genetics  Alcohol does not appear to be a risk factor

28.  Obstructive jaundice occour frequently when the cancer is located in the head of pancreas  Abdominal discomfort  Pruritus  Weight loss  New onset of diabetes mellitus

29.  Dual phase contrast enhanced CT  EUS and fine-needle aspirtion  Percutaneus biopsy of the pancreatic primary or liver metastases is only acceptable in patients with inoperabl or metastatic disease  Serum markers – carbohydrate antigen 19-9 (CA 19-9)

30. ◦ Pylorus-preserving pancreatoduodenectomy (modified Whipple’s procedure) ◦ Distal pancreatectomy with splenectomy Postoperative treatment – adjuvant chemotherapy Fluorouracyl and gemcitabine

32.  Demographic/genetic factors  Obesity – metabolic syndrome  Weight loss  Female sex hormones  Gallblader hypomotility  Age

33.  Biliary colic – long lasting pain in right uper quadrant – radiation to the interscapular area  Begins quite suddenly. It is steady  Nausea and vomiting

35.  Acute inflammation of the gallblader  Obstruction of the cystic duct by a stone  Attack of biliary pain that progressivly worsens  The patient is anorectic and often vomiting  Low grade fever  Subcostal palpation or cough produces pain – Murphy’s sign

36.  Empyema and hydrops –persistent cystic duct obstruction – pusforming bacterial organisms  Gangrene and perforation  Fistula formation

37.  Stones  Tumors Obstructive jaundice Serum bilirubin, aminotransferases, alkaline phosphatase, glutamyl transpetidase US/EUS – widened billducts (intra and/or extra hepatular)

39.  Abdominal pain  High grade fever  Obstructive jaundice