Clinical History:
- A 40-year-old woman developed increasingly severe abdominal pain over a two day period. In the emergency room, physical examination demonstrated board-like rigidity of her abdomen along with extreme tenderness. A plain film radiograph of the abdomen demonstrated dilated loops of bowel, several radiopaque gallstones in the gallbladder, but no free air. The total bilirubin was 3.8 mg/dL, AST 25 U/L, ALT 30 U/L, albumin 3.5 g/dL, total protein 5.8 g/dL, glucose 120 mg/dL, calcium 7.8 mg/dL, phosphorus 3.3 mg/dL, and lipase 2,250 U/L. The gross photograph depicts the process (image 7.1). The microscopic appearance is seen in images 7.2 and 7.3.
What is the diagnosis? This is acute pancreatitis.
What is the probable etiology? Probably gallstones were the cause, since these were seen on x-ray, and there is no history of alcoholism. Less common causes for acute pancreatitis include hypertriglyceridemia, trauma, viral infections, and drugs.
The pathophysiology of acute pancreatitis is thought to be related to the premature activation of trypsinogen in the pancreatic interstitium, with the subsequent activation of other pancreatic zymogens, leading to the autodigestion seen grossly and microscopically. Chronic pancreatitis more typical of chronic alcoholism is thought to be related to inspissation of duct secretions with acinar cell injury.
What is the course and what are the possible complications? (One complication is pictured in image 7.4). Acute pancreatitis is a medical emergency, and patients can die from it. It often resolves without sequelae. With chronic pancreatitis, pancreatic pseudocysts can develop (as shown in image 7.4). Repeated bouts of acute pancreatitis can lead to chronic pancreatitis. Severe chronic pancreatitis often has an etiology of alcoholism. Loss of enough pancreas so that islets as well as acinar parenchyma are destroyed is not common, so diabetes mellitus is a rare complication.
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