Foundations · Year 1 · from Foundations
Case 1: Acute Pancreatitis (Zymogen Premature Activation)
Clinical Image
Source: Radiopaedia - Acute pancreatitis - CC BY-NC-SA 3.0
Case Presentation
A 45-year-old man with a history of heavy alcohol use presents to the emergency department with severe epigastric pain radiating to his back, accompanied by nausea and vomiting for the past 12 hours. The pain is constant, worse when lying flat, and partially relieved by leaning forward. Physical examination reveals epigastric tenderness with guarding. Vital signs show temperature 38.1C, heart rate 105, blood pressure 140/90, and respiratory rate 20. Laboratory studies reveal markedly elevated serum lipase at 1,850 U/L (normal <60) and amylase at 1,200 U/L (normal <100). Serum triglycerides are normal and there is no biliary dilation on ultrasound, suggesting alcohol as the etiology. CT scan with contrast shows diffuse pancreatic enlargement with peripancreatic fat stranding and small fluid collections consistent with acute interstitial edematous pancreatitis. The patient is admitted for IV fluid resuscitation, pain control, and bowel rest. He is counseled on alcohol cessation as the key to preventing recurrence.
Key Learning Points
- Acute pancreatitis results from premature intrapancreatic activation of digestive enzyme zymogens (particularly trypsinogen to trypsin), causing autodigestion of pancreatic tissue
- Normally, protective mechanisms prevent zymogen activation until they reach the small intestine: trypsinogen is activated by enterokinase in the duodenum, which then activates other zymogens in an amplifying cascade
- Serum lipase and amylase are elevated because cellular injury releases these enzymes into the bloodstream; lipase is more specific for pancreatic injury