Case 7: Jack Spratt could eat no fat

Body in Health:

 What are the function/anatomy (structure and location, innervation, blood supply,
lymphatic)/histology of the pancreas?
o Function: the pancreas has a mixture of exocrine (products delivered by a duct) and
endocrine (ductless system, straight into the bloodstream) cells.
 Exocrine: the exocrine pancreas is classified as a lobulated serous gland
which produces pancreatic juice (which contains bicarbonate – which
neutralises acid entering the duodenum - and digestive enzyme precursors –
which will develop to break down carbohydrates, proteins and lipids in the
stomach and duodenum). It is composed of grape like cluster cells called
acini, connected by short intercalated ducts. The intercalated ducts unite
with those draining adjacent lobules and drain into a network of intralobular
collecting ducts, which in turn drain into the main pancreatic duct. The
pancreatic duct runs the length of the organ and united with the bile duct to
form the hepatopancreatic ampulla of Vater (duct). This opens into the
duodenum via the major duodenal papilla.
 Endocrine: the endocrine part of the pancreas is made up of cell clusters
called islets of Langerhans’s; α-cells secrete glucagon (increase glucose in
blood), β-cells secrete insulin (decrease glucose in blood), δ-cells secrete
somatostatin (regulates/stops α and β cells), and PP cells secrete pancreatic
polypeptide
o Anatomy: the pancreas is divided into five parts; the head, uncinated process, neck,
body and tail.
 Head: the widest part of the pancreas, and it lies in the C-curve created by
the duodenum, is connected to it via connective tissue
 Uncinated process: a projection arising from beneath the lower part of the
head and extending medially to lie beneath the body of the pancreas. It lies
posterior to the superior mesenteric vessels.
 Neck: located between the head and the body of the pancreas. It overlies
the superior mesenteric vessels which form a groove in its posterior aspect.
 Body: centrally located, crossing the midline of the human body to lie
behind the stomach and to the left of the superior mesenteric vessels
 Tail: the left end of the pancreas that lies within close proximity to the
spleen. This is the only part of the pancreas that is intraperitoneal
o Histology:
 The tissues with an endocrine role can be seen under staining as lightly-
stained clusters of cells
 Darker-staining cells form clusters called acini. Due to their secretory
function, these cells have many small granules of zymogens which are visible
 How are fats digested?
o Fats ingested are usually in triglyceride form. A combination of stomach churning
and bile salts turns ingested fats into emulsified fats. Afterwards pancreatic lipases
 metabolism these emulsified fats in to fatty acids and monoglycerides. In order for
the fats to pass into the intestine, it needs to become hydrophilic. So the bile salts
form around the fat droplets to facilitate transportation (micelles) into the intestinal
cells – this process is called emulsification. As a result of the hydrophilic micelles, the
fat droplets can be absorbed passively (via simple diffusion) at the apical membrane.
Once inside the cell, the triglycerides are reassembled in the smooth endoplasmic
reticulum. They are then repackaged with cholesterol esters and proteins the Golgi,
to become chylomicrons. These chylomicrons are then released from the cell by
exocytosis, into the lacteals (intracellularly)
 How are micro/macronutrients absorbed in the small intestine?
 What are the function/anatomy (structure and location, innervation, blood supply,
lymphatic)/histology of the gall bladder?
o Function: Its primary function is to store and concentrate bile, a yellow-green
digestive substance . When food enters the small intestine, a hormone called
cholecystokinin (CCK) is released, signalling the gallbladder to contract and secrete
bile into the small intestine through the common bile duct (to the
hepaticopancreatic duct)
o Anatomy: it is a pear shaped, hollow structure located under the liver and on the
right hand side of the abdomen.
o Histology
 What is the function/composition of bile?
o Role
 Bile is necessary for the digestion of fat. Bile acids are derivatives of
cholesterol synthesised by hepatocytes. Bile acids contain both hydrophobic
(lipid soluble) and hydrophilic faces (making them amphipathic). As a result,
their amphipathic nature enables bile acids to carry out two important
functions:
1. Emulsification of lipid aggregates: bile acids have the ability to break
down or emulsify fat globules into minute droplets. Emulsification of
fat is important because it increase the surface are of fat, making it
available for digestion by lipases, which cannot access the inside of
lipid droplets
2. Solubilisation and transport of lipids in an aqueous environment:
bile acids are lipid carriers and are able to solubilise many lipids by
forming micelles – aggregates of lipids such as fatty acids,
cholesterol and monoglycerides – that remain suspended in water.
Bile acids are also crucial for transport and absorption of the fat-
soluble vitamins
o Composition
 97% water
 0.7% bile salts
 0.2% bilirubin
 0.51% fats (cholesterol, fatty acids)
 Inorganic material, mainly sodium, potassium, calcium and bicarbonate
 Where is bile deposited in the body?
 o Bile is produced by the liver and stored in the gall bladder. During digestion, bile is
then transported to the duodenum via the bile duct which joins with the pancreatic
duct to form the hepaticopancreatic ampulla of Vater duct. This enters the
duodenum via the major duodenal papillae

Body in Disease:

 What is pancreatitis, causes and symptoms

o What is it: this is a condition where the pancreas becomes inflamed. It can last for a
short time and get better (acute), or for a long time and get gradually worse
(chronic)
o Causes: Acute pancreatitis is most often linked to galls stones and drinking too much
alcohol
o Symptoms:
 Acute:
1. Sudden and severe abdominal pain
2. Nausea
3. Vomiting
4. Loss of appetite
5. Fast heartbeat
 Chronic
1. Abdominal pain (usually dull pain)
2. Pale, runny and oily faeces that smells bad
3. Bloated and flatulence
4. Weight loss
5. Nausea and Vomiting
6. Diabetic symptoms (feeling very thirsty and needing to urinate
often)
 What are gall stones, causes and symptoms
o What is it: these are small stones, usually made of cholesterol, that form in the
gallbladder
o Causes:
 Imbalance in the chemical make-up of bile inside the gall bladder.
Cholesterol stones form when cholesterol levels in your bile are much
greater than your bile acid levels, which causes the cholesterol in your bile
to solidify
 Dietary factors, such as diets high in cholesterol, saturated fats, refined
sugar and low fibre, increase the risk of developing gallstones
o Symptoms: many people live with gallstones without symptoms and are unaware
they have them unless it becomes trapped in a duct inside the gallbladder or they
develop complications such as inflammation of the gallbladder. The most common
symptoms include the following:
 Abdominal pain (this usually last between 1 to 5 hours). The pain usually
begins after eating fatty foods.
 Nausea
  Vomiting
 Excessive sweating
 Jaundice
 High temperature (above 38ᴼC)
 Loss of appetite
 Itchy skin
 Causes of mouth ulcers (including diet)
o There are many causes for mouth ulcers:
 Trauma to the mucosa
 Stress or anxiety
 Low immunity (feeling ‘run down’)
 Certain foods (e.g. chocolate, coffee, nuts, strawberries, cheese. Tomatoes,
wheat flour)
 Smoking cessation
 Lack of vitamin B12 or iron
 How does pancreatitis cause malabsorption (links to mouth ulcers)
 Effects of pancreatitis on the body
 Why was the abdomen rigid and distended
 What are abnormal bowel sounds
o Abdominal bowel sounds, are sounds created by the intestines. They are made by
the movement of food being pushed through the intestines. A health care
practitioner can check abdominal sounds by listening to the abdomen with a
stethoscope (auscultation). Reduced bowel sounds include a reduction in the
loudness, tone or regularity of the sounds. They are signs that intestinal activity has
slowed. Increased bowel sounds can sometimes be heard even without a
stethoscope.

Treatments, Procedures and Professional Concern:

 Treatments for pancreatitis (long term and short term)

o Acute Pancreatitis: intravenous fluids, pain relief, liquid food through the stomach,
removal of gall stones, insulin injections/infusions
o Chronic Pancreatitis: damage to the pancreas is permanent, but treatment can help
control the condition and help manage any symptoms. People with this condition
are usually advised to make lifestyle changes; they’re also given medication to
relieve pain. Surgery may also be an option for those experiencing severe pain
 What is ERCP? When is it done?
 What are the treatments for mouth ulcers?
o Self-Care:
 Bonjela
 Using a soft toothbrush
 Using SLS free toothpaste
 Avoiding certain foods
o Pharmacy medicines
  Antimicrobial mouthwash (which would prevent infections of the mouth
ulcers)
 Topical painkillers
 Corticosteroid lozenges, may reduce pain and speed up healing
o Prescribed Medicines
 Stronger course of corticosteroids
 What is it and what is normal serum amylase activity?
o An inflamed pancreas (pancreatitis) can cause the organ to become overactive and
produce high levels of amylase enzyme. In a healthy individual, a normal blood
amylase level is around 23-85 units per litre (U/L).
 What is an ultrasound scan and when is it used?
 What is a dental technician?