Core clinical presentation/

61. Lymphadenopathy
1. Abdominal pain
Difficulty swallowing (Dysphagia) 62. Mass in abdomen
2. Abnormal fetal growth 31.
Distressed patient 63. Multiple regional musculoskeletal pain
3. Abnormal behavior 32.
Dizziness 64. Numbness or tingling
4. Acute aggression 33.
Drug/alcohol abuse 65. Painful eye
5. Acute confusion 34.
Dry eye 66. Palpitations
6. Acute diarrhea 35.
Dying patient with cancer pain 67. Pelvic pain/discomfort
7. Acute hemiparesis 36.
Ear pain 68. Penetrating injury
8. Acute joint pain 37.
Excessive weight gain 69. Personality disorder
9. Acute multi-focal skin lesions 38.
Failure to thrive in childhood 70. Pre-eclampsia
10. Acute multiple trauma 39.
Falls 71. Pregnancy
11. Acute spreading skin lesion 40.
Fever/rigors 72. Pruritus
12. Altered consciousness 41.
Frequency or discomfort passing urine 73. Rectal bleeding
13. Altered menstruation 42.
Haematuria 74. Red eye
14. Altered mood 43.
Haemetemesis 75. Reduced cognition
15. Altered voice 44.
Haemoptysis 76. Retention of urine
16. Anxiety 45.
Headache 77. Salivary gland swelling
17. Bed-wetting 46.
Impaired gait 78. Seizures
18. Bleeding during pregnancy 47.
Impaired hearing 79. Single regional musculoskeletal,including
19. Breathlessness 48.
neck and back, pain
20. Calf pain 49. Incontinence
80. Solitary, changing skin lesion
21. Chest pain 50. Infertility
81. Sore throat
22. Chronic diarrhea 51. Jaundice
82. Swollen feet/legs
23. Chronic joint pain 52. Labour and delivery
83. Thirst
24. Chronic multi-focal skin lesions 53. Learning disability
84. Tinnitus
25. Collapse 54. Leg ulceration
85. Tiredness
26. Constipation 55. Limping child
86. Vaginal discharge/irritation
27. Cough 56. Long bone fracture
87. Visual disturbance
28. Deliberate self-harm 57. Lump in breast
88. Vomiting
29. Delirium 58. Lump in groin
89. Weakness
30. Difficulty breathing 59. Lump in neck
90. Weight loss
60. Lump in scrotum
91. Wheeze
Prof. Dr. El-Yassin 1
1.
Abdominal
pain

Prof. Dr. El-Yassin 2

Pancreatic Secretions

Prof.Dr. Hedef Dhafir El-Yassin MRSC

Prof. Dr. El-Yassin 3

Objectives:
1. To list and describe the exocrine secretion of
the pancrease
2. To describe the alkaline secretion of the
pancrease
3. To state the control of pancreatic exocrine
secretion
4. To define acute pancreatitis
5. To define chronic pancreatitis
6. To list and describe the clinically significant
pancreatic enzymes

Prof. Dr. El-Yassin 4

Prof. Dr. El-Yassin 5
Prof. Dr. El-Yassin 6
Exocrine Secretions of the Pancreas
● 1. Digestive enzymes:
● Proteases
● Pancreatic Lipase
● Amylase
● Other Pancreatic Enzymes
◦ Nucleases. These hydrolyze ingested nucleic acids
(RNA and DNA) into their component nucleotides.
◦ Elastase: Cuts peptide bonds next to small, uncharged
side chains such as those of alanine and serine.

Prof. Dr. El-Yassin 7

2. Bicarbonate and Water

● Epithelial cells in pancreatic ducts are the source

of the bicarbonate and water secreted by the
pancreas. The mechanism of bicarbonate
secretion is essentially the same as for acid
secretion parietal cells and is dependent on the
enzyme carbonic anhydrase. In pancreatic duct
cells, the bicarbonate is secreted into the lumen
of the duct and hence into pancreatic juice.

Prof. Dr. El-Yassin 8

Prof. Dr. El-Yassin 9
What is Acute Pancreatitis?
● When protective mechanisms of the pancreas
are overcome (the pancreas begins digesting
itself and the surrounding tissues. The resulting
inflammation and tissue damage is termed
"pancreatitis." Clinically, patients develop upper
abdominal pain, often radiating into the back, with
nausea, and sometimes with systemic symptoms
such as fever and shock.

Prof. Dr. El-Yassin 10

Prof. Dr. El-Yassin 11
Prof. Dr. El-Yassin 12
What is Chronic Pancreatitis?
● By definition, chronic pancreatitis implies
permanent damage with fibrosis and loss of
functioning tissue. There may not be much
inflammatory infiltrate. Ducts are often narrowed
in some areas and dilated in others. About 80%
of patients have chronic upper abdominal pain.
Malabsorption with diarrhea and/or weight loss
may occur.

Prof. Dr. El-Yassin 13

Prof. Dr. El-Yassin 14
Clinically significant pancreatic enzymes
1. α-Amylase: (EC3.2.1.1; 1,4- α-D-glucan
glucanohydrolase; AMY) is small enough to pass the
glumeruli of the kidneys and thus it is the only
plasma enzyme physiologically found in urine.

Normal values: 28-100 U/L =0.48-1.7 µkat/L

CAUSES OF RAISED PLASMA AMYLASE ACTIVITY

● Marked increase (five to 10 times the upper

reference limit):
● acute pancreatitis: the degree of elevation does not correlates
with the severity
● severe glomerular impairment:
● perforated peptic ulcer especially if there is perforation into
the lesser sac.

Prof. Dr. El-Yassin 15

Pancreatic pseudocyst
● If the plasma amylase activity fails to fall after an
attack of acute pancreatitis there may be leakage
of pancreatic fluid into the lesser sac (a
pancreatic pseudocyst). Urinary amylase levels
are high, differentiating it from macroamy
lasaemia. This is one of the few indications for
estimating urinary amylase activity, which is
inappropriately low relative to the plasma activity
if there is glomerular impairment or
macroamylasaemia

Prof. Dr. El-Yassin 16

Macroamylasaemia
● In some patients a high plasma amylase
activity is due to a low renal excretion of the
enzyme, despite normal glomerular function.
The condition is symptomless; it is thought
that either the enzyme is bound to a high
molecular weight plasma component such as
protein, or that the amylase molecules form
large polymers that cannot pass through the
glomerular membrane. This harmless
condition may be confused with other causes
of hyperamylasaemia

Prof. Dr. El-Yassin 17

2. Lipase: (EC 3.1.1.3; triacylglycerol
acylhydrolase; LPS). LPS is a small molecule
and is filtered through the glomerulus. It is
totally reabsorbed by the renal tubules, and it
is not normally detected in urine.
● Clinical Significance
● Normal values: 40-200 U/L
● Plasma lipase levels are elevated in acute
pancreatitis and carcinoma of the pancreas.

Prof. Dr. El-Yassin 18

● Note: serum amylase is increased in
mumps, pancreatic disease or due to some
other cause, where as lipase is increased
only in pancreatitis. Therefore, the
determination of both amylase and lipase
together helps in the diagnosis of acute
pancreatitis.

Prof. Dr. El-Yassin 19

● Exocrine secretion of the pancreas are due to:
◦ Acid must be quickly and efficiently neutralized to prevent
damage to the duodenal mucosa
◦ Macromolecular nutrients - proteins, fats and starch - must
be broken down much further before their constituents can
be absorbed through the mucosa into blood

● The mechanism of bicarbonate secretion is

essentially the same as for acid secretion parietal
cells and is dependent on the enzyme carbonic
anhydrase.
● Secretion from the exocrine pancreas is regulated by
both neural and endocrine controls

Conclusions:
Prof. Dr. El-Yassin 20
● Acute Pancreatitis: the pancreas begins digesting
itself and the surrounding tissues
● Chronic Pancreatitis: implies permanent damage with
fibrosis and loss of functioning tissue
● Amylase and lipase are two clinically important
enzymes . Serum amylase is increased in mumps,
pancreatic disease or due to some other cause,
where as lipase is increased only in pancreatitis.
Therefore, the determination of both amylase and
lipase together helps in the diagnosis of acute
pancreatitis.

Conclusions:
Prof. Dr. El-Yassin 21
Prof. Dr. El-Yassin 22