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Acute pancreatitis
Epidemiology
Incidence
An incidence of 5% has been reported in the West
which is higher (25%) in some countries (e.g., Scandinavian
countries) because of variations in alcohol consumption as well as
early detection.[1]
Mortality
The overall mortality rate is between 10% and 20%
depending on many factors including pathology, clinical presentation
and diagnostic capability in addition to various prognostic factors
as outlined in the Ranson's criteria, APACHE II and the CT severity
index.[2]
Etiology
Gall stones obstructing the
pancreatic duct (30%) and chronic alcohol abuse (15%) represent the common causes. Infections
such as mumps and coxackie B. hereditary genetic mutations, hypercalcemia, pancreatic tumors and drugs
such as azathioprine, oestrogens, corticosteroids. Iatrogenic causes include
postsurgical acute pancreatitis and endoscopic retrograde cholangeiopancreatography
(ERCP). Hyperlipidemias (hypertriglyceridemia, hyperchylomicronemia) have
also been known to be complicated by pancreatitis.[1]
Clinical suspicion
Clinical picture is suggestive
with severe agonizing epigastric pain which may radiate in a band
like manner to the back accompanied
by nausea and vomiting. This pain lasts for days and may be relieved
by leaning forwards and is accompanied by epigastric tenderness. However there are 3 cardinal manifestations.
- Pain.
- Vomiting.
- Shock (especially in
fulminant
cases).
Diagnosis
A serum amylase raised more
than 3 times greater than the upper limit of normal confirms the diagnosis
but is not related to severity.
In doubtful cases serum lipase, and serum trypsin levels will be elevated
in acute pancreatitis.
Prognosis
Modified Ranson's criteria
These are features which when
present during the first 48 hours indicate severe pancreatitis and poor
prognosis.
Age >55 years, leucocytosis
>16000, LDH >400 IU/L + hypocalcemia
liver cell failure, respiratory
failure, diabetes.
Treatment
Rest to the pancreas: All oral
feeding is stopped and nasogastric feeding and suction is used to reduce vomiting
& abdominal distension. Water and electrolyte replacement (up to
10L per day in severe cases) and treatment of complications.
Pain management: Pethidine 100mg IM every 3-4 hours. Morphine is
theoretically
contraindicated because it causes spasm of the sphincter of Oddi,
however this has not been seen to be the case clinically.
Surgery and ERCP: In severely ill patients where
the cause is a stone obstructing the common bile duct and endoscopic sphincterotomy
may be useful. In cases of necrotizing pancreatitis (as proved by FNA),
debridement may be appropriate after 2 weeks from the initial
presentation if at all possible.
Prophylactic systemic antibiotics use (e.g. imipenem) is
controversial and should only be used in severe necrotizing cases.
References
- VL, Go, Everhart, JE. Pancreatitis. In: Digestive diseases
in the United States: Epidemiology and impact, Everhart, JE
(Ed), US Department of Health and Human Services, Public Health
Service, National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases. US Government
Printing Office NIH Publication no. 94-1447, Washington, DC
1994. p.693.
- Sarles, H. Revised classification of
pancreatitis-Marseilles. Dig Dis Sci 1985; 30:573.
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