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.

  1. Pain.
  2. Vomiting.
  3. 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

  1. 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.
  2. Sarles, H. Revised classification of pancreatitis-Marseilles. Dig Dis Sci 1985; 30:573.
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