Acute pancreatitis overview

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American College of Gastroenterology Guidelines

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Acute Pancreatitis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic criteria

History and Symptoms

Physical Examination

Laboratory Findings

Abdominal X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Approach to Therapy

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Tarek Nafee, M.D. [3]

Overview

Acute pancreatitis is a rapidly-onset inflammation of the pancreas. Depending on its severity, it can have severe complications and high mortality despite treatment. While mild cases are often successfully treated with conservative measures, such as NPO (abstaining from any oral intake) and IV fluid rehydration, severe cases may require admission to the ICU or even surgery (often more than one intervention) to deal with complications of the disease process.

Historical Perspective

Dutch physician and anatomist, Nicholaes Tulp in the year 1652 gave the first clear description of acute pancreatitis. The first systemic analysis of acute pancreatitis was presented by Reginald Huber Fitz in 1889. During the 20th century many theories were proposed with regards to whether surgery is to be preferred as the initial approach to the treatment of acute pancreatitis. Hans Chiari in 1896 proposed that the basic mechanism of the disease was autodigestion of pancreas. The father of modern anatomical pathology, Giovanni Battista Morgagni gave the first description of pancreatic pseudocysts.

Classification

Acute pancreatitis can either be classified according to its phase (early or late), or according to its level of severity.

Pathophysiology

The pathophysiology of acute pancreatitis involves acute inflammation and edema of the pancreas. The process is mediated by the abnormal activation of trypsinogen to trypsin inside the pancreas, and the involvement of other mediators such as cathepsin, lysosomal enzymes, and caspases. Intrapancreatic activation of amylase and lipase is what causes necrosis of pancreatic cells.

Causes

There are many causes for acute pancreatitis. The most common causes include; idiopathic, alcohol, gallstones, trauma, steroids, scorpion bites, mumps, autoimmune diseases, ERCP, and certain medications.

Differentiating Acute pancreatitis from Other Diseases

Acute pancreatitis should be differentiated from other conditions that may produce symptoms similar to that of acute pancreatitis. These conditions include gallstones, pancreatic cysts, pancreatic pseudocysts, and chronic pancreatitis.

Epidemiology and Demographics

The annual incidence in the U.S. is 18 per 100,000 population. In a European cross-sectional study, the incidence of acute pancreatits increased from 12.4 to 15.9 per 100,000 annually from 1985 to 1995; however, mortality remained stable as a result of better outcomes.

Risk Factors

There are several factors that can put someone at risk for acute pancreatitis. The most common cause and the most common risk factor is heavy alcohol use. Other risk factors include trauma, family history, hypertriglyceridemia, cystic fibrosis, renal failure, SLE, being on certain medications, and male gender.

Natural History, Complications and Prognosis

Pancreatitis can be mild or severe, and the natural history depends upon the severity of the condition, and the timeliness of intervention. Acute pancreatitis can result in complications such as hemorrhagic pancreatitis, multisystem organ failure, infection, SIRS, ARDS, hyperglycemia, hypocalcemia, shock, hemorrhage, thrombosis, common bile duct obstruction, and development of chronic pancreatitis. Prognosis can be determined with the use of many criteria such as Ranson's criteria, the Glasgow score, the APACHE II score, and the BISAP score.

Screening

There is no established screening recommendations for pancreatitis in the general population.

Diagnosis

History and Symptoms

Patient history should include the evaluation of risk factors for pancreatitis, such as heavy alcohol use, certain medications, family history, history of autoimmune diseases, and history of gallstone diseases. Common symptoms of acute pancreatitis include severe epigastric abdominal pain (which worsens on eating) radiating to the back and and the shoulder blades, anorexia, nausea, vomiting, diarrhea, fever and chills. There may also be symptoms of indigestion and abdominal bloating.

Physical Examination

Physical examination findings in acute pancreatitis can include fever, tachycardia, abdominal tenderness, distension, jaundice, pallor, and discoloration of the flanks and umbilicus.

Laboratory Findings

Laboratory tests that should be obtained include a complete blood count, liver function tests, serum amylase and lipase, serum calcium levels, arterial blood gas, and blood glucose levels.

CT

Although ultrasound imaging and CT scanning of the abdomen can be used to confirm the diagnosis of pancreatitis, neither is usually necessary as a primary diagnostic modality. In addition, CT contrast may exacerbate pancreatitis, although this is disputed.

MRI

MRI can also be used and has some advantages over the use of CT. One of the advantages is that there is less chance of contrast induced nephropathy. In addition, the organs and vessels can be visualized better, and it is easier to distinguish between mild and severe pancreatitis.

Ultrasound

Although ultrasound imaging and CT scanning of the abdomen can be used to confirm the diagnosis of pancreatitis, neither is usually necessary as a primary diagnostic modality.

Other Imaging Findings

Other Diagnostic Studies

ERCP in acute pancreatitis is used both to treat pancreatitis, and to determine the cause of idiopathic pancreatitis. There are specific indications for when to use ERCP, and one must keep in mind that ERCP is also a cause of pancreatitis.

Treatment

Medical Therapy

Medical therapy for acute pancreatitis includes pain control, bowel rest, nutritional support, intravenous fluids, and occasionally antibiotics. ERCP is also a possible treatment for acute pancreatitis, but can also cause pancreatitis.

Surgery

Surgery in the treatment of acute pancreatitis is indicated for infected pancreatic necrosis, in cases of diagnostic uncertainty and in the presence of complications.

Primary Prevention

Primary prevention against the development of acute pancreatitis includes avoiding aspirin in children and alcohol abuse, as well as genetic counseling, immunization and proper safety precautions to avoid abdominal trauma.

Secondary Prevention

The secondary prevention of acute pancreatitis primarily focuses on prevention of recurrence. The secondary prevention of acute pancreatitis varies according to the underlying etiology of the primary event. Cholecystectomy, alcohol abstinence, withdrawal of aggravating medications, weight control, and control of hyperlipidemia are among the most common methods of preventing recurrence of acute pancreatitis.

References


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