Pancreatitis
From Medical-Wiki
Pancreatitis is defined as a reversible inflammation of the pancreas. It is associated most commonly with alcoholism and gallbladder disease. It may occur in an acute mild form, an acute fulminant form, as a chronic condition, or as an intermittently reoccurring state.
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Clinical presentation
Patients with pancreatitis may present with complaints of severe upper abdominal pain radiating straight through to the back. They will typically also have associated nausea and vomiting—often severe.
Differential diagnosis
When a patient presents with symptoms indicative of pancreatitis, a differential diagnosis includes alcohol consumption, gallstones, peptic ulcer disease, perforated ulcer, early appendicitis, bowel obstruction, mesenteric ischemia, hypertriglyceridemia, hypercalcemia, infection, posttraumatic injury, pregnancy, or pulmonary, renal, or cardiovascular disorders.
Diagnosis
Physical findings
Physical examination varies from mild epigastric tenderness on deep palpation to an acute abdomen with distention.
Laboratory findings
Laboratory findings reveal elevated serum lipase and amylase levels, but these levels correlate poorly with disease severity. [1]
Radiological findings
Endoscopic ultrasonography and magnetic resonance cholangiopancreatography have substantially improved the means of determining the cause of pancreatitis, its severity, and the nature of complications. Thus recent changes in guidelines have suggested that endoscopic retrograde cholangiopancreatography (ERCP) be utilized early on in patients with or at risk for biliary sepsis or obstruction, cholangitis, or worsening or persistent jaundice. Further, endoscopic retrograde cholangiopancreatography should be used to evaluate less common causes of pancreatitis such as sphincter of Oddi dysfunction, pancreas divisum, and pancreatic duct strictures. Finally, contrast-enhanced computed tomography (CT) should be used to diagnose acute pancreatitis.
This does not discount the importance of parameters measured by tests such as arterial blood gases, complete blood count (CBC), and serum chemistries such as calcium, glucose, and creatinine. [2]
Morbidity & mortality
Acute mild pancreatitis has a mortality rate of 1%. However, mortality can be as high as 10% to 30% in cases of severe acute pancreatitis if accompanied by infected versus sterile necrosis. [3]
In 70% to 80% of cases, the cause of death in acute pancreatitis is secondary pancreatic infection. Cardiovascular, pulmonary, and renal failure are also common. Cardiovascular failure may be secondary to bleeding into the retroperitoneal space. Pulmonary complications may sometimes include adult respiratory distress syndrome. Acute renal failure may result from acute tubular necrosis caused by cardiovascular collapse and hypotension. [4]
There are a number of means of assessing risk criteria—Ranson’s clinical criteria may be considered the most classic. However, research has suggested that the Computed Tomography Severity Index (score of ≥ 5 vs < 5) is superior in predicting adverse outcomes of prolonged hospitalization and mortality.
Treatment
Mild pancreatitis may be managed with initial parenteral rehydration, adequate pain control, and enteral nutritional support. This is a different from the course taken some years ago when patients were kept NPO with a nasogastric tube in place for a number of days. Subsequent studies have revealed that the morbidity of this regimen outweighed the value of any pain relief from preventing gastric distension. [5]
Management of severe pancreatitis should be done in the intensive care unit. The patient should be aggressively rehydrated, placed NPO, treated with appropriate analgesia, and consulted on by appropriate specialists—gastroenterology, surgery or interventional radiology if ERCP will be needed in the case of gallstones and obstructive jaundice or peripancreatic necrosis. If there is a question of infection, antibiotics should be initiated. Infected pancreatic necrosis often requires surgical debridement.
