Pancreatitis: Acute

• What is Pancreatitis (Acute)
• Statistics on Pancreatitis (Acute)
• Risk Factors for Pancreatitis (Acute)
• Progression of Pancreatitis (Acute)
• Symptoms of Pancreatitis (Acute)
• Clinical Examination of Pancreatitis (Acute)
• How is Pancreatitis (Acute) Diagnosed?
• Prognosis of Pancreatitis (Acute)
• How is Pancreatitis (Acute) Treated?
• Pancreatitis (Acute) References

What is Pancreatitis (Acute)

Acute Pancreatitis is a condition in which there is acute inflammation of the pancreas. The pancreas is an organ which has two major factors:

1. It secretes powerful enzymes into the first part of the small bowel (the duedenum) which helps to digest food components such as fats, proteins, and starches.
2. It secretes hormones such as insulin and glucagon into the blood stream, which helps with the regulation of the blood sugar level.

Pancreatitis is believed to occur due to inappropriate activation of the digestive enzymes, while they are still within the pancreas, in response to some cause. This causes inflammation and digestion of the pancreas tissue itself. When the condition is severe, other organ systems may be affected by the severe inflammation and fluid loss(e.g. lungs, kidneys).

Statistics on Pancreatitis (Acute)

This is a common condition, with overall incidence between 10-30 per 100,000. It is more common in different regions depending on how common the main risk factors are. It would be more common in areas with high rates of gallstones or alcohol consumption.

Risk Factors for Pancreatitis (Acute)

The two main risk factors are:

• Gallstones – most common cause (35-60%)
• Alcohol (20-35%) The other causes make up the remaining 25% or so of cases:
• Viral infections (mumps, Coxsackie virus);
• Metabolic (high Calcium, high lipids)
• Trauma
• Drugs – steroids, oestrogen contraceptives, thiazide diuretics
• Iatrogenic (caused by medical interventions) – as a result of ERCP;
• Many others. It is sometimes of unknown cause (up to 10%)

Progression of Pancreatitis (Acute)

An attack of acute pancreatitis can be severe. There may be extensive damage to the pancreas and fluid loss into the abdomen. Pancreatitis can be fatal acutely – usually due to local or systemic (generalised) complications.

Local complications:

• Extensive pancreatic tissue damage: if very severe may result in Diabetes (this is a rare cause of diabetes) since there is not enough normal pancreatic tissue;
• Pseudocyst formation – this is a collection of fluid. It is called a pseudocyst because it is contained in fibrous (scar) tissue rather than lined by epithelim as proper cysts are.
• Abscess formation – a collection of pus may form. This is noted by a persistent swinging fever and sometimes a palpable mass.

Systemic complications include:

• Acute renal failure; due to dehydration with fluid loss into the abdomen;
• Lung failure (Acure respiratory distress syndrome);
• Clotting abnormality (DIC) which has a high mortality

A patient that has suffered one episode of acute pancreatitis is at risk of more episodes, and some may develop chronic pancreatitis if the cause is not addressed.

How is Pancreatitis (Acute) Diagnosed?

• Full blood count, CRP – higher white cell count and CRP indicates severe inflammation;
• Urea and electrolytes -to assess renal function
• Liver Function Tests – assess severity and may indicate common bile duct stone;
• Serum Lipids – elevated triglycerides can be a cause.
• Calcium – level of decrease helps with severity assessment;
• Arterial blood gases – low oxygen in severe cases.
• Blood glucose – often raised.
• Chest x-ray– looks for complications – in severe cases ARDS;

Prognosis of Pancreatitis (Acute)

The prognosis varies depending on the severity of the episode. The mortality rate overall is about 10%. The more severe spectrum (acute haemorrhagic pancreatitis) has a mortality exceeding 30%.

Older patients, and those with more severely abnormal blood tests have a higher mortality rate and are more often treated in the Intensive Care Unit.

In those recovering, avoidance of the risk factors (such as abstinence from alcohol) will prevent relapse.

How is Pancreatitis (Acute) Treated?

Pancreatitis is initially mainly managed supportively. The patient is kept nil by mouth and resuscitated with oxygen, IV fluids (sometimes requiring a transfusion) and a nasogastric tube is inserted to help decompress the stomach to reduce the vomiting and abdominal distention. In severe cases the patient is managed in the high dependency unit or intensive care unit.

Cases of biliary pancreatitis (due to a bile duct stone) will require removal of this stone by ERCP and sphincterotomy when the patient is stable and at the earliest convenience -usually within 24-48 hours.

Surgery is reserved for very rare cases initially, or later if there are certain complications such as a pseudocyst or abscess which will not spontaneously resolve.

Pancreatitis (Acute) References

1. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001
2. Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.
3. Haslet C, Chiliers ER, Boon NA, Colledge NR. Principles and Practice of Medicine. Churchill Livingstone 2002.
4. Hurst JW (Editor-in-chief). Medicine for the practicing physician. 4th edition Appleton and Lange 1996.
5. Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002
6. Longmore M, Wilkinson I, Torok E. OXFORD HANDBOOK OF CLINICAL MEDICINE. Oxford Universtiy Press. 2001
7. McLatchie G and LEaper DJ (editors). Oxford Handbook of Clinical Surgery 2nd Edition. Oxford University Press 2002.
8. MEDLINE Plus
9. Raftery AT Churchill’s pocketbook of Surgery. Churchill Livingsone 2001.
10. Tjandra, JJ, Clunie GJ, Thomas, RJS,; Textbook of Surgery, 2nd Ed, Blackwell Science, Asia. 2001.