Summary of acute pancreatitis This is a relatively common serious cause of abdominal pain in the middle aged and elderly. Often due to gallstone and alcohol. Clinical presentation is often severe constant epigastric pain radiating to the back. Serum amylase and lipase are one of the most important tests for suspicion of acute pancreatitis. Treatment is conservative and nil by mouth.
| Video: Acute Pancreatitis Overview |
Overview Acute pancreatitis is a relatively common condition presenting with severe, acute, constant epigastric pain. Incidence of ~5 per 100,000/year. Acute pancreatitis has a significant mortality. Early complications include acute renal failure, DIC, hypocalcemia and ARDS.
| Definition Acute Pancreatitis: An inflammatory process in which pancreatic enzymes are activated and cause autodigestion of the gland. Chronic Pancreatitis: Irreversible damage causing fibrosis and scarring to the pancreas, resulting in exocrine and endocrine dysfunction Pancreatic pseudocyst: Cystic space within the pancreas not lined by epithelial cells, often associated with chronic pancreatitis. |
Patient with severe epigastric pain
Pancreatic anatomy Pancreas extends retroperitoneally across posterior abdominal wall. It means "All (pan) Flesh (Kreas)". The pancreas consists of the following parts:
The head is encircled by duodenum and tail in contact with spleen. Pancreas has a poorly developed capsule & therefore adjacent structures (common bile duct, duodenum, splenic vein, transverse colon) are commonly involved in inflammatory process.
Blood Supply
Venous drainage
Nerve invervation
Lymphatic drainage
Embryology
Pancreatic physiology exocrine (98%) & endocrine (2%) functions
Exocrine: Pancreatic acinar cells produce digestive enzymes, which are stored in secretory granules. The Pancreatic exocrine secretion is regulated by cephalic, gastric & intestinal stimuli. Acinar cells secrete pancreatic juice made up the enzymes:
Exocrine section is stimulated by:
Endocrine: Islets of Langerhans – clusters of hormone-producing cells secreted directly into circulation. Endocrine cells of the pancreas:
| Cells of the Pancreas | Secretion | Function |
| Acinar cells secrete enzymes into the duodenum |
Nucleases | Breaksdown nucleotides |
| Proteases | Digests Proteins | |
| Lipases | Digests lipids | |
| B-amylase | Digests carbohydrates | |
| Islets of Lagerhan secrete hormones into the bloodstream |
Glucagon | Stimulates glucose release into the bloodstream from glucose stores |
| Insulin | Increases cell uptake and storage of glucose |
| Risk Factors |
| Middle aged |
| Gallstones |
| Alcohol |
| Hypertriglyceridaemia |
Medications
|
| HIV/AIDS |
| Endoscopic retrograde cholangiopancreatography |
| Trauma |
| SLE |
| Sjogren's syndrome |
Clinical Presentation Severe constant epigastric pain radiating to the centre of the back, with associated nausea and vomiting. The patient may be distressed, sweating and mildy pyrexial. Signs of guarding, tripod position seems of relieve pain. Signs of shock is severe acute pancreatitis. The oftiquoted, but uncommon bluish discolouration in the loins (Grey Turner's sign) only develops after several days
Investigations Serum amylase and lipase are diagnostic. Serum lipase remains elevated for longer then serum amylase and is more specific, but less sensitive. Other investigations include CRP (elevated), FBC, LFT (show abnormality), EUC and serum glucose. Abdominal x-ray can be performed but often show un-specific findings. CT may be required (shows pancreatic oedema, haemorrhage and necrosis). Ultrasound scan must be done within 48hours of admission to identify gallstone in the bile duct.
| Remember Amylase is not specific to the pancreas. It can be elevated in gastrointestinal ischemia with infarction or perforation, vomiting associated with pancreatitis can cause elevated amylase of salivary origin. Elevated serum lipase level is more specific than is amylase to pancreatic origin and remains elevated longer than does amylase |
Diagnosis Should be suspected in a patient with acute onset of a persistent, severe, epigastric pain with tenderness on palpation. Requires the presence of 2 of the following 3 criteria:
Glasgow Imrie criteria (PANCREAS)
Grades of severity
Aetiology The most common cause of acute pancreatitis is gallstones (60%) and alcohol (30%). Many are idopathic. Good acronym to remember is GETSMASHED
Pathophysiology Inflammation of pancreas results in cell death. The pancreatic cells release its enzymes everywhere resulting in further pancreatic inflammation. The enzymes self-digests the pancreatic tissue. Lipase and amylase levels are increased in the blood.
Difference between acute pancreatitis and chronic pancreatitis
Treatment of pancreatitis is mainly supportive and includes “pancreatic rest". Withholding food or liquids by mouth until symptoms subside, and adequate narcotic analgesia, usually with meperidine.
Management Conservative treatment involves oxygen, obtaining IV access for IV fluids and collecting bloods. IV analgesia + antiemetic. Nil-by-mouth and provide and nasogastric tube. Insert urinary catheter and monitor urine output hourly. Also monitor blood pressure and heart rate. Consider early insertion of a central venous line to monitor central venous pressure and guide IV fluid therapy in the seriously ill particularly the elderly.
Complications Acute pancreatitis has a significant mortality. Early complication include acute renal failure, disseminated intravascular coagulation (DIC), hypocalcemia, respiratory distress. late complications include pancreatic abscess or pseudo abscess and fat necrosis. Necrosis may be sterile or infected. Haemorrhage may occur and result in Cullen's sign (periumbilical eccymosis) on 5% of cases. If risk factors for pancreatitis is not changed, chronic pancreatitis may result long-term.
Continuous pancreatic inflammation may develop into full blown MODS or SIRS.
Signs of systemic inflammatory response syndrome (SIRS)
SIRS—defined by presence of two or more criteria:
Prognosis Mortality is associated with pancreatic necrosis and the presence of sepsis.
Difference between acute and chronic pancreatitis
