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Acute pancreatitis: Difference between revisions
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(Created page with "Acute pancreatitis is a reversible inflammatory condition of the pancreas that varies in intensity from just oedema and adiponecrosis to widespread parenchymal necrosis. It occurs when something causes the digestive enzymes to be activated in the pancreas itself, which self-digest the organ. The disease has a significant mortality, around 5%. In most patients the disease is mild and patients recover after a few days. However, 20% develop severe (necrotising) pancreatiti...") |
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Acute pancreatitis is a reversible inflammatory condition of the pancreas that varies in intensity from just oedema and adiponecrosis to widespread parenchymal necrosis. It occurs when something causes the digestive enzymes to be activated in the pancreas itself, which self-digest the organ. The disease has a significant mortality, around 5%. | '''Acute pancreatitis''' is a reversible inflammatory condition of the pancreas that varies in intensity from just oedema and [[adiponecrosis]] to widespread parenchymal necrosis. It occurs when something causes the digestive enzymes to be activated in the pancreas itself, which self-digest the organ. The disease has a significant mortality, around 5%. | ||
In most patients the disease is mild and patients recover after a few days. However, 20% develop severe (necrotising) pancreatitis with complications or organ failure, which has a high mortality. | In most patients the disease is mild and patients recover after a few days. However, 20% develop severe (necrotising) pancreatitis with complications or organ failure, which has a high mortality. | ||
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There are multiple possible causes, memorised by the acronym ''GET SMASHED'' | There are multiple possible causes, memorised by the acronym ''GET SMASHED'' | ||
* Gallstones | * [[Gallstone disease|Gallstones]] | ||
* Ethanol (Alcoholism) | * [[Alcohol|Ethanol]] (Alcoholism) | ||
* Trauma | * Trauma | ||
* Steroids | * [[Corticosteroid|Steroids]] | ||
* Mumps (and Coxsackie) Virus | * Mumps (and Coxsackie) Virus | ||
* Autoimmune | * Autoimmune | ||
* Scorpion venom | * Scorpion venom | ||
* Hypercalcaemia, | * [[Hypercalcaemia]], [[Hyperlipidaemia]] | ||
* ERCP | * [[ERCP]] | ||
* Drugs | * Drugs | ||
Other causes are Vascular (shock, arteroembolism, polyarteritis nodosa), mutations (PRSS1, SPINK1), etc. | Other causes are Vascular ([[shock]], arteroembolism, polyarteritis nodosa), mutations (PRSS1, SPINK1), etc. | ||
== Pathology == | == Pathology == | ||
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Most patients with acute pancreatitis have acute, persistent, severe epigastric pain which often radiates to the back. This is often described as a “belt-like” pain with the pain being in a belt-like distribution around the abdomen and back. | Most patients with acute pancreatitis have acute, persistent, severe epigastric pain which often radiates to the back. This is often described as a “belt-like” pain with the pain being in a belt-like distribution around the abdomen and back. | ||
Nausea/vomiting also occurs in most patients. Other symptoms are rare, unless they’re also associated with the underlying cause (like jaundice due to choledocholithiasis). Patients with severe acute pancreatitis may have fever, tachypnoea, and haemodynamic instability. | Nausea/vomiting also occurs in most patients. Other symptoms are rare, unless they’re also associated with the underlying cause (like [[jaundice]] due to [[choledocholithiasis]]). Patients with severe acute pancreatitis may have fever, tachypnoea, and haemodynamic instability. | ||
In mild acute pancreatitis, the epigastrium may be minimally tender to palpation. In severe acute pancreatitis however, the epigastrium is significantly tender. | In mild acute pancreatitis, the epigastrium may be minimally tender to palpation. In severe acute pancreatitis however, the epigastrium is significantly tender. | ||
Clinical deterioration, failure to improve after a week, or development of sepsis may occur during the disease course if local complications develop (especially if they become infected), or if the oedematous pancreatitis has progressed to a necrotising one. | Clinical deterioration, failure to improve after a week, or development of [[sepsis]] may occur during the disease course if local complications develop (especially if they become infected), or if the oedematous pancreatitis has progressed to a necrotising one. | ||
== Diagnosis and evaluation == | == Diagnosis and evaluation == | ||
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* Acute, persistent, severe epigastric pain (often radiates to the back) | * Acute, persistent, severe epigastric pain (often radiates to the back) | ||
* Elevation in serum lipase or amylase to > 3 the upper normal limit | * Elevation in serum [[lipase]] or [[amylase]] to > 3 the upper normal limit | ||
* Characteristic findings of acute pancreatitis on imaging | * Characteristic findings of acute pancreatitis on imaging | ||
In case of jaundice, elevated bilirubin, elevated liver tests or cholestatic enzymes, gallstone or another obstruction of the biliary tree is the likely cause. | In case of jaundice, elevated [[bilirubin]], elevated [[Liver function test|liver tests]] or [[Cholestatic enzyme|cholestatic enzymes]], [[Choledocholithiasis|gallstone]] or another obstruction of the biliary tree is the likely cause. | ||
Imaging may be performed with ultrasound, contrast CT, or MRI. It is not necessary to obtain imaging in uncomplicated cases where the first two criteria are fulfilled. | Imaging may be performed with [[ultrasound]], contrast [[CT]], or [[MRI]]. It is not necessary to obtain imaging in uncomplicated cases where the first two criteria are fulfilled. | ||
On abdominal ultrasound, the pancreas appears enlarged and hypoechoic. Local complications (peripancreatic fluid collection/acute necrotic collection) are visible as anechoic masses, with internal echoes if they contain necrosis. | On abdominal ultrasound, the pancreas appears enlarged and hypoechoic. Local complications (peripancreatic fluid collection/acute necrotic collection) are visible as anechoic masses, with internal echoes if they contain necrosis. | ||
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After the diagnosis is made, the underlying cause must be sought. This includes a thorough history to look for risk factors, serum triglyceride level, calcium level, and abdominal ultrasound for gallstone. Endoscopic ultrasound may be used if initial investigations does not reveal the etiology. | After the diagnosis is made, the underlying cause must be sought. This includes a thorough history to look for risk factors, serum triglyceride level, calcium level, and abdominal ultrasound for gallstone. Endoscopic ultrasound may be used if initial investigations does not reveal the etiology. | ||
The severity of the pancreatitis must be assessed, both based on clinical assessment and the SIRS score. Severe acute pancreatitis (as determined by the presence of haemodynamic instability, hypoxaemia, acid- | The severity of the pancreatitis must be assessed, both based on clinical assessment and the SIRS score. Severe acute pancreatitis (as determined by the presence of [[haemodynamic instability]], [[hypoxaemia]], [[acid-base disorder]], [[altered mental status]], etc.) should be managed in an [[intensive care unit]]. High <abbr>[[CRP]]</abbr> (> 100 mg/L) suggests necrotising pancreatitis. Important to note that serum lipase/amylase are not predictors of severity, and so the degree of enzyme elevation does not correlate with the severity of the disease. | ||
== Treatment == | == Treatment == | ||