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Acute pancreatitis: Difference between revisions

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<section begin="radiology" />'''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 relatively high mortality, around 5%.<section end="radiology" />
<section begin="clinical biochemistry" /><section begin="radiology" />'''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 relatively high mortality, around 5%.<section end="radiology" /><section end="clinical biochemistry" />


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. Having many episodes of acute pancreatitis may lead to [[chronic pancreatitis]].
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. Having many episodes of acute pancreatitis may lead to [[chronic pancreatitis]].
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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.<section begin="radiology" /><section begin="clinical biochemistry" />
<section begin="radiology" />
== Diagnosis and evaluation ==
== Diagnosis and evaluation ==
The diagnosis of acute pancreatitis is made when two of the following three are present:
The diagnosis of acute pancreatitis is made when two of the following three are present:
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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.
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.
 
<section end="clinical biochemistry" />
=== Imaging ===
=== Imaging ===
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. Ultrasound is usually the first choice modality. If complications are suspected, CT is usually the better first choice.
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. Ultrasound is usually the first choice modality. If complications are suspected, CT is usually the better first choice.
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=== Etiology ===
=== 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.
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.
 
<section begin="clinical biochemistry" />
=== Severity assessment ===
=== Severity assessment ===
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.
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.
 
<section end="clinical biochemistry" />
== Treatment ==
== Treatment ==
Management of acute pancreatitis is conservative and supportive, as it's usually self-limiting. This involves pain control, IV fluids (large amounts), and correction of electrolyte and metabolic abnormalities. Mild (oedematous) pancreatitis is self-limited, and so these measures are usually sufficient, and the patient recovers within a week. Feeding should be initialised early but slowly with a soft diet when the pain is decreasing and the inflammatory markers are improving. In more severe cases, the patient should be nil per os (no oral feeding).
Management of acute pancreatitis is conservative and supportive, as it's usually self-limiting. This involves pain control, IV fluids (large amounts), and correction of electrolyte and metabolic abnormalities. Mild (oedematous) pancreatitis is self-limited, and so these measures are usually sufficient, and the patient recovers within a week. Feeding should be initialised early but slowly with a soft diet when the pain is decreasing and the inflammatory markers are improving. In more severe cases, the patient should be nil per os (no oral feeding).