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Acute pancreatitis

Last updated: August 27, 2021

Summarytoggle arrow icon

Acute pancreatitis is an inflammatory condition of the pancreas most commonly caused by biliary tract disease or alcohol abuse. Damage to the pancreas causes local release of digestive proteolytic enzymes that autodigest pancreatic tissue. Acute pancreatitis usually presents with epigastric pain radiating to the back, nausea and vomiting, and epigastric tenderness on palpation. The diagnosis is made based on the clinical presentation, elevated serum pancreatic enzymes, and findings on imaging (CT, MRI, ultrasound) that suggest acute pancreatitis. Treatment is mostly supportive and includes bowel rest, fluid resuscitation, and pain medication. Enteral feeding is usually quickly resumed once the pain and inflammatory markers begin to subside. Interventional procedures may be indicated for the treatment of underlying conditions, such as ERCP or cholecystectomy in gallstone pancreatitis. Localized complications of pancreatitis include necrosis, pancreatic pseudocysts, and abscesses. Systemic complications involve sepsis, ARDS, organ failure, and shock and are associated with a considerable rise in mortality.

Most common causes [1]

  • Biliary pancreatitis; (∼ 40% of cases; mostly caused by gallstones)
  • Alcohol-induced (∼ 20% of cases)
  • Idiopathic (∼ 25% of cases)

Other causes [1]

I GET SMASHED: Idiopathic, Gall stones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion poison, Hypercalcemia, Hypertriglyceridemia, ERCP, and Drugs are the most common causes of acute pancreatitis.

Mechanisms of development

Sequence of events leading to pancreatitis

Sequelae of pancreatitis (depending on the severity of pancreatitis)

Acute pancreatitis is diagnosed based on a typical clinical presentation, with abdominal pain radiating to the back, and either detection of highly elevated pancreatic enzymes or characteristic findings on imaging. Serum hematocrit is an easy test that should be conducted to help quickly predict disease severity.

Laboratory tests

Determining calcium values is very important: Hypercalcemia may cause pancreatitis, which may then, in turn, cause hypocalcemia!

Imaging

References:[4][5][6][7][8][9][10][11][12][13][14][15][16]

Reference:[17]

The differential diagnoses listed here are not exhaustive.

Overview of acute and chronic pancreatitis
Acute pancreatitis Chronic pancreatitis
Characteristics
  • Progressive inflammation
  • Irreversible damage with impairment of exocrine and endocrine function
Etiology Most common causes
Less common causes
Pathophysiology
Course
  • Sudden onset
  • Recurrent, progressive episodes
Clinical features Main symptoms
  • Constant, severe epigastric pain (classically radiating towards the back)
  • Nausea, vomiting
  • Fever
  • Weakness
  • Epigastric abdominal pain (main symptom)
    • Radiating towards the back
    • Relieves on bending forward, exacerbates after eating
  • Cramping abdominal pain, bloating, diarrhea, constipation, flatulence
  • Nausea
Further symptoms
Diagnostics Laboratory studies
Imaging
Treatment
Complications
Prognosis
  • Mortality
    • In patients without organ failure: < 1%
    • In patients with organ failure: ∼ 30% [17]
  • Dependent on alcohol use, smoking, and presence of end-stage liver disease [18]

General measures

Drug therapy

Procedures/surgery

The most important therapeutic measure is adequate fluid replacement (minimum of 3–4 liters of crystalloids per day)!

"PANCREAS" - Perfusion (fluid replacement), Analgesia, Nutrition, Clinical (observation), Radiology (imaging), ERC (endoscopic stone extraction), Antibiotics, Surgery (surgical intervention, if necessary).

References:[17][19][20][21][22][23][24]

Localized

Systemic [29]

We list the most important complications. The selection is not exhaustive.

Amylase and lipase, which are used for the diagnosis of pancreatitis, cannot be used to predict the prognosis!

  • Prognostic score: Numerous scoring systems exist for assessing the severity and predicting the prognosis of acute pancreatitis, such as the Ranson criteria.
    • Consists of 11 parameters (five factors are assessed at admission and the other six during the next 48 hours) that are used to create a prognostic score
    • Mortality increases with an increasing score

References:[30][31][32]

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