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Pancreatitis

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Pancreatitis is "inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis (International Symposium on Acute Pancreatitis, Atlanta, 1992). The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis."[1] Management of acute necrotizing pancreatitis has been reviewed.[2]

Contents

Classification

Acute pancreatitis

Acute necrotizing pancreatitis

Acute necrotizing pancreatitis is a "severe form of acute inflammation of the pancreas characterized by one or more areas of necrosis in the pancreas with varying degree of involvement of the surrounding tissues or organ systems. Massive pancreatic necrosis may lead to diabetes mellitus, and malabsorption.[3]

Chronic pancreatitis

Chronic pancreatitis is "inflammation of the pancreas that is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus. It is characterized by the irregular destruction of the pancreatic parenchyma which may be focal, segmental, or diffuse.[4]

Etiology/cause

The most common causes are gallstones and alcohol.[5]

Diagnosis

Acute pancreatitis

The diagnostic criteria for pancreatitis are "two of the following three features: 1) abdominal pain characteristic of acute pancreatitis, 2) serum amylase and/or lipase ≥3 times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on a CT scan."[6]

Two clinical practice guidelines state:

"It is usually not necessary to measure both serum amylase and lipase. Serum lipase may be preferable because it remains normal in some nonpancreatic conditions that increase serum amylase including macroamylasemia, parotitis, and some carcinomas. In general, serum lipase is thought to be more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis"[6]
"Although amylase is widely available and provides acceptable accuracy of diagnosis, where lipase is available it is preferred for the diagnosis of acute pancreatitis (recommendation grade A)"[7]

Chronic pancreatitis

Chronic pancreatitis may occur without pain, especially patients who first start having symptoms in middle age[8][9].

Treatment

Acute pancreatitis

Bowel rest

Approximately 20% of patients have a relapse of pain during acute pancreatitis.[10] Approximately 75% of relapses occur within 48 hours of oral refeeding.

The incidence of relapse after oral refeeding may be reduced by post-pyloric enteral, rather than parenteral, feeding prior to oral refeeding.[10]

Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours after onset of symptoms may be useful during acute biliary pancreatitis if there are signs of:[11]

  • Cholangitis (serum bilirubin level >1.2 mg/dL [20 µmol/L] and/or dilated CBD on ultrasound or CT and temperature >38.5°C)
  • Cholestasis (serum bilirubin: >2.3 mg/dL [40 mumol/L] and/or dilated common bile duct)

Necrosectomy

Video-assisted retroperitoneal debridement (VARD) may be better than open necrosectomy.[12]

Chronic pancreatitis

Prognosis

Short term

Clinical practice guidelines state:

2006: "The two tests that are most helpful at admission in distinguishing mild from severe acute pancreatitis are APACHE-II score and serum hematocrit. It is recommended that APACHE-II scores be generated during the first three days of hospitalization and thereafter as needed to help in this distinction. It is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscitation."[6]
2005: "Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score" [7]

Risk factors at hospital discharge that predict subsequent hospital admission constitute a clinical prediction rule.[13]

APACHE II score

"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality [6] Online calculator

BISAP Score

The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is a sum of the following signs within 24 hours of presentation:[14][15]

A BISAP score ≥3 is associated with an increased risk of complications.[14]

The BISAP may not be as accurate as Ranson's and have a lower area under the receiver operating characteristic curve.[15]

Ranson's Score

A score developed by Ranson predicts mortality.[16] At admission:

  1. age in years > 55 years
  2. white blood cell count > 16000 cells/mm3
  3. blood glucose > 11 mmol/L (> 200 mg/dL)
  4. serum AST > 250 IU/L
  5. serum LDH > 350 IU/L

At 48 hours:

  1. Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
  2. Hematocrit fall > 10%
  3. Oxygen PO2 < 60 mmHg)
  4. BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
  5. Base deficit (negative base excess) > 4 mEq/L
  6. Sequestration of fluids > 6 L

A score of 3 or more suggest severe pancreatitis with a mortality of 15%.

Long term

Chronic pancreatitis is more likely among alcoholic pancreatitis.[17]

Prevention

Cholecystectomy to prevent recurrence should be considered when "significantly elevated liver enzymes (≥threefold increase of alanine aminotransferase or aspartate aminotransferase) on day 1" or "the presence of gallstones/sludge in the gall bladder" is seen with ultrasonography[18]

References

  1. Anonymous (2014), Pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Baron TH, Morgan DE (1999). "Acute necrotizing pancreatitis.". N Engl J Med 340 (18): 1412-7. PMID 10228193.
  3. Anonymous (2014), Acute necrotizing pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
  4. Anonymous (2014), Chronic pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
  5. Anonymous (2014), Pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
  6. 6.0 6.1 6.2 6.3 Banks P, Freeman M (2006). "Practice guidelines in acute pancreatitis". Am J Gastroenterol 101 (10): 2379-400. DOI:10.1111/j.1572-0241.2006.00856.x. PMID 17032204. Research Blogging.
  7. 7.0 7.1 UK Working Party on Acute Pancreatitis (2005). "UK guidelines for the management of acute pancreatitis". Gut 54 Suppl 3: iii1-9. DOI:10.1136/gut.2004.057026. PMID 15831893. Research Blogging.
  8. Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP (November 1994). "The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis". Gastroenterology 107 (5): 1481–7. PMID 7926511[e]
  9. Layer P, DiMagno EP (August 1999). "Early and late onset in idiopathic and alcoholic chronic pancreatitis. Different clinical courses". Surg. Clin. North Am. 79 (4): 847–60. PMID 10470331[e]
  10. 10.0 10.1 Petrov MS, van Santvoort HC, Besselink MG, Cirkel GA, Brink MA, Gooszen HG (2007). "Oral Refeeding After Onset of Acute Pancreatitis: A Review of Literature". DOI:10.1111/j.1572-0241.2007.01357.x. PMID 17573797. Research Blogging.
  11. van Santvoort HC, Besselink MG, de Vries AC, et al. (July 2009). "Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study". Ann. Surg. 250 (1): 68–75. DOI:10.1097/SLA.0b013e3181a77bb4. PMID 19561460. Research Blogging.
  12. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al. (2010). "A step-up approach or open necrosectomy for necrotizing pancreatitis.". N Engl J Med 362 (16): 1491-502. DOI:10.1056/NEJMoa0908821. PMID 20410514. Research Blogging.
  13. Whitlock TL, Tignor A, Webster EM, Repas K, Conwell D, Banks PA et al. (2011). "A scoring system to predict readmission of patients with acute pancreatitis to the hospital within thirty days of discharge.". Clin Gastroenterol Hepatol 9 (2): 175-80; quiz e18. DOI:10.1016/j.cgh.2010.08.017. PMID 20832502. Research Blogging.
  14. 14.0 14.1 Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, Johannes RS et al. (2009). "A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis.". Am J Gastroenterol 104 (4): 966-71. DOI:10.1038/ajg.2009.28. PMID 19293787. Research Blogging.
  15. 15.0 15.1 Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A et al. (2010). "Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis.". Am J Gastroenterol 105 (2): 435-41; quiz 442. DOI:10.1038/ajg.2009.622. PMID 19861954. Research Blogging.
  16. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC (1974). "Prognostic signs and the role of operative management in acute pancreatitis.". Surg Gynecol Obstet 139 (1): 69-81. PMID 4834279.
  17. Lankisch PG, Breuer N, Bruns A, Weber-Dany B, Lowenfels AB, Maisonneuve P (2009). "Natural history of acute pancreatitis: a long-term population-based study.". Am J Gastroenterol 104 (11): 2797-805; quiz 2806. DOI:10.1038/ajg.2009.405. PMID 19603011. Research Blogging.
  18. Trna J, Vege SS, Pribramska V, Chari ST, Kamath PS, Kendrick ML et al. (2012). "Lack of significant liver enzyme elevation and gallstones and/or sludge on ultrasound on day 1 of acute pancreatitis is associated with recurrence after cholecystectomy: a population-based study.". Surgery 151 (2): 199-205. DOI:10.1016/j.surg.2011.07.017. PMID 21975288. Research Blogging.
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