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Pancreatitis

Pancreatitides

The clinical term “Pancreatitis” refers to the acute and chronic inflammation of the pancreatic gland as a result of its enzymatic autodigestion. Pancreatitis is one of the leading cause of gastrointestinal mortality and morbidity among hospitalized patients.


Presentation

Patients suffering from acute or chronic pancreatitis may commonly present with the following symptomatology:

  • Upper abdominal pain is associated with the retroperitoneal irritation caused by the pancreas inflammation.
  • Referred pain at the back, spinal and dermatomal nerves of the back are subsequently irritated by any inflammation at the retroperitoneal spaces.
  • Post prandial abdominal pain because the obstructed ampulla or sphincter of Oddi may cause pain after a fatty or heavy meal. 
  • Nausea and vomiting, the digestive dysfunctions associated with pancreatitis can cause these common symptomatology.
  • Severe prostration, pancreatic juices may spill out from the inflamed pancreas and irritate other areas of the peritoneum and retroperitoneum.
  • Weight loss is a sign of a defective digestive process.
  • Steatorrhea, obstructed pancreatic juices may retard the normal digestion of fats in the intestine; thus, it is disposed in the same unmetabolized form.
Pleural Effusion
  • When the pleural effusion had not completely resolved following 3 weeks of treatment, another CT scan was performed, revealing that the pseudocyst was still present in the pancreas and causing the pleural effusion.[physio-pedia.com]
  • pleural effusion) Hemorrhage Intractable chronic abdominal pain Pseudocysts Suspected pancreatic neoplasm Vascular complications Decompression procedures are used in patients with large duct disease.[aafp.org]
  • effusion, APO, ARDS, atelectasis) AXR (e.g. localised ileus, exclusion of bowel obstruction) Ultrasound (e.g. gallstones and biliary obstruction) CT (dynamic contrast-enhanced) pancreatic oedema and haemorrhage, necrosis, viable and non-viable tissue[lifeinthefastlane.com]
  • Rapid breathing may also occur if people have inflammation of the lungs, areas of collapsed lung tissue ( atelectasis ), or accumulation of fluid in the chest cavity ( pleural effusion ).[merckmanuals.com]
  • Pleural effusion is usually present. Shallow breathing from pain can lead to lung collapse . Pancreatic enzymes may attack the lungs, causing inflammation .[en.wikipedia.org]
Tachypnea
  • When tachypnea and pending respiratory failure develops, intubation should be performed. Inpatient transfer Transfer patients with Ranson scores of 0-2 to a hospital floor.[emedicine.medscape.com]
  • The physical examination findings may be normal or reveal fever, hypotension, tachycardia, tachypnea, or diaphoresis.[aafp.org]
  • Symptoms of severe pancreatitis development include tachycardia, hypoxia, tachypnea, and changes in mental status. [1] [2] Complications that may occur with severe forms of this disease include pancreatic fluid-filled collections (57% of cases), pseudocysts[physio-pedia.com]
Dyspnea
  • The patient had no fever, abdominal pain, chest pain, dyspnea, or symptoms related to the urinary system, nor had she suffered from any recent trauma.[physio-pedia.com]
Fever
  • Typical signs include epigastric tenderness, fever, and tachycardia. Elevated serum amylase and lipase concentration supports, but is not pathognomonic for, the diagnosis of acute pancreatitis.[bestpractice.bmj.com]
  • Establishing the diagnosis The patient will often present with upper abdominal pain, nausea, vomiting and low grade fever. Severe cases can present with shock or coma.[clinicaladvisor.com]
  • Typically, a child will have severe abdominal pain, perhaps with nausea and vomiting (rarely fever). The majority of cases of acute pancreatitis resolve within a week, and there are no long-term complications.[childrenshospital.org]
Sepsis
  • One patient died from severe sepsis. Adverse events included severe abdominal pain and productive cutaneous fistulae (two patients).[ncbi.nlm.nih.gov]
  • […] is difficult (in the presence of SIRS) Sepsis is a major cause of death in severe pancreatitis Non-pancreatic infection plays a major role in this mortality.[lifeinthefastlane.com]
  • See also the following: Emergency Department Management Most of the pancreatitis cases presenting to the emergency department (ED) are treated conservatively, which includes fluid resuscitation, pain management, and sepsis control.[emedicine.medscape.com]
Ecchymosis
  • […] and edema in the subcutaneous tissue around the umbilicus) and Grey Turner sign (ecchymosis of the flank).[aafp.org]
Constitutional Symptom
  • Patient had no constitutional symptoms. The only medication he received prior to presentation was amoxicillin/clavulanic acid as prophylaxis for a dental procedure with his symptoms starting on day 9th of therapy.[ncbi.nlm.nih.gov]
Abdominal Pain
  • A 58-year-old Caucasian man presenting for acute sharp abdominal pain with associated nausea and heaves. Pain was non-radiating and worsening with movement. Patient had no constitutional symptoms.[ncbi.nlm.nih.gov]
  • The signs and symptoms of acute pancreatitis include: Upper abdominal pain Abdominal pain that radiates to your back Abdominal pain that feels worse after eating Fever Rapid pulse Nausea Vomiting Tenderness when touching the abdomen Symptoms of chronic[dhawy.com]
  • Here we report a 30year old male with past medical history of end-stage renal disease who presented in emergency department with acute abdominal pain. Laboratory work up revealed normal lipase and amylase level.[ncbi.nlm.nih.gov]
  • Chronic pancreatitis signs and symptoms include: Abdominal pain - this can vary from sudden and severe to constant with episodes of worsening abdominal pain; Unexplained weight loss; Fatty stool and diarrhea.[barnesjewish.org]
  • In the "proton pump inhibitors era", a penetrating peptic ulcer (PPU) represents an exceptional cause of abdominal pain, and was more frequently observed in the past where there was not an effective antacid treatment.[ncbi.nlm.nih.gov]
Vomiting
  • We present a case that presented with 1-day history of vomiting, diffuse abdominal pain, and altered mental status. Initial investigations showed highly elevated calcium levels, acute pancreatitis, and kidney failure.[ncbi.nlm.nih.gov]
  • Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support.[nlm.nih.gov]
  • During the initial visit, the doctor might ask you to describe the color and type of your child's vomit.[kidshealth.org]
Nausea
  • It is well tolerated, being the most frequent adverse effects asthenia, nausea and reversible increase of liver enzymes levels. Severe adverse effects are extremely rare.[ncbi.nlm.nih.gov]
  • We present a rare case in which a 96-year-old woman suffered from abdominal pain, nausea, and lack of appetite for over a month. She was diagnosed with acute calculous cholecystitis and pancreatitis.[ncbi.nlm.nih.gov]
  • Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support.[nlm.nih.gov]
  • Establishing the diagnosis The patient will often present with upper abdominal pain, nausea, vomiting and low grade fever. Severe cases can present with shock or coma.[clinicaladvisor.com]
Upper Abdominal Pain
  • The signs and symptoms of acute pancreatitis include: Upper abdominal pain Abdominal pain that radiates to your back Abdominal pain that feels worse after eating Fever Rapid pulse Nausea Vomiting Tenderness when touching the abdomen Symptoms of chronic[dhawy.com]
  • Patients suffering from acute or chronic pancreatitis may commonly present with the following symptomatology: Upper abdominal pain is associated with the retroperitoneal irritation caused by the pancreas inflammation.[symptoma.com]
  • Establishing the diagnosis The patient will often present with upper abdominal pain, nausea, vomiting and low grade fever. Severe cases can present with shock or coma.[clinicaladvisor.com]
  • […] and symptoms include: Upper abdominal pain Losing weight without trying Oily, smelly stools (steatorrhea) When to see a doctor Make an appointment with your doctor if you have persistent abdominal pain.[mayoclinic.org]
  • Symptoms include upper abdominal pain, pain after eating, nausea and fever. You may need to be hospitalized for treatment for acute pancreatitis. Treatment includes oxygen, medications, possible surgery, removal of gallstones.[cedars-sinai.edu]
Diarrhea
  • Once digestive problems are treated, people often gain weight and their diarrhea improves. Diabetes caused by chronic pancreatitis almost always requires treatment with insulin.[drugs.com]
  • Chronic pancreatitis causes severe abdominal pain, nausea, vomiting, diarrhea, and weight loss. Treatment often requires a hospital stay. The best way to prevent chronic pancreatitis is to drink alcohol only in moderation or not at all.[cedars-sinai.edu]
  • Episodes of abdominal pain and diarrhea lasting several days come and go over time and can progress to chronic pancreatitis.[transplant.surgery.ucsf.edu]
  • Chronic pancreatitis signs and symptoms include: Abdominal pain - this can vary from sudden and severe to constant with episodes of worsening abdominal pain; Unexplained weight loss; Fatty stool and diarrhea.[barnesjewish.org]
  • However in the later stages of the diseases, the exocrine insufficiency, which is typically manifested by voluminous diarrhea and endocrine insufficiency which is commonly known as diabetes often set in and these or other conditions typically need to[hopkinsmedicine.org]
Tachycardia
  • Typical signs include epigastric tenderness, fever, and tachycardia. Elevated serum amylase and lipase concentration supports, but is not pathognomonic for, the diagnosis of acute pancreatitis.[bestpractice.bmj.com]
  • […] position bandlike radiation to the back ( 50%) pain is absent in 5-10% of cases and can be a feature of fatal disease nausea and vomiting anorexia fever and chills dyspnoea steatorrhoea Examination Appearance may vary from well to seriously ill SIRS: tachycardia[lifeinthefastlane.com]
  • The physical examination findings may be normal or reveal fever, hypotension, tachycardia, tachypnea, or diaphoresis.[aafp.org]
  • Symptoms of severe pancreatitis development include tachycardia, hypoxia, tachypnea, and changes in mental status. [1] [2] Complications that may occur with severe forms of this disease include pancreatic fluid-filled collections (57% of cases), pseudocysts[physio-pedia.com]
Jaundice
  • Nausea and vomiting Raised blood pressure Dehydration Internal bleeding Elevated heart rate and breathing rate Fever Jaundice Weight loss and loss of appetite Chronic pancreatitis may also lead to diabetes and even pancreatic cancer Causes The majority[news-medical.net]
  • A gradual or sudden severe pain in the center part of the upper abdomen that goes through to your back; this pain may get worse when you eat and builds to a persistent pain Nausea and vomiting Fever Jaundice (a yellowing of the skin) due to blockage of[giwebmd.com]
  • Symptoms may be attributable to the failure of: biliary outflow: jaundice exocrine function: malabsorption endocrine function: diabetes Acute pancreatitis and chronic pancreatitis are assumed to be different disease processes, and most cases of acute[radiopaedia.org]
  • […] pancreatitis you may experience regular pain within the upper part of the abdomen and possibly some of the following symptoms, caused by difficulty in digesting food properly: Stomach cramps Bloating and wind Foul smelling stools Unexplained weight loss Jaundice[diabetes.co.uk]
  • If the bile duct is narrowed, the patient may develop jaundice .[ddc.musc.edu]
Grey Turner's Sign
  • (Rare) signs of haemorrhage on the physical exam include: Cullen sign : periumbilical bruising Grey-Turner sign : flank bruising There continues to be debate over the precipitating factor leading to acute pancreatitis, with duct occlusion being an important[radiopaedia.org]
  • […] have low blood pressure , in addition to the following symptoms: Weakness or feeling tired ( fatigue ) Feeling lightheaded or faint Lethargy Irritability Confusion or difficulty concentrating Headache Cullen's sign (bluish skin around the belly button) Grey-Turner[emedicinehealth.com]
  • […] of fatal disease nausea and vomiting anorexia fever and chills dyspnoea steatorrhoea Examination Appearance may vary from well to seriously ill SIRS: tachycardia, tachypnoea, pyrexia jaundice evidence of retroperitoneal haemorrhage ( flank echymosis (Grey-Turner[lifeinthefastlane.com]
Shoulder Pain
  • pain Short-term symptoms can include dehydration and low blood pressure.[kidshealth.org]
Dark Urine
  • urine, which had begun 2 weeks previously Past Medical History: Left lower extremity lymphedema, Raynauds disease, transient ischemic attacks, ischemic heart disease, left side hydronephrosis, lymph node biopsy in 1999, and chronic smoking Laboratory[physio-pedia.com]

Workup

The following diagnostic modalities and tests are being used to work up patients with pancreatitis:

  • Alkaline phosphatase: A positive blood test of an elevated pancreatic enzyme alkaline phosphatase is very suggestive of a pancreatitis.
  • Stool analysis of fats: Patients with chronic pancreatitis are usually analyzed with degree of fats in the stools which is indicative of a defective lipid metabolism and absorption.
  • Abdominal and endoscopic Ultrasound is used to determine degree of obstruction in the bile duct system and the presence of obstructive bile stones.
  • Computerized tomography (CT scan) will identify the size and location of gallstones, and the extent of pancreatic inflammation [8].
  • Magnetic resonance imaging (MRI) will elucidate a more detailed view of the pancreas and the biliary tree.
Dyslipidemia
  • Périard D, Telenti A, Sudre P, Cheseaux JJ, Halfon P, et al. (1999) Atheroge-nic dyslipidemia in HIV-infected individuals treated with protease inhibitors.The Swiss HIV cohort study. Circulation 100: 700-705.[omicsonline.org]
Pleural Effusion
  • When the pleural effusion had not completely resolved following 3 weeks of treatment, another CT scan was performed, revealing that the pseudocyst was still present in the pancreas and causing the pleural effusion.[physio-pedia.com]
  • pleural effusion) Hemorrhage Intractable chronic abdominal pain Pseudocysts Suspected pancreatic neoplasm Vascular complications Decompression procedures are used in patients with large duct disease.[aafp.org]
  • effusion, APO, ARDS, atelectasis) AXR (e.g. localised ileus, exclusion of bowel obstruction) Ultrasound (e.g. gallstones and biliary obstruction) CT (dynamic contrast-enhanced) pancreatic oedema and haemorrhage, necrosis, viable and non-viable tissue[lifeinthefastlane.com]
  • Rapid breathing may also occur if people have inflammation of the lungs, areas of collapsed lung tissue ( atelectasis ), or accumulation of fluid in the chest cavity ( pleural effusion ).[merckmanuals.com]
  • Pleural effusion is usually present. Shallow breathing from pain can lead to lung collapse . Pancreatic enzymes may attack the lungs, causing inflammation .[en.wikipedia.org]

Treatment

Patients initially diagnosed with pancreatitis are usually hospitalized for stabilization and treatment. Initially, patients are asked to fast (NPO) until the pancreatic inflammation subsides. When the pancreatic inflammation is controlled, patients may be started on clear liquids and low fat diets [9]. Patients are placed in intravenous resuscitation to address dehydration and institute Intravenous analgesics to control pain symptoms. Non-medical approach to pancreatitis include biliary repair of obstruction using ERCP, cholecystectomy if bile stones are formed from the gallbladder [10], and pancreatic drainage of fluids and necrotic debris.

Prognosis

A great majority of pancreatitis cases is self-limiting without the need for surgery and medical interventions. Although, severe cases may lead to significant morbidity and mortality in 10 to 15% of cases. Patients with primary biliary problems are more associated with a worse prognosis compared to the alcohol induced form which has a lower morbidity rating. The advances in the medical health care delivery and supportive management have significantly reduced the morbidity and mortality ratings of pancreatitis in general. However, in patients seen in the emergency room presenting with organ failure, the mortality rate will rise to 30% in these cases [6].

The following systemic manifestations are among the serious systemic manifestations of pancreatitis: Acute renal failure, acute respiratory distress syndrome (ARDS), cardiac insufficiency, hypovolemic shock, and hemorrhage. An increase in the neutrophil lymphocytic ratio (NLR) observed within the first 48 hours of pancreatitis is associated with a severe form of pancreatitis and a poor prognosis [7].

Etiology

Pancreatitis is commonly caused by obstructive biliary stones and chronic alcoholic intake [1]. An estimated 10-30% of pancreatitis cases have an unknown or idiopathic etiology. Some diagnostic modalities like the endoscopic retrograde cholangio-pancreatography (ERCP) can cause pancreatitis among patients after the procedure. The pathology in this complication is the eminent dysfunction of the sphincter of Oddi during and after the procedure. Blunt abdominal trauma and penetrating injuries to the abdomen can cause direct damage to the pancreatic gland and cause pancreatitis, this is seen in approximately 1.5% of cases. Less common causes of pancreatitis like viral infection has been documented especially with mumps, coxsackie, cytomegalovirus, Epstein-Barr, varicella, rubella and hepatitis virus infections. Accounting for 2% of cases of pancreatitis are drug-induced, the following drugs are proven to cause pancreatitis among susceptible patients:

  • Azathioprine
  • Chlorthiazide and Hydrochlorthiazide
  • Metronidazole
  • Methyldopa
  • Piroxicam
  • Cimetidine
  • Corticosteroids
  • Nitrofurantoin
  • Estrogens
  • Sulfonamides 

Epidemiology

In the United States, there is an estimated 40 cases of pancreatitis per 100,000 adults per year [2]. In 1998 alone, an estimated 183,000 cases of acute pancreatitis have been admitted in the hospitals, and the trend has continually increased in the following decades [3]. The worldwide incidence of pancreatitis is between 5 to 80 cases per 100,000 population, with the highest incidence noted in the United States and Finland [4]. In the United States, the majority of cases of pancreatitis is alcohol induced while European countries and Hong Kong has a predominance of microlithiasis induced type of pancreatitis.

The relative median age of onset for pancreatitis is dependent on its etiology [5]. For example alcoholic pancreatitis which peaks at 39 years old, biliary pathology which are more prone by 69 years old, and drug induced types of pancreatitis that occurs at a mean age of 42. There is a male predominance over its female counterpart for pancreatitis. A racial predilection among the black population is notably observed over the light skinned races.

Sex distribution
Age distribution

Pathophysiology

During the process of normal digestion, the inactivated enzymes from the exocrine pancreas traverse to the intestinal lumen where they are activated to digest the food contents of the small intestine. In the actual pancreatitis, these enzymes are activated within the gland causing cellular autodigestion, irritation, and inflammations. Acute inflammation will convey the usual signs and symptoms of acute pancreatitis. When recurrent bouts of acute pancreatic inflammation occurs in a long standing period, this is now referred to as chronic pancreatitis. The post inflammatory scarring of the pancreatic tissues will cause a subsequent loss of function of the gland causing digestion problems and diabetes consequently.

Prevention

One of the corner stone in the control of pancreatitis is the eventual control of alcohol dependence. Smoking can also impair digestion and advertently cause pancreatitis; thus, abstinence from this vice can prevent the inflammation. The dietary modifications of a low fat diet can reduce the incidence of pancreatitis, and reduce its digestive menace. Adequate hydration can help keep the pancreas hydrated and safe.

Summary

Pancreatitis is a clinical disease characterized by the inflammation of the exocrine pancreas which may lead to autodigestion of the gland itself. Pancreatitis is generally classified as acute which presents suddenly and resolves in days, and chronic which presents in the course of many years. In most mild cases of pancreatitis, the inflammation subsides spontaneously even without treatment but in some occasion pancreatitis can be very severe that it can cause life threatening complications.

Patient Information

Definition

Pancreatitis is a clinical disease characterized by the inflammation of the exocrine pancreas which may lead to auto digestion of the gland. 

Cause

Pancreatitis is primarily caused by alcohol binge drinking and biliary microlithiasis obstructions. Less common causes include: Viral infection, abdominal trauma, hereditary, and diagnostic procedures like ERCP.

Symptoms

Upper abdominal pain is a very common presenting sign of pancreatitis. Other signs includes nausea and vomiting, prostration, steatorrhea and weight loss.

Diagnosis

Blood test with alkaline phosphatase, ERCP, Ultrasound, CT scan and MRI.

Treatment and follow-up

Patients are asked to fast with intravenous fluid support. Pain management and surgical correction of underlying pathology. Patients are advised to refrain from alcohol intake to prevent recurrence.

References

Article

  1. Whitcomb DC, Yadav D, Adam S, et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008; 8(4-5):520-31.
  2. Granger J, Remick D. Acute pancreatitis: models, markers, and mediators. Shock. Dec 2005; 24 Suppl 1:45-51.
  3. Singla A, Csikesz NG, Simons JP, Li YF, Ng SC, Tseng JF, et al. National hospital volume in acute pancreatitis: analysis of the Nationwide Inpatient Sample 1998-2006. HPB (Oxford). Aug 2009; 11(5):391-7.
  4. Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc. Dec 2002; 56(6 Suppl):S226-30.
  5. Morinville VD, Barmada MM, Lowe ME. Increasing incidence of acute pancreatitis at an American pediatric tertiary care center: is greater awareness among physicians responsible? Pancreas. Jan 2010; 39(1):5-8.
  6. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. May 18 2006; 354(20):2142-50.
  7. Suppiah A, Malde D, Arab T, Hamed M, Allgar V, Smith AM, et al. The Prognostic Value of the Neutrophil-Lymphocyte Ratio (NLR) in Acute Pancreatitis: Identification of an Optimal NLR. J Gastrointest Surg. Feb 1 2013.
  8. Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: prognostic value of CT. Radiology. Sep 1985; 156(3):767-72.
  9. Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin Gastroenterol Hepatol. Aug 2007; 5(8):946-51.
  10. Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. Apr 2010; 251(4):615-9.

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Last updated: 2018-06-22 12:34