Pancreatitis
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]
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.[2]
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.[3]
Etiology/cause
The most common causes are gallstones and alcohol.[4]
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."[5]
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 includingmacroamylasemia, 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"[5]
- "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)"[6]
Chronic pancreatitis
Chronic pancreatitis may occur without pain, especially patients who first start having symptoms in middle age[7][8].
Treatment
Acute pancreatitis
Bowel rest
Approximately 20% of patients have a relapse of pain during acute pancreatitis.[9] 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.[9]
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:[10]
- 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)
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."[5]
- 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" [6]
APACHE II score
"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality [5] 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:[11][12]
- Blood urea nitrogen level >25 mg/dL
- Impaired mental status
- Systemic inflammatory response syndrome
- age >60
- Pleural effusion on imaging studies
A BISAP score ≥3 is associated with an increased risk of complications.[11]
The BISAP may not be as accurate as Ranson's and have a lower area under the receiver operating characteristic curve.[12]
Long term
Chronic pancreatitis is more likely among alcoholic pancreatitis.[13]
References
- ↑ Anonymous (2024), Pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Acute necrotizing pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Chronic pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Pancreatitis (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ 5.0 5.1 5.2 5.3 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.
Cite error: Invalid
<ref>tag; name "pmid17032204" defined multiple times with different content Cite error: Invalid<ref>tag; name "pmid17032204" defined multiple times with different content Cite error: Invalid<ref>tag; name "pmid17032204" defined multiple times with different content - ↑ 6.0 6.1 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.
Cite error: Invalid
<ref>tag; name "pmid15831893" defined multiple times with different content - ↑ 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]
- ↑ 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]
- ↑ 9.0 9.1 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.
- ↑ 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.
- ↑ 11.0 11.1 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.
- ↑ 12.0 12.1 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.
Cite error: Invalid
<ref>tag; name "pmid19861954" defined multiple times with different content - ↑ 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.