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."

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.

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.

Etiology/cause

The most common causes are gallstones and alcohol.

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."

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"

"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)"

Treatment

Acute pancreatitis

Bowel rest

Approximately 20% of patients have a relapse of pain during acute pancreatitis. 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.

Prognosis

Acute pancreatitis

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."

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"

APACHE II score

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