GASTRO
November 1, 2006

Acute Pancreatitis

Stephen J. Pandol M.D.
Dr. Pandol is Professor of Medicine, UCLA School of Medicine and Staff Physician, Department of Medicine, VA Greater Los Angeles Health Care System and University of California, Los Angeles.

The pancreas is an important gland located near the stomach and the small intestine which makes a variety of key chemicals ("enzymes") that help regulate different bodily processes. The pancreas secretes enzymes into the small intestine that help us digest food, and it also produces and then releases the hormones insulin and glucagon into the bloodstream to control the level of sugar (glucose). Sometimes the enzymes become active while they are still inside the pancreas. When this happens, they damage the pancreas itself.

In a healthy person, digestive enzymes produced by the pancreas are activated when they reach the small intestine. Sometimes, however, the enzymes become active while they are still inside the pancreas. When this happens, they damage the pancreas itself ("pancreatitis") and cause a variety of other problems.

There are two kinds of pancreatitis: acute and chronic. Acute pancreatitis happens in sudden, brief attacks,while chronic pancreatitis lasts longer and causes a slow but steady destruction of the pancreas. Both can cause other serious problems such as bleeding, damage to the heart and other organs, and infection.

Acute Pancreatitis
The two main effects of acute pancreatitis are acute inflammation and damage to tissues inside the gland. In its most severe forms, there can be a widespread inflammatory response involving organs both near to and distant from the pancreas; and actual death of some pancreatic tissue, a condition called necrosis.

The most common first symptom is abdominal pain, often accompanied by vomiting, fever, tachycardia (racing of the heart), high white blood cell count and increased levels of pancreatic enzymes in the blood and urine. In severe cases, acute pancreatitis affects other organs, (e.g., lungs, kidneys, liver, the cardiovascular and central nervous systems).

Acute pancreatitis can be further subdivided into mild and severe: in the mild form, the disease causes little organ dysfunction and the body recovers more or less on its own; in the severe form, the disease causes multiple organ failure, tissue death, abscesses and pseudocysts. Pseudocysts are discussed below.

How Common is Acute Pancreatitis?
Studies show that approximately 70% of the cases of acute pancreatitis are related to gallstones or alcohol abuse. Other causes account for another 20%, and about 10% of cases have no known cause. It is not known why and how some cases of acute pancreatitis lead to the chronic form of the disease.

There is uncertainty as well about how common acute pancreatitis really is. Estimates range from 5 people per 100,000 all the way up to 73 per 100,000. The reason for this is that pancreatitis is easy to miss or misdiagnose. Also, many people do not seek medical attention because their symptoms are mild or because of limited access to medical care.

Alcohol abuse is more commonly associated with male cases than female cases, whereas gallstone disease is more commonly associated with female cases. For this reason, the total number of acute pancreatitis cases, and the disease's distribution by sex, in different areas of the world have a lot to do with local alcohol customs and the prevalence of gallstones.

How the Disease Works
As stated above, the majority of people with acute pancreatitis either abuse alcohol or suffer from gallstones. We do not know, however, whether these factors actually cause acute pancreatitis directly. Significant progress, however, has been made in understanding how the disease works once it has started. Researchers are moving closer to identifying targets for therapy at the cellular level and, hopefully, this will soon lead to the development of more effective drugs to treat acute pancreatitis.

How Acute Pancreatitis Is Diagnosed
A person with acute pancreatitis most commonly seeks treatment for severe abdominal pain, sometimes radiating to the back. The pain is often accompanied by nausea and vomiting. Other symptoms may include rapid heart rate, low blood pressure and dehydration. Rarely, people with acute pancreatitis will have bruising around the belly button (Cullen's sign) or on the outside of the upper thigh (Grey Turner's sign) which suggest the presence of what is called hemorrhagic (bleeding) pancreatitis.

Where there are symptoms and signs of acute pancreatitis, tests such as measures of serum enzymes and pancreatic imaging studies (i.e., ultrasound, CT) are needed to establish the diagnosis. Table 1 presents an overview of the diagnostic tests.

Table 1.
Standard Diagnostic Tests.
Test Sensitivity Specificity Comment
Serum enzymes high moderate > 3x normal increases specificity
Ultrasound moderate high Best for gallstones
CT moderate high Detects calcifications, fluid collections
CT with pancreatic protocol and IV contrast moderate high Detects necrosis
Adapted from , www.gastroslides.org


Looking for Contributing Factors
Figure 1 shows the most common factors that contribute to acute pancreatitis. How these factors influence the development of the disease is not entirely known, though it is important to identify them, as their removal may decrease the risk of further episodes of acute pancreatitis. Examples include counseling for alcohol abuse; correcting metabolic causes (such as high triglyceride or calcium levels in the blood); stopping certain medications; and treatment with corticosteroids when an autoimmune disorder is suspected. It is also important in the elderly to quickly determine if pancreatic cancer is the cause of pancreatitis.

Often, contributing factors for someone with an episode of acute pancreatitis cannot be identified right away. In this case, imaging techniques are used. Autoimmune pancreatitis can be diagnosed by imaging and other tests, while the genetic causes require formal genetic testing.

Figure 1.
Causes of Acute Pancreatitis.
Acute Pancreatitis pie chart

  • Autoimmune
  • Drug induced
  • Iatrogenic
  • IBD related
  • Infections
  • Inherited
  • Metabolic
  • Neoplastic
  • Structural
  • Toxic
  • Traumatic
  • Vascular

Adapted from , www.gastroslides.org


Severity and Outcome

Early assessment of severity is critical for identifying those who require intensive monitoring and support.

A practical approach to determining severity is to monitor the indicators listed in Table 2, together with other tests.

Table 2.
Early Indicators of Severity.
  • Tachycardia, hypotension
  • Tachypnea, hypoxemia
  • Hemo-concentration
  • Oliguria
  • Encephalopathy
Adapted from , www.gastroslides.org


Managing Acute Pancreatitis

Supportive Care
The main treatment of acute pancreatitis is largely supportive (Table 3). People with severe pancreatitis should seek immediate medical attention; they require monitoring and treatment in a hospital ICU. Monitoring includes assessment of neurological status, vital signs, arterial oxygen saturation, kidney function, abdominal physical findings and blood calcium concentrations. The table below lists general supportive care.

Table 3.
Treatment for Acute Pancreatitis.
Supportive Car Other Treatments
  • Monitoring
    • Vital signs
    • Urine output
    • O2 saturation
    • Hematocrit
    • Ca2+/glucose
  • Fluid replacement
  • Analgesia
  • Acid suppression
  • Antibiotics
  • NG tube
  • Nutritional support
  • Urgent ERCP
Adapted from , www.gastroslides.org

Other Treatments
Although many doctors prescribe treatments to reduce stomach acid, their benefits are unclear. Nasogastric suction, in which the stomach contents are emptied using a tube through the nose, has not been shown to shorten episodes of acute pancreatitis but is a good way to relieve the discomfort of nausea and vomiting.

If imaging studies show gall bladder obstruction and infection caused by gallstones, doctors may recommend immediate surgery to remove the gallstone or stones.

For those with severe pancreatitis, preventive antibiotic therapy can be particularly effective. However, not all medical experts agree about this.

In those who have signs of pancreatic infection (pseudocysts or abcesses), the suspicious pancreatic lesion should be tested for infection. Lesions found to be infected can be removed or destroyed using radiology or surgery. Antibiotics may also be used.

Antibiotics
Antibiotics are used both to prevent infections and to treat existing infections during pancreatitis. For those with severe pancreatitis, preventive antibiotic therapy can be particularly effective. However, not all medical experts agree about this.

A recent study showed that preventive antibiotics reduced mortality, but the advantage was limited to those with severe acute pancreatitis who received so-called broad-spectrum antibiotics that fight a wide variety of bacteria. The largest Randomized Control Trial compared a combination of two agents as against a placebo (ciprofloxacin + metronidazole vs. placebo) involving 114 people showed no benefit. Antibiotics used in acute pancreatitis include imipenim alone; cefurozime alone; ceftazidime, amikacin and metronidazole; and ciprofloxacin and metronidazole.

Pain Management
Abdominal pain is the number one symptom of acute pancreatitis. In severe pancreatitis, adequate pain control sometimes requires the use of IV narcotics. In the past, meperidine was favored over morphine. However, because repeated doses of meperidine can lead to accumulation of a substance, normeperidine, which causes neuromuscular irritation and seizures, its popularity has diminished.

Better choices for pain management are hydromorphone, fentanyl and morphine. It is important to be careful with these medicines, because all narcotics cause depression of respiratory and cardiovascular functions, which can be made worse by other drugs used in acute pancreatities cases such as calcium channel blockers and beta-adrenergic antagonists.

Nutrition
People with mild acute pancreatitis should not eat until the pain goes away, bowel sounds (e.g., stomach grumbling and rumbling) become normal and appetite returns. Food should be reintroduced slowly — so long as there is no pain, nausea or vomiting. There is a risk of relapse if oral feedings are begun too soon or if feeding is advanced too rapidly.

Those with severe pancreatitis, whose symptoms last more than 5 days, are often given a feeding tube.

Other Complications
Other common complications of acute pancreatitis include pseudocysts and bleeding.

Pseudocysts are collections of pancreatic fluid contained by scar tissue. The fluid contains high concentrations of pancreatic enzymes. Pseudocysts are common, appearing in up to 10% of those with acute pancreatitis. They may cause upper abdominal pain, a full feeling, nausea and vomiting. Pseudocysts sometimes rupture and leak pancreatic fluid into the abdominal cavity.

Most pseudocysts go away by themselves and are only drained when there is evidence of infection or when the pseudocyst continues to enlarge.

Summary
Acute pancreatitis is a poorly-understood disorder with a wide variety of types, symptoms and complications. The two keys to providing the best care are to recognize the severity of the disease, and to identify any causes, complications and contributing factors, as early as possible. Key facts to remember are:

Pancreatitis has two forms: acute and chronic

Many cases of pancreatitis appear to be caused by gallstones or alcohol abuse.

In some cases, there is no clear cause.

Symptoms include abdominal pain, nausea, vomiting, fever and a rapid pulse.

Treatments include pain killing narcotics, IV fluids, antibiotics and surgery.
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