Acute pancreatitis, Symptoms, Etiology, Diagnosis, and Therapy

Definition:

Acute inflammation of the pancreas, which leads to destruction of the gland’s parenchyma, these leads in turn to release of pancreas digesting enzymes leading to self-digestion, necrosis, water lost, and maybe to superinfection.

Symptoms:

-        The typical Bild of acute pancreatitis, is the acute onset (within 10-20 minutes) of upper abdominal pain, at mid epigastrium or right upper abdomen, with band-like radiation to the back 

-        The pain lasts for days, and relives by bending forward

-        Nausea and vomiting by about 90% of the patients.

-        Grey-turner’s sign: ecchymotic discoloration of the flanks due to retroperitoneal bleeding by necrosis.  Is rare 1%

-        Cullen’s sign: periumbilical discoloration is rare 1%

Diagnosis:

Physical examination:

-        Abdomen may be distended with tender and guarding.

-        Fever

-        Tachycardia

-        Be severe cases shock and coma

-        Cullen’s sign or Grey-turner’s sign 1%.

-        Findings suggesting the causes such as hepatomegaly by alcohol, xanthomas bei hyperlipidemia and parotid swelling be mumps

Laboratory tests:

-        Serum amylase: raises 6-12 hours of onset and lasts for 10 hours in blood. Usually still elevated 3-5 days.  Sensitivity and specificity are low.

-        Urine amylase: amylase/creatinine-clearance ACCR = 3%. By macroamylasemia doesn’t raise.  

-        Lipase: raises earlier and lasts longer, more specific and sensitive 85-100% than amylase.

NOTE:  combination of the enzymes doesn’t improve diagnostic accuracy, daily measurement of the enzymes doesn’t asses the progress, and the level of the elevation of the enzymes doesn’t correlate with the severity of the disease !

Abdominal ultrasound: Ideal to image the gallbladder and biliary tree, may reveal enlargement with hypoechoic pancreas

Chest film: may reveal pleura effusion (lift sided or bilateral), ARDS

Abdomen- CT: INDICATED WENN patients with pancreatitis don’t improve under conservative therapy (after 48-72 hours) to assess the complications such as necrosis, pseudocysts

Abdomen-MRT: advantages over the CT is in the fewer nephrotoxicity, better distinguish between fluids due to Abscess, necrosis, hemorrhage or pseudocysts, and imaging the pile tree with MRCP.

Causes of acute pancreatitis:

1-     Gallstones: 35-40% of the cases.

2-     Biliary sludge should be suspected in the absence of other causes

3-     Alcohol 30% of cases

Hypertriglyceridemia, > 1000 mg/dl, 1-3.5 %: Poorly controlled diabetes, alcoholism, obesity, pregnancy, prior pancreatitis, and a personal or family history of hyperlipidemia should suggest the diagnosis of HTGP

4-     Medicaments 03-1.4%.

5-     Post-ERCP pancreatitis, 3-5% of pat. undergoing ERCP.  25% of pat. undergoning Ampulla manometry

6-     Genetic mutations: Inherited forms of pancreatitis may present as recurrent acute pancreatitis: PRSS1, CFTR, CTRC ect…

7-     Infections and toxins: the routine search for an infectious etiology in idiopathic pancreatitis is not recommended

-        Viruses: Mumps, coxsackievirus, hepatitis B, cytomegalovirus, varicella-zoster, herpes simplex, HIV

-        Bacteria – Mycoplasma, Legionella, Leptospira, Salmonella

-        Fungi – Aspergillus

-        Parasites – Toxoplasma, Cryptosporidium, Ascaris

8-     Trauma

9-     Autoimmune pancreatitis: can cause acute pancreatitis, but it usually mimic a pancreatic tumor: weight los , jaundice, and pancreatic enlargement: consider IgG4/ANA

10-  Tumors of the ampulla/ periampullary tumors.  Intraductal tumors (IPMN)

11-  Rare causes: Pancreas Divisum, sphincter oddi dysfunction.

12-  30% idiopathic: the chance of recurrence is little, thus intensive search for the cause in the first attack of idiopathic pancreatitis is not necessary.

Therapy:

First step: asses disease severity, acute pancreatitis has two wide groups:

According to revised Atlanta classification:

1-     Acute edematous pancreatitis

2-     Acute necrotizing pancreatitis

The severity of acute pancreatitis can be:

1-     Mild: no local or systemic complications

2-     Moderate: local or systemic complications that last < 48 hours

3-     Severe: systemic complications that last > 48 hours

Local complications are such: fluid collection, pseudocysts, necrosis

Systemic complications are organ failure: respiratory, cardiovascular, renal. 

Some scores to predict the severity of acute pancreatitis such Ranson, APACHI II und BISAP, Ranson and BISAP scores are shown below:

Step two:

Therapy of mild acute pancreatitis:

-        supportive care including pain control

-        intravenous fluids

-        and correction of electrolyte and metabolic abnormalities.

-        Nutrition: oral feeding can be started as the pain get better, that would happen in 24-48 hours.

The majority of patients require no further therapy and recover and eat within three to seven days.

Therapy of severe acute pancreatitis:

-         intensive care unit monitoring

-         fluid replacement: After initial resuscitation with 20 cc/kg of intravenous fluid given over 60 to 90 minutes, approximately 250 to 300 cc of intravenous fluids per hour are typically required for 48 hours if the cardiac status permits.

-         Hypocalcemia should be corrected if ionized calcium is low or symptomatic. Low magnesium levels should be corrected.

-         Serum glucose levels should be carefully monitored.

-         Pain control: Hydromorphone, Fentanyl

-         Nutritional support (parenteral or nasojujenal tube) should be provided to those who are unlikely to resume oral intake for more than five to seven days. Oral feeding can be started as the local complications start getting better

-         Infection-Prophylaxis: imipenem 500 mgx3 day/ meropenem 1g x3 day.  by patients with CT-proven necrosis, for no more that 14 days unless infection is proven.

Necrosectomy: indicated by:

-         Infected pancreatic necrosis

-         sterile pancreatic necrosis with abdominal pain preventing oral intake.

Therapy of special conditions

Gallstones pancreatitis:

-        ERCP should be done within 72 hours

-        Cholecystectomy within 7 days after recovering, and 3 weeks after recovery by necrotizing pancreatitis

-        Biliary sludge is indication to cholecystectomy by pat. With pancreatitis.

Hypercalcemia:

1-     Apheresis (2c): indicated by severe pancreatitis with TG levels > 1000 mg/dl

After one cycle if TG < 500 mg/dl, apheresis should be stoped, if not, further cycles are needed.

2-     Intravenous Insulin (2c) (normal insulin) with Glucose 5% as infusion at a rate of 0.1-0.3 IE Insulin/Kg/hours until TG level of < 500 mg/dl be reached

Control TG every 24 hours, glucose every 4 hours (keep Glucose level between 150-200)

Indication: - Apheresis not available or not to be tolerated      - Serum glucose > 500 mg/dl.

3-     Antihyperlipidemic agents: -  Gemfibrozil 600 mg x2 a day (2c)

4-     Dietary therapy: fat restriction   

Splenic vein thrombosis:

19% in cases: treatment of the cause, anticoagulation by extend of the thrombosis to the V. portae or. V. mesenterica superiora

Autoimmune pancreatitis:

One of the criteria to establish its diagnosis is the HISORt Criteria:

Histology

Imaging on computed tomography: diffuse enlargement, featureless borders, delayed enhancement

Serologic testing: Elevated serum IgG4 levels  

Other organ involvement: bile duct strictures, autoimmune thyroiditis, interstitial nephritis, Sjogren syndrome.

Response to glucocorticoid therapy

Therapy:

glucocorticoid 40mg/day for 4-6 weeks then taper at 5 mg/week

control with CT/MRT after 4-6 weeks of glucocorticoid therapy to confirm response, otherwise another causes of AP should be considered.