Pancreatitis

– Acute or chronic inflammation of the pancreas.

Causes and Incidence

The most common cause of acute pancreatitis is heavy alcohol consumption and biliary tract disease. Other causes include infections (e.g., mumps, hepatitis); drugs (thiazides, steroids, azathioprine, pentamidine); vasculitis; and surgery on pancreas, stomach, or biliary tract. The most common cause of chronic pancreatitis is alcoholism. Other causes are hyperparathyroidism, stenosis of the pancreatic duct, and carcinoma. The incidence varies with location and is high where the incidence of alcoholism is high. In tropical countries such as India, Indonesia, and Nigeria, a form of idiopathic pancreatitis occurs in children and young adults.

Disease Process

Acute pancreatitis is a result of autodigestion in which normally excreted pancreatic enzymes digest pancreatic tissue. Bile and phospholipase A combine to cause severe tissue necrosis. Elastase dissolves elastic fibers in the blood vessels and causes hemorrhage. Release of kinins causes vasodilation, vascular permeability, and pulmonary edema. Hypercalcemia and transient hyperglycemia develop. Chronic pancreatitis results from repeated acute episodes or from a slow sclerosing process, resulting in fibrosis and obstruction of the pancreatic ducts.

Symptoms

Acute
Severe abdominal pain radiating to the back; fever, sweating, rapid pulse, shallow respirations, and decreased breath sounds; decreased blood pressure; blunted sensorium

Chronic
Intermittent or chronic dull, boring abdominal pain relieved somewhat by sitting and leaning forward; weight loss, steatorrhea, diarrhea, nausea, vomiting
Complications: Adult respiratory distress syndrome, disseminated intravascular coagulation, cardiac, renal, or pulmonary failure; infected necrosis of the pancreas; and pancreatic pseudocyst, leading to hemorrhage and rupture of the pancreas, are all possible complications that often lead to death.

Diagnostic Tests

Acute
Elevated amylase 2 to 12 hours after onset, dropping to normal within 72 hours; elevated lipase, WBC, glucose, and serum bilirubin levels

Chronic
Pancreatic calcification, enlarged ducts, abnormal size and consistency of pancreas on computed tomography or ultrasound; secretin test with normal volume and low bicarbonate

Treatments

Surgery
Acute: debridement of tissue in necrotizing pancreatitis; drainage of pancreatic pseudocyst or abscesses; removal of stones obstructing the common bile duct Chronic: pancreaticojejunostomy, pancreatectomy, Whipple procedure, autotransplantation for severe intractable pain and complications.

Drugs
Acute: narcotic analgesics for pain; antacids by nasogastric tube; histamine receptor antagonists for gastrointestinal bleeding; antiinfective drugs for abscesses; adrenergics for hypotension Chronic: analgesics for pain; pancreatic enzyme supplements; antacids; histamine receptor antagonists to improve effects of enzyme supplements; insulin or oral hypoglycemic therapy if indicated.

General
Acute: endoscopic sphincterotomy for biliary pancreatitis; hemodynamic monitoring; central venous pressure catheter; nasogastric tube; peritoneal lavage; correction of electrolyte imbalances; total parenteral nutrition; discontinue alcohol or drug use; NPO to rest gastrointestinal tract and diminish pancreatic activity, then lowfat, high-carbohydrate diet Chronic: enteral nutritional support if indicated; discontinue use of alcohol with alcohol rehabilitation program.