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Pancreatitis

Pancreatitis is inflammation or infection of the pancreas. The pancreas, a gland located behind the stomach, releases the hormones insulin and glucagon and substances that help with digestion.

Pancreatitis may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years. It has multiple causes and symptoms.

For more information, see the specific type of pancreatitis:

1. Acute pancreatitis
2. Chronic pancreatitis
3. Pancreatic Abscess
4. Pancreatic Pseudocyst

Symptoms

The most common symptoms of pancreatitis are severe upper abdominal pain radiating to the back, nausea, and vomiting that is worsened with eating. The physical exam will vary depending on severity and presence of internal bleeding. Blood pressure may be elevated by pain or decreased by dehydration or bleeding. Heart and respiratory rates are often elevated. The abdomen is usually tender but to a lesser degree than the pain itself. As is common in abdominal disease, bowel sounds may be reduced from reflex bowel paralysis. Fever or jaundice may be present. Chronic pancreatitis can lead to diabetes or pancreatic cancer. Unexplained weight loss may occur from a lack of pancreatic enzymes hindering digestion.

Symptoms may include:

• Abdominal pain
• Chills
• Clammy skin
• Fatty stools
• Fever
• Mild jaundice
• Nausea
• Sweating
• Weakness
• Weight loss
• Vomiting

Causes

Eighty percent of pancreatitis is caused by alcohol and gallstones. Gallstones are the single most common etiology of acute pancreatitis.[1] Alcohol is the single most common etiology of chronic pancreatitis. [2][3][4][5][6]

Some medications are commonly associated with pancreatitis, most commonly corticosteroids such as prednisolone, but also including the AIDS drugs didanosine and pentamidine, diuretics, the anticonvulsant valproic acid, the chemotherapeutic agents L-asparaginase and azathioprine, estrogen by way of increased blood triglycerides,[7] cholesterol-lowering statins[citation needed] and the antihyperglycemic agent sitagliptin.[8]

There is an inherited form that results in the activation of trypsinogen within the pancreas, leading to autodigestion. Involved genes may include Trypsin 1, which codes for trypsinogen, SPINK1, which codes for a trypsin inhibitor, or cystic fibrosis transmembrane conductance regulator.[9]

Other common causes include trauma, mumps, autoimmune disease, scorpion stings, high blood calcium, high blood triglycerides, hypothermia, and endoscopic retrograde cholangiopancreatography (ERCP). Pancreas divisum is a common congenital malformation of the pancreas that may underlie some recurrent cases. Pregnancy can be a cause, possibly by increasing blood triglycerides. Diabetes mellitus type 2 is associated with a 2.8-fold higher risk.[10]

Less common causes include pancreatic cancer, pancreatic duct stones,[11] vasculitis (inflammation of the small blood vessels in the pancreas), coxsackievirus infection, and porphyria—particularly acute intermittent porphyria and erythropoietic protoporphyria.

Infectious Causes

A number of infectious agents have been recognized as causes of pancreatitis.[12]

• Viruses
  • Coxsackie virus
  • Cytomegalovirus
  • Hepatitis B
  • Herpes simplex virus
  • Mumps
  • Varicella-zoster virus
• Bacteria
  • Legionella
  • Leptospira
  • Mycoplasma
  • Salmonella
• Fungi
  • Aspergillus
• Parasites
  • Ascaris
  • Cryptosporidium
  • Toxoplasma

Tests & Diagnosis

Diagnosing pancreatitis requires two of the following:

• Characteristic abdominal pain
• Blood amylase or lipase at least three times normal
• Abdominal ultrasound is generally performed first, which is advantageous for the diagnosis of the causes of the pancreas, for example, detecting gallstones, diagnosing alcoholic fatty liver (combined with history of alcohol consumption). They are both the main causes of pancreatitis. Abdominal ultrasound also shows an inflamed pancreatitis clearly. It is convenient, simple, non-invasive and inexpensive.[13]
• Characteristic CT scan[14]

Amylase or lipase is frequently part of the diagnosis; lipase is generally considered a better indicator, but this is disputed.[21][22] Cholecystitis, perforated peptic ulcer, bowel infarction, and diabetic ketoacidosis can mimic pancreatitis by causing similar abdominal pain and elevated enzymes.[citation needed] The diagnosis can be confirmed by ultrasound and/or CT.

• Abdominal x-rays
• Abdominal ultrasound
• Abdominal CT scans
• Blood and urine tests

Treatment

The treatment of pancreatitis is supportive and depends on severity. Morphine generally is suitable for pain control. There is a claim that morphine may constrict the sphincter of Oddi, but this is controversial. There are no clinical studies to suggest that morphine can aggravate or cause pancreatitis or cholecystitis. [23] Oral intake, especially fats, is generally restricted at first. Fluids and electrolytes are replaced intravenously. However there is also evidence showing that earlier nutrition and feeding contributes to better recovery. The underlying cause should also be treated (targeting gallstones, discontinuing medications, cessation of alcohol etc.) The patient is monitored for complications.

See the specific type of pancreatitis for additional details.

Preventions

See the specific type of pancreatitis for details.

Prognosis

Severe acute pancreatitis has high mortality rates, especially where necrosis of the pancreas has occurred.[24] Several scoring systems are used to predict the severity of an attack of pancreatitis. They each combine demographic and laboratory data to estimate severity or probability of death. Examples include APACHE II, Ranson, and Glasgow. Apache II is available on admission; Glasgow and Ranson are simpler but cannot be determined for 48 hours. One form of the Glasgow criteria suggests that a case be considered severe if at least three of the following are true:[25]

• Age > 55 years
• Blood levels:
  • Oxygen < 60mmHg or 7.9kPa
  • White blood cells > 15
  • Calcium < 2 mmol/L
  • Urea > 16 mmol/L
  • Lactate dehydrogenase (LDH) > 600iu/L
  • Aspartate transaminase (AST) > 200iu/L
  • Albumin < 32g/L
  • Glucose > 10 mmol/L

Complications

Early complications include shock, infection, systemic inflammatory response syndrome, low blood calcium, high blood glucose, and dehydration. Blood loss, dehydration, and fluid leaking into the abdominal cavity can lead to kidney failure. Respiratory complications are often severe. Pleural effusion is usually present. Shallow breathing from pain can lead to lung collapse. Pancreatic enzymes may attack the lungs, causing inflammation.

Late complications include recurrent pancreatitis and the development of pancreatic pseudocysts—collections of pancreatic secretions that have been walled off by scar tissue. These may cause pain, become infected, rupture and bleed, block the bile duct and cause jaundice, or migrate around the abdomen. Acute necrotizing pancreatitis can lead to a pancreatic abscess, a collection of pus caused by necrosis, liquefaction, and infection. This happens in approximately 3% of cases,[26] or almost 60% of cases involving more than two pseudocysts and gas in the pancreas.

References

1. NIDDK 2008
2. http://www.umm.edu/altmed/articles/pancreatitis-000122.htm
3. Apte MV, Pirola RC, Wilson JS (June 2009). "Pancreas: alcoholic pancreatitis—it's the alcohol, stupid". Nat Rev Gastroenterol Hepatol 6 (6): 321–2.
4. Yadav D, Hawes RH, Brand RE, et al. (June 2009). "Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis".
5. Pancreatitis Explained Better Health Channel. State Government of Victoria. 2011.
6. Johnson, CD; Hosking, S (1991). "National statistics for diet, alcohol consumption, and chronic pancreatitis in England and Wales, 1960–88"
7. Smith, Emma; Murray Longmore; Wilkinson, Ian; Tom Turmezei; Chee Kay Cheung (2007). Oxford handbook of clinical medicine (7th ed.). Oxford [Oxfordshire]: Oxford University Press. p. 584. ISBN 0-19-856837-1.
8. Beneficial Endocrine but Adverse Exocrine Effects of Sitagliptin in the Human Islet Amyloid Polypeptide Transgenic Rat Model of Type 2 Diabetes - Interactions With Metformin
9. "Genetic Testing for Pancreatitis"
10. "Increased risk of acute pancreatitis and biliary disease observed in patients with type 2 diabetes: a retrospective cohort study"