Pancreatitis
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| ICD-10 | K85., K86.0-K86.1 |
|---|---|
| ICD-9 | 577.0-577.1 |
Pancreatitis is inflammation of the pancreas.
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[edit] Causes
The most common causes of acute pancreatitis are gallstones and excessive consumption of alcohol (together accounting for more than 80% of cases). Less common causes include hypertriglyceridemia (but not hypercholesterolemia) and only when triglyceride values exceed 1500 mg/dl (16 mmol/L), hypercalcemia, viral infection (e.g. mumps), trauma (to the abdomen or elsewhere in the body) including post-ERCP (i.e. Endoscopic Retrograde Cholangio-Pancreatography), vasculitis (i.e. inflammation of the small blood vessles within the pancreas), and autoimmune pancreatitis. Pregnancy can also cause pancreatitis, but in some cases the development of pancreatitis is probably just a reflection of the hypertriglyceridemia which often occurs in pregnant women. Pancreas divisum, a common congenital malformation of the pancreas may underlie some cases of recurrent pancreatitis.
Many medications have been reported to cause pancreatitis. Some of the more common ones include the AIDS drugs DDI and pentamidine, diuretics such as furosemide and hydrochlorothiazide, the chemotherapeutic agents L-asparaginase and azothioprine, and estrogen. Just as is the case with pregnancy associated pancreatitis, estrogen may lead to the disorder because of its effect to raise blood triglyceride levels.
It is worth noting that pancreatic cancer is seldom the cause of pancreatitis.
Idiopathic pancreatits is the term used to denote pancreatitis of undetermined cause - representing approximately 25 to 30 percent of cases.
[edit] Symptoms and Signs
Severe, upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis. Traditionally it is stated that the pain of pancreatitis is relieved by bending forward. Nausea and vomiting are prominent symptoms. Findings on the physical exam will vary according to the severity of the pancreatitis, and whether or not it is associated with significant internal bleeding. The blood pressure may be high (when pain is prominent) or low (if internal bleeding or dehydration has occurred). Typically, both the heart and respiratory rates are elevated. Often, in more severe cases, there is evidence of a pleural effusion (i.e. water on the lung). Abdominal tenderness is usually found but may be less severe than expected given the patient's degree of abdominal pain. Bowel sounds may be reduced as a reflection of the reflex bowel paralysis (i.e. ileus) that may accompany any abdominal catastrophe. If there has been severe internal bleeding, the skin around the umbilicus or the flanks may be discolored with a dark reddish or purple hue (so-called Cullen's sign and Grey-Turner's sign respectively). The discoloration is blood which has tracked along the retroperitoneal fascial plane.
[edit] Diagnosis
The diagnosis of pancreatitis is made when a patient has suggestive symptoms and signs and also has an elevation in one or more blood levels of certain pancreatic enzymes. Most frequently, measurement is made of amylase and/or lipase, and often one, or both, are elevated in cases of pancreatitis. It should be kept in mind that conditions other than pancreatitis may lead to rises in these enzymes and, further, that those conditions may also cause pain that resembles that of pancreatitis (e.g. cholecystitis, perforated ulcer, bowel infarction (i.e. dead bowel as a result of poor blood supply), and even diabetic ketoacidosis.
Although ultrasound imaging and CT scanning of the abdomen can be used to confirm the diagnosis of pancreatitis, neither is usually necessary as a primary diagnostic modality.
[edit] Complications
Acute (early) complications of pancreatitis include shock, hypocalcemia (low blood calcium), high blood glucose, dehydration, and kidney failure (resulting from inadequate blood volume which, in turn, may result from a combination of fluid loss from vomiting, internal bleeding, or oozing of fluid from the circulation into the abdominal cavity in response to the pancreas inflammation). Respiratory complications are frequent and are major contributors to the mortality of pancreatitis. Some degree of pleural effusion is almost ubiquitous in pancreatitis. Some or all of the lungs may collape (atelectasis) as a result of the shallow breathing which occurs because of the abdominal pain. Pneumonitis may occur as a result of pancreatic enzymes directly damaging the lung, or simply as a final common pathway response to any major insult to the body (i.e. ARDS or Adult Respiratory Distress Syndrome). Likewise, SIRS (Systemic inflammatory response syndrome) may ensue.
Infection of the inflamed pancreatic bed can occur at any time during the course of the disease. In fact, in cases of severe hemorrhagic pancreatitis, antibiotics should be given prophylactically.
Late complications of pancreatitis include recurrent pancreatitis and the development of pancreatic pseudocysts. A pancreatic pseudocyst is essentially a collection of pancreatic secretions which has been walled off by scar and inflammatory tissue. Pseudocysts may cause pain, may become infected, may rupture and hemorrhage, may press on and block structures such as the bile duct, thereby leading to jaundice, and may even migrate around the abdomen.
[edit] Treatment
The treatment of pancreatitis will, of course, depend on the severity of the pancreatitis itself. Still, general principles apply and include 1. provision of pain relief (with morphine, contrary to earlier pronouncements, being the agent of choice), 2. provision of adequate replacement fluids and salts (intravenously), 3. limitation of oral intake (with dietary fat restriction the most important point), and 4. monitoring and assessment for, and treatment of, the various complications listed above.
[edit] Types
There are three forms of pancreatitis, which are different in causes and symptoms, and require different treatment:
- Acute pancreatitis: One-time occurrence
- Chronic pancreatitis: Persists even after the cause has been removed
- Hereditary pancreatitis: - A genetic abnormality leads to activation of enzymes. Acute hepatic porphyrias including acute intermittent porphyria, hereditary coproporphyria and variegate porphyria are genetic disorders that can be linked to both acute and chronic pancreatitis. Acute pancreatitis has also occurred with erythropoietic protoporphyria.
