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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. Within the past 12 months, Dr. Pandol reports no commercial conflicts of interest. 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). 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.1 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:2 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.3 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.4,5 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.
Adapted from 3, 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.6,7 Figure 1. Causes of Acute Pancreatitis.
Adapted from 3, www.gastroslides.org Severity and OutcomeEarly 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.8 Table 2. Early Indicators of Severity.
Adapted from 3, www.gastroslides.org Managing Acute PancreatitisSupportive 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.
Adapted from 3, www.gastroslides.org Other TreatmentsAlthough 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. 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.9 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.10 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.12 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.
References 1. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. 2006; 354: 2142-50. This article provides a clinical overview of the acute pancreatitis. return 2. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg. 1993; 128: 586-90. This article reports the proceedings of a symposium designed to classify severity of acute pancreatitis. return 3. Gorelick F, Pandol SJ, Topazian M. Pancreatic physiology, pathophysiology, acute and chronic pancreatitis. Gastrointestinal Teaching Project, American Gastroenterologic Association 2006. This work is compilation of approximately 500 teaching slides that cover the topics of pancreatic physiology and pathophysiology as well as acute and chronic pancreatitis. Go to: www.gastroslides.org. return 4. Pandol SJ. Acute pancreatitis. Curr Opin Gastroenterol. 2005 ;21: 538-43. This article provides a current review of issues related to mechanisms, diagnosis and treatment of acute pancreatitis. return 5. Gukovskaya AS, Pandol SJ. Cell death pathways in pancreatitis and pancreatic cancer. Pancreatology. 2004; 4: 567-86. This article reviews the mechanisms involved in pancreatic necrosis during acute pancreatitis. return 6. Whitcomb DC. Value of genetic testing in the management of pancreatitis. Gut. 2004; 53: 1710-7. This article reviews the genetic causes of pancreatitis and the indications for genetic testing. return 7. Okazaki K, Uchida K, Matsushita M, Takaoka M. Autoimmune pancreatitis. Intern Med. 2005; 44: 1215-23. This article is a review on autoimmune pancreatitis, its recognition, diagnosis and treatment. return 8. Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002; 9: 1309-18. This article provides a review of tests used to classify acute pancreatitis by severity. It confirms the value of CRP measurement as a simple predictor of severity. return 9. Beger HG, Rau B, Isenmann R, Schwarz M, Gansauge F, Poch B. Antibiotic prophylaxis in severe acute pancreatitis. Pancreatology. 2005; 5: 10-9. This article considers the controversies surrounding the prophylactic administration of antibiotics in severe pancreatitis. The authors make recommendations on antibiotic use. return 10. Isenmann R, Runzi M, Kron M, Kahl S, Kraus D, Jung N, Maier L, Malfertheiner P, Goebell H, Beger HG; German Antibiotics in Severe Acute Pancreatitis Study Group. Prophylactic antibiotic treatment in people with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology. 2004; 126: 997-1004. This article is a report of the largest randomized controlled trial designed to determine the effect of prophylactic antibiotic administration on outcome in people with severe acute pancreatitis. The results do not show benefit of antibiotics on outcome. return 11. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006; 30: 143-56. This article is a meta-analysis relating methods of nutrition support to outcome in acute pancreatitis. The results support early enteral feeding in acute pancreatitis. return 12. Gomez-Cerezo J, Barbado Cano A, Suarez I, Soto A, Rios JJ, Vazquez JJ. Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000. Am J Gastroenterol. 2003; 98: 568-77. This article reviews the results of various trials for treatment of pancreatic ascites and provides recommendations for treatment from the results of the review. return |
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Too much Vitamin A from meat and dairy products can weaken the bones of
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