Acute pancreatitis

Acute pancreatitis
Updated: 03/25/2019
© Jun Wang, MD, PhD

General features
  • Clinical emergency
  • More common in women, in African Americans
  • Commonly associated with biliary tract disease in women, alcoholism in men
  • Overall mortality: 10% if edematous vs. 50% if hemorrhagic/necrotic, higher in biliary pancreatitis, most deaths due to failure of multiple organ system in the first week, and infections in subsequent weeks
Etiology
  • Metabolic: Alcoholism; hyperlipoproteinemia, hypercalcemia; certain drugs (e.g., azathioprine); cigarette smoking
  • Genetic: Mutation of trypsin, trypsin regulators, or calcium metabolism regulators
  • Mechanical: Bile duct obstruction (increase intrapancreatic ductal pressure and leads to the accumulation of enzyme-rich fluid in the interstitium); trauma; iatrogenic injury including perative injury/Endoscopic procedures with dye injection
  • Toxins: Such as scorpion bite in Trinidad
  • Vascular: Shock; atheroembolism; vasculitis
  • Infectious: Mumps
Pathogenesis
  • Destruction of pancreatic tissue due to inappropriate release and activation of pancreatic enzymes
  • Activation of systemic inflammatory response
  • Alcohol effects:
Sphincter of Oddi spasm
Abnormal blood flow and glandular secretion
Toxic metabolics: Non-oxidative and oxidative
CCK and secretin release
CCK sensitization
Clinical presentations
  • Persistent epigastric abdominal pain, radiating to back
  • Epigastric tenderness to palpation
  • Fever, tachypnea, hypoxemia, hypotension, etc
  • Severity and outcome predictor: Ranson criteria, APACHE II score, etc
Key laboratory findings
  • Elevated amylase and lipase, diagnostic if at least 3 times above normal range, glycosuria  and hypocalcemia
  • Elevated trypsinogen activation peptide (TAP)
  • Leukocytosis
  • Signs of DIC
  • Acute renal tubular necrosis
  • Hypocalcemia
  • Hyperglycemia
Key pathological features
  • Swollen, indurated, edematous or hemorrhagic/necrotic, yellow chalky nodules of fat necrosis in pancreas, mesenteric and peritoneal fat
  • Acute interstitial type: Acute inflammatory cell infiltrate admixed with edema and fibrinous exudate
  • Acute hemorrhagic types: Patchy necrosis, periductal or perilobular; interstitial edema, fat necrosis, neutrophils, acinar and blood vessel destruction, interstitial hemorrhage
Radiologic findings
Diagnosis
  • Two of the three criteria
Acute onset of persistent, severe, epigastric pain often radiating to the back
Elevation in serum lipase or amylase to three times or greater than the upper limit of normal
Characteristic findings of acute pancreatitis on imaging
Severity prediction
Treatment
  • Supportive, antibiotics for infection
  • Surgery for gallstone, pancreatic duct disruption, pseudocysts, etc


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