Acute Pancreatitis

ACUTE PANCREATITIS

Acute pancreatitis can be seen in the emergency department and involves an acute inflammation of the pancreas, usually from alcohol abuse or gallstones. It can be mild to severe, based on associated symptoms along with the inflammation. Gallstones cause about 40 percent of cases by increasing the pressure inside the pancreatic ductal system. Bile itself may be toxic to the pancreatic tissue.

Alcohol abuse causes 30 percent of cases; it is not always made more prevalent by drinking more alcohol because the susceptibility to the disease varies with the person. The cells of the pancreas metabolize alcohol so that it becomes a toxic metabolite that aids in the autodigestion of pancreatic tissues. It can also cause plugs of protein in the pancreatic ducts, leading to obstructive damage to the pancreas.

There can be genetic causes of acute pancreatitis, which can be autosomal dominant. Cystic fibrosis itself can cause both chronic and acute pancreatitis. Patients who’ve had an ERCP will have a risk of acute pancreatitis as well. Hypertriglyceridemia is a common cause of acute pancreatitis in some people.

Pancreatitis can be interstitial in nature or necrotizing in nature. Interstitial pancreatitis is seen with an enlarged pancreas and self-limited disease. Necrotizing pancreatitis is seen in up to 10 percent of cases. Because there is necrosis, the disease is prolonged and tends to be more severe. The disease can also be mild, moderate, or severe. Mild disease is confined to the pancreas, while moderate disease involves the possibility of systemic disease but no organ failure. Severe disease will lead to multiple organ failure and a high rate of death.

The complications can be localized or systemic. Localized disease processes include collection of enzyme-rich pancreatic fluid and necrotic material around the pancreas. These can wall off, leading to pancreatic pseudocyst formation. Systemic complications include cardiovascular failure, shock, respiratory failure, and acute kidney injury. Look for systemic inflammatory response syndrome if the temperature is very high, very low, or if there is tachycardia, tachypnea, and either a very low or very high white blood cell count. Most patients who die will die of multiple organ failure within a week of onset.

Look for the patient with acute, steady upper abdominal pain of moderate to severe intensity. Many will have pain radiating to the back. Sitting up or leaning forward will reduce the severity of the pain. There will be tachycardia, postural hypotension, fever, and altered sensorium. Some will have scleral icterus or true jaundice, depending on the cause. Ileus can be present and the abdomen will be severely tender. Ascites can be seen and, if there is ecchymosis around the umbilicus, this indicates a poor prognosis.

The patient’s diagnosis can be confirmed with a serum amylase and lipase level. CT scanning with IV contrast can also show evidence of pancreatic inflammation. There are many different causes of pain that can be in the differential diagnosis; however, the lipase and amylase will usually provide the correct diagnosis. An abdominal ultrasound may be helpful but isn’t as helpful as the abdominal CT scan. Plain films of the abdomen will show calcifications of the gallstones, ileus, and chronic pancreatitis calcifications but will not prove acute pancreatitis. The chest x-ray will show atelectasis or a pleural effusion. Endoscopic ultrasound can be used but it isn’t as good as the CT scan of the abdomen.

The treatment of acute pancreatitis is generally supportive. The patient is kept NPO and provided with IV fluids. Aggressive IV fluid resuscitation is often necessary in the first 24 hours. Lactated Ringer’s solution is preferred. Supplemental oxygen is provided with strict intake and output measured. Pain relief is done using hydromorphone or fentanyl. Medications for nausea and vomiting can be used. The diet can be advanced as tolerated, with TPN used to treat severely affected patients. Other patients can have a tube placed from the nose to the jejunum. Antibiotics are given if there is significant necrosis that becomes infected. Patients with gallstone-related disease who do not resolve spontaneously need an ERCP.