Diagnosis

Acute pancreatitis

Etiology

Cause [4gs][dcs]

• PANCREATITIS: Perforated ulcer, Alcohol, Neoplasm, Cholelithiasis, Renal disease, ERCP, Anorexia, Trauma, Infections, Toxins, Incineration, Surgery/Scorpion bite

• Hyperlipidemia, Hypercalcemia (hyperparathyroidism), Trauma, Surgery, ERCP, pancreatic cancer, pancreatic divisum, Vasculitis, Scorpion/snake venom

• Viral infection: mumps, coxsackie B, CMV, EBV, hepatitis virus, echovirus, varicella-zoster virus, measles virus, and rubella virus

• Bacterial infection: Mycoplasma pneumoniae, Salmonella, Campylobacter, Mycobacterium tuberculosis, Ascaris, and AIDS

• Drugs: Azathioprine, Sulfonamides, Sulindac, Tetracycline, Valproic acid, Didanosine, Methyldopa, Estrogens, Furosemide, 6-Mercaptopurine, Pentamidine, 5-aminosalicylic acid compounds, Corticosteroids, Octreotide, Metronidazole, cimetidine, isoniazid, glucocorticoids

• Hereditary pancreatitis: PRSS1, CFTR, SPINK1

• Tumor: pancreatic ductal carcinoma, ampullary carcinoma, islet cell tumor, solid pseudotumor of the pancreas, sarcoma, lymphoma, cholangiocarcinoma, cystic neoplasms (IPMN, mucinous or serous cystadenoma), metastatic tumor

• Autoimmune pancreatitis: rare, prevalence 0.82 per 100,000, related to Ig-G4

Pathophysiology

• Obstruction of pancreatic digestive enzymes and activation within the pancreas leads to organ injury and Pancreatitis

Complications[5hg]

• Multi organ failure

• Prolonged/recurrent disease --> chronic pancreatitis (irreversible pancreatic damage)

• Severe pancreatitis: [dcs]

  1. Organ failure: sBP < 90 mmHg, [Pa O2] < 60 mm Hg, renal failure, GI hemorrhage

  2. Local complications (eg, necrosis, abscess, pseudocyst)

  3. Ranson score ≥ 3 or APACHE score ≥ 8

Epidemiology

Incidence per 100.000 [4gs][a2t][bnn][dfy][b7h][sc5][uv6][piv][5hg]

Approach

• Blood test: Amylase, lipase, ASAT, ALAT, GGT, ALP, creatinine, electrolytes, glucose, complete blood count, CRP, LD

• Blood gas

• Abdominal x-ray

• Ultrasound abdomen

• CT abdomen

• ERCP

• MRCP

• CT-guided or EUS-guided aspiration/drainage

• Genetic testing

Treatment

1. Fluid resuscitation [dcs]

2. Nutritional support

3. Antibiotics:

   • Imipenem if complicated by infected pancreatic necrosis

   • Antibiotic prophylaxis in severe pancreatitis is controversial

4. Surgery:

   • Gallstone pancreatitis: Cholecystectomy

   • Pancreatic duct obstruction: drainage tube, ERCP-stent, distal pancreatectomy or a Whipple procedure

   • Pseudocysts: large or symptomatic -> aspiration/drainage:

     • percutaneous, endoscopic, surgical management

   • Infected pancreatic necrosis: aspiration or surgical necrosectomy

   • Abscess: drainage and antibiotics --> if no response: surgical debridement and drainage

Differential diagnoses

Acute mesenteric ischemia, Acute respiratory distress syndrome, Aortic dissection, Cholangitis, Cholecystitis, Choledocholithiasis, Cholelithiasis, Chronic pancreatitis, Colorectal cancer, Gastric cancer, Gastritis, Gastroenteritis, Gastrointestinal obstruction, Hypovolemia, Irritable bowel syndrome, Macroamylasemia, Macrolipasemia, Malabsorption, Myocardial infarction, Pancreatic cancer, Pancreatic pseudocyst, Perforated ulcer, Peritonitis, Pneumonia, Ruptured aortic aneurysm, Shock, Ulcer disease, Viral hepatitis