Pancreatitis Disease

DESCRIPTION

An inflammatory, auto-digestive process of the pancreas

Acute pancreatitis
- Inflammatory episode with symptoms related to intrapancreatic activation of enzymes with pain, nausea and vomiting, and associated intestinal ileus
- It varies widely in severity, complications, and prognosis
Chronic pancreatitis
- Progressive functional destruction of the pancreas that may exist in the absence of an etiology
- Results in both exocrine and endocrine deficiencies
- Pain, maldigestion, and diabetes mellitus are the major features
System(s) affected: Gastrointestinal
Genetics: Hereditary pancreatitis is a very rare condition with an autosomally dominant inheritance pattern
Incidence/Prevalence in USA: Urban - 22/100,00; rural - 10/100,000
Predominant age:
- Acute pancreatitis – none
- Chronic pancreatitis – 35–45 years (usually related to alcohol)
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Abdominal pain – epigastric, may radiate straight through to back
Nausea and/or vomiting
Mild abdominal distention
Fever (100–101°F [37.7–38.3°C])
Hypotension/shock (40%)
Mild jaundice
Diminished or absent bowel sounds
Flank discoloration (Grey Turner's sign)
Umbilical discoloration (Cullen's sign)
Pleural effusion

CAUSES

Gallstones
Alcohol
Trauma/surgery
Post endoscopic retrograde cholangiopancreatography (ERCP)
Medications (eg, didanosine)
Metabolic
- Hypertriglyceridemia
- Hypercalcemia
- Renal failure
Hereditary
Systemic lupus erythematosus
Infections
- Mumps
- Coxsackie B
- Hepatitis A and B
- Ascariasis
- Salmonella
Penetrating peptic ulcer (rare)
Cystic fibrosis
Tumors (eg, ampullary)
Idiopathic
Pancreas divisum
Scorpion venom
Sphincter of Oddi dysfunction

RISK FACTORS

See Causes

LABORATORY

Acute pancreatitis
- Elevated serum amylase
- Elevated serum lipase
- Elevated (mild) alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) – when associated with alcoholic hepatitis or choledocholithiasis
- Elevated alkaline phosphatase (mild) – when associated with alcoholic hepatitis or choledocholithiasis
- Hyperbilirubinemia – when associated with alcoholic hepatitis or choledocholithiasis
- Glucose increased – in severe disease
- Calcium decreased – in severe disease
- WBC 10,000 – 25,000
Chronic pancreatitis
- Sometimes none
- Hyperglycemia
- Steatorrhea
- Flare-ups may mimic acute pancreatitis
- Elevated alkaline phosphatase, bilirubin

Drugs that may alter lab results: Insulin and corticosteroids
Disorders that may alter lab results:

Biliary tract disease
Penetrating peptic ulcer
Intestinal obstruction
Intestinal ischemia/infarction
Ruptured ectopic pregnancy
Renal insufficiency
Burns
Macroamylasemia, macrolipasemia

PATHOLOGICAL FINDINGS

Acute pancreatitis: autodigestion of the pancreas, interstitial edema, hemorrhage, cell and fat necrosis
Chronic pancreatitis: calcification, fibrosis

SPECIAL TESTS

N/A

IMAGING

Acute pancreatitis
- Plain film of abdomen – signs of ileus
- Chest x-ray – pleural effusion
- Ultrasound/CT scan of abdomen
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Dynamic CT scan
Chronic pancreatitis
- X-ray of abdomen – pancreatic calcification
- Ultrasound and/or CT scan of abdomen – pseudocyst formation/calcification
- Endoscopic retrograde cholangiopancreatography (ERCP) – ductal deformity, retained common bile duct (CBD) stone, pancreatic duct stones and strictures
- Endoscopic sphincterotomy – early CBD stone removal improves outcome in severe cases
- Endoscopic ultrasound

DIAGNOSTIC PROCEDURES

Acute pancreatitis
- CT-guided aspiration of necrotic areas
- ERCP for common duct stone removal
Chronic pancreatitis
- Secretin stimulation test
- Para-aminobenzoic acid test (bentiromide [Chymex] test)
- Lunch test meal

APPROPRIATE HEALTH CARE

Acute pancreatitis – hospitalization, unless very mild and able to maintain oral intake
Chronic pancreatitis – outpatient except for complications

GENERAL MEASURES

Acute pancreatitis
- P – pain control: meperidine
- A – arrest shock: IV fluids
- N – nasogastric tube for vomiting
- C – calcium monitoring
- R – renal evaluation
- E – ensure pulmonary function
- A – antibiotics
- S – surgery or special procedures in selected cases
Chronic pancreatitis
- Pain – alcohol abstinence, analgesia (avoid narcotics if possible), celiac ganglion block, surgery, pancreatic enzyme preparations
- Maldigestion – pancreatic enzyme supplements, H2-blockers
- Diabetes mellitus – insulin

SURGICAL MEASURES

Acute pancreatitis
- Infected necrosis
- Peritoneal lavage
Chronic pancreatitis
- Pain
- Pseudocyst drainage

ACTIVITY

Acute pancreatitis – usually bedrest although sitting in a chair may be more comfortable. Advance as able.
Chronic pancreatitis – not restricted

DIET

Acute pancreatitis: begin diet after pain, tenderness, and ileus have resolved; small amounts of high-carbohydrate, low-fat, and low-protein foods. Advance as tolerated. NPO or nasogastric tube if vomiting.
Chronic pancreatitis: small meals high in protein. Adjust if diabetes mellitus is present.

PATIENT EDUCATION

For patient education materials favorably reviewed on this topic, contact: National Digestive Diseases Information Clearinghouse, Box NDDIC, Bethesda, MD 20892, (301)468-6344

PREVENTION/AVOIDANCE

Avoid alcohol
Correct underlying causes, i.e., lipids, drug use, ARDS

POSSIBLE COMPLICATIONS

Acute pancreatitis – pseudocyst
Chronic pancreatitis – pseudocyst, abscess, biliary/duodenal obstruction, portal/splenic vein thrombosis, diabetes mellitus

EXPECTED COURSE AND PROGNOSIS

Acute pancreatitis: 85–90% resolve spontaneously, 3–5% mortality
- Poor prognosis indicated by:
  - On admission: age > 55 years, WBC > 16,000/mm, blood glucose > 200 mg/dL (11.1 mmol/L), serum LDH > 2 × normal, serum SGOT > 6 × normal
  - Within 48 hours: hematocrit decrease > 10%, serum calcium < 8 mg/dL, BUN increase > 5 mg/dL, arterial pO₂ < 60 mm Hg, base deficit > 4 mEq/L, fluid retention > 6 L
Chronic pancreatitis: may have recurrent episodes of “acute pancreatitis,” slow progression, may “burn out” with resolution of symptoms. Narcotic addiction is frequent.

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: Mumps, sometimes complicated by pancreatitis
Geriatric: Vascular disease
Others: N/A

PREGNANCY

Acute fatty liver of pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.