Acute Pancreatitis
Acute pancreatitis is an acute inflammation of the pancreas resulting due to many conditions but presents with a simple abdominal pain.
Conditions Causing Acute Pancreatitis
The two leading causes of acute pancreatitis are gallstones and alcohol abuse.
Other causes are blunt trauma to the abdomen, mumps, autoimmune disease, scorpion venom, ERCP (endoscopic retrograde cholangitis - pancreatography), hypercalcemia, and hyperlipidemia drugs such as steroids, valproic acid, tetracycline, sulfa drugs, etc.
Pathogenesis
Gallstones and alcohol abuse are some of the most common causes of pancreatitis. Let us learn in detail the pathogenesis of pancreatitis in these conditions.
The pancreas usually secretes its enzymes in an inactive form (zymogen) within the acinar cells.
What is the reason for this? This is a clever protective mechanism of the pancreas to prevent self-digestion of its tissues by its own enzymes.
When the enzymes reach the duct, they get activated and are ready for their functions.
In the case of a gallstone, the pancreatic duct is obstructed. This eventually results in ductal hypertension. This stagnation of pancreatic enzymes within the duct leads to the premature activation of the enzymes within the acinar cells resulting in pancreatic auto-digestion.
In alcohol abuse, the condition starts like this.
Alcohol increases the zymogen secretion. As a result, the pancreatic fluid becomes more viscous and forms mucous plugs. These block the duct again, leading to ductal hypertension, which, in turn, leads to stagnation and premature activation of pancreatic enzymes, ultimately leading to auto-digestion.
This causes inflammation of the acinar cells, which presents as acute pancreatitis.
Clinical Features
Being an inflammatory condition, the underlying tissue damage produces abdominal pain. It is the main complaint presented by the patient. Pain is usually localized in the epigastric region and radiates to the back. It is aggravated in a lying down position and relieved on leaning forward. So, the patient is comfortable in bending forward.
Nausea, vomiting, fever, tachycardia, and jaundice can be present. In the event of co-existing pleural effusion, the patient can also have breathlessness.
In some cases, Grey-Turner’s sign, which is the discoloration of the flanks, may be seen.
Discoloration in the periumbilical region can be found in some cases (hemorrhagic pancreatitis), which is due to peritoneal hemorrhage. This is called Cullen’s sign.
On auscultation, there can be reduced bowel sound due to ileus.
Diagnosis
When the patient presents with typical signs of pancreatitis, the first thing is to do is place the patient nil per oral, followed by blood investigations.
Serum lipase will be increased, and it is also the specific marker for acute pancreatitis.
Serum amylase levels are also increased. But remember that it is not specific for pancreatitis as it will be increased in other conditions such as:
- Ectopic pregnancy
- Salpingitis
- Intestinal obstruction
- Ectopic amylase production in the case of breast and lung cancers.
Contrast-enhanced CT is the gold standard for diagnosing acute pancreatitis.
In which the pancreas is seen as a low-density image due to edema caused by inflammation. There is also an increase in the size of the organ.
A plain x-ray of the abdomen and chest is done.
On X-ray, the colon cut-off sign is elicited, which is the dilatation of the transverse colon with no gas in the descending colon. This is due to the spasm of the phrenicocolic (Hensing's) ligament. There will also be a small dilatation of the proximal small bowel known as a sentinel loop.
Blood glucose levels may show hyperglycemia due to reduced insulin production by the inflamed pancreas. Serum calcium level is reduced due to saponification in the pancreas.
Other tests like total blood count, liver function test, renal function test for serum urea & creatinine, arterial blood gas, and USG abdomen are also taken to know the severity of the disease.
Differential Diagnosis
It is important to differentiate acute pancreatitis from conditions that present with similar features as perforated peptic ulcer, bowel perforation, cholangitis, cholecystitis, and mesenteric ischemia.
Complications
Most of the time, the condition is relatively mild. Severe complications like acute renal failure, chronic pancreatitis, pseudocyst of the pancreas, pancreatic ascites, pancreatic pleural effusion mostly on the left side, pancreatic abscess, splenic vein thrombosis, ARDS due to lecithinase activity making less availability of surfactants, and at last even multi-organ dysfunction can occur.
Treatment
Acute pancreatitis usually resolves on the correct treatment at the correct time. After placing the patient on NPO, the patient is placed on maintenance IV fluids. For this purpose, normal saline or crystalloids are used.
To relieve abdominal pain, analgesics such as pethidine can be given.
Warning: Never give morphine in acute pancreatitis as it aggravates the condition by producing spasms of the sphincter of Oddi.
To compensate for the loss of calcium due to saponification, calcium gluconate is given. IV ranitidine or omeprazole can be used to prevent stress ulcers. Proper electrolyte management should be done.
Empirical antibiotics such as cephalosporins, imipenem, etc., should be given to avoid further complications.
Urinary catheterization is done for monitoring urine output. And hemodialysis is needed if kidney failure develops. Nasogastric tube placement for feeding is often useful.
Surgical Management
If the patient’s condition is not improving after proper medication, it's the call for surgical management.
The injured necrotic tissue is first debrided by necrosectomy. After this, Beger’s lavage is done, which is the continuous closed peritoneal lavage with 10 to 12 liters of normal saline until the fluid gets clear.
If the condition is due to gallstones, gallstones are removed operatively after medically managing the acute inflammatory episode. Cholecystectomy can be done to prevent a recurrence.
References
- Bailey and Love’s Short practice of surgery, 26e, page no: 1127-1134
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849938/
Authors Footnote
The etiology behind pancreatitis is diverse, and you often miss out on some.
In order to remember them, you can use the mnemonic ‘ I GET SMASHED’:
I - Idiopathic
G - Gallstones
E - Ethanol
T - Trauma
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion poison
H - Hypercalcemia, Hypertriglyceridemia
E - ERCP
D - Drugs.
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