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Acute pancreatitis

Aetiology

  • Gallstones and alcohol account for 80% cases of acute pancreatitis
  • Gallstones less than 5mm diameter are more likely to cause pancreatitis than larger ones
  • Less than 5% patients with gallstones develop pancreatitis
  • 20% cases are idiopathic
  • Aetiological factors can be summarised as follows:
    • Idiopathic
    • Obstruction
      • Choledocolithiasis
      • Ampullary or pancreatic tumours
    • Pancreatic structural anomalies
    • Toxins
      • Alcohol
      • Drugs - salicylates, azathioprine, cimetidine
    • Trauma
      • Accidental
      • Iatrogenic
    • Metabolic abnormalities
    • Infection
    • Vascular anomalies

Epidemiology

  • The incidence of acute pancreatitis is about 50 per 100,000 population per year
  • 80% have mild disease
  • 40% of those with severe disease develop infected pancreatic necrosis
  • The mortality associated with infected necrosis is about 40%
  • 50% of deaths occur within first week due to multi-organ failure
  • This usually occurs in the absence of local complications

Clinical features

  • Sudden onset epigastric pain
  • Constant in nature and radiates through to back
  • Patients are often pyrexial and dehydrated
  • Tenderness may be localised to epigastrium or generalised
  • Differential diagnosis includes
    • Perforated peptic ulcer
    • Acute cholecystitis
    • Mesenteric ischaemia
  • Eponymous signs of retroperitoneal haemorrhage are rare and appear late include
    • Cullen's sign
    • Grey Turner's sign

Cullen's sign

Grey Turner's sign

Pictures provided by Vikram Kate, Jawaharial Institute of Postgraduate Medical Education and Research, Pondicherry, India

Causes of hyperamylasaemia

  • Perforated peptic ulcer
  • Cholecystitis
  • Generalised peritonitis
  • Intestinal obstruction
  • Mesenteric infarction
  • Ruptured AAA
  • Ruptured ectopic pregnancy

Diagnosis

  • Serum amylase has low sensitivity and specificity
  • A serum amylase of 3x upper limit of normal has sensitivity = 60% and specificity = 95%
  • 20% cases of pancreatitis have normal serum amylase (particularly alcoholic aetiology)
  • Serum lipase more sensitive and may remain elevated longer
  • A serum lipase of 4x upper limit of normal has higher sensitivity and good specificity
  • Features suggestive of a gallstone aetiology include:
    • Female sex
    • Age more than 50 years
    • Amylases > 4000 IU/L
    • Bilirubin > 25 umol/L
    • AST > 100 IU/L
    • ALP > 300 IU/L

Prognostic factors

  • 80% of patients have mild pancreatitis with good recovery
  • Mild disease accounts for less than 5% of the mortality form pancreatitis
  • Mortality from pancreatitis due to:
    • Early multiple organ failure
    • Late infected pancreatic necrosis
    • Haemorrhage
    • Associated co-morbidity
  • Aim of prognostic scores is to identify patients with severe pancreatitis
  • Need to have high sensitivity and specificity
  • Ideally should be applicable on admission

Ranson's criteria

  • On admission 
    • Age > 55 yrs
    • WCC > 16,000
    • LDH > 600 U/l
    • AST >120 U/l
    • Glucose > 10 mmol/l
  • Within 48 hours
    • Haematocrit fall >10%
    • Urea rise >0.9 mmol/l
    • Calcium < 2 mmol
    • pO2  < 60 mmHg
    • Base deficit > 4
    • Fluid sequestration > 6L
  • Can not be applied fully for 48 hours
  • Also poor predictor later in the disease
  • 'Single snapshot in a whole feature length film'

APACHE II score

  • Multivariate scoring system
  • Measure objective parameter - vital signs and biochemical analysis
  • Account for premorbid state and age
  • Can be used throughout course of illness

Contrast-enhanced CT scoring system

Grade Criteria
A Normal
B Focal or diffuse glandular enlargement
Small intra-pancreatic fluid collection
C Any of the above
Peripancreatic inflammatory changes
Less than 25% gland necrosis
D Any of the above
Single extrapancreatic fluid collection
25-50% gland necrosis
E Any of the above
Extensive extrapancreatic fluid collection
Pancreatic abscess
More than 50% gland necrosis

Contrast enhanced CT showing oedema and necrosis of most of the body and tail of the pancreas

Early treatment of acute pancreatitis

  • Aims of treatment are to :
    • To halt progression of local disease
    • Prevent remote organ failure
  • Requires full supportive therapy – often on ITU or HDU
  • Urinary catheter, CVP line and possibly arterial line
  • Regular assessment of U+Es, Ca, blood sugar, LFTs
  • Patients require:
    • Fluid resuscitation with both colloid and crystalloid
    • Correction of hypoxia with an increased inspired oxygen or ventilation
    • Adequate analgesia - opiate or epidural
  • Increasing evidence that antibiotic prophylaxis useful in severe pancreatitis
  • ERCP maybe of benefit within the first 48 hours in patients with predicted severe disease

Nutritional support

  • Pancreatitis is associated with a catabolic state
  • The benefit of pancreatic 'rest' by limiting oral intake is unproven
  • Evidence that early enteral nutrition is safe
  • Nasojejunal feeding limits pancreatic secretion
  • Preferable to oral or nasogastric feeding

Complications of acute pancreatitis

Local

  • Necrosis +/- infection
  • Pancreatic fluid collections
  • Colonic necrosis
  • Gastrointestinal haemorrhage
  • Splenic rupture

Systemic

  • Hypovolaemia and shock
  • Coagulopathy
  • Respiratory failure
  • Renal Failure
  • Hyperglycaemia
  • Hypocalcaemia

Pseudocysts

  • Fibrous walled peri-pancreatic fluid collection
  • Present for more than 1 month
  • No epithelial lining. Fluid has high amylase content
  • Acute fluid collections are not pseudocysts
  • 35% patients with pancreatitis develop peri-pancreatic fluid collections
  • More than 50% resolve spontaneously over a 3 month period
  • Complication rate increases after 6 weeks
  • Diagnosis may be suggested by persistent elevation of serum amylase
  • Planned intervention at 6 weeks

Classification of pseudocysts

  • Type 1 - normal duct anatomy. No fistula between duct and cyst
  • Type 2 - abnormal duct anatomy - No fistula
  • Type 3 - abnormal duct anatomy and fistula

Investigation of pseudocysts

  • Ultrasound will allow assessment of changes in the size of the cyst
  • Endoscopic ultrasound increasingly used
  • CT to define relationship to adjacent organs

  • ERCP to define duct anatomy

Treatment options

Percutaneous drainage

  • Ultrasound or CT guided
  • 80% successful in type 1 cyst
  • Less successful if fistula to duct present
  • Occasionally associated with pancreatic abscess or fistula

Endoscopic drainage + insertion of pigtail catheter

  • Transpapillary or transmural

Surgical drainage

  • Cystogastrotomy
  • Roux Loop Cystojejunostomy
  • Allows adequate internal drainage
  • Biopsy cyst wall to exclude cystadenocarcinoma
  • Mortality similar to percutaneous drainage ( 5%)
  • Lower recurrence rate ( approximately 5 vs. 20%)

Timing of intervention in pancreatitis

  • All patients should undergo ultrasound within 24 hours of admission
  • If confirms gallstones and severe pancreatitis consider ERCP within 48 hrs
  • RCT confirm reduction in morbidity and mortality with early duct clearance
  • If patient fails to settle during first week of admission
  • Contrast enhanced CT to assess pancreatic necrosis
  • If suspicion of infection - CT guided aspiration
  • Consider pancreatic necrosectomy if
    • Clinical deterioration
    • Bacteriological proof on infection
  • Antibiotics do not prevent infected necrosis in acute necrotising pancreatitis
  • Operative mortality >40%

pancreatic necrosis

Picture provided by Jean-Pierre Arsenault, University of Montreal, Coventry.

Bibliography

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Formela L J.  Inflammatory mediators in acute pancreatitis.  Br J Surg 1995; 82: 6 - 16.

Glazer G,  Mann D V et al.  United Kingdom guidelines for the management of acute pancreatitis.  Gut 1998;  42 (Suppl 2);  S1-S13.

Grace P A  Williamson R C.  Modern management of pancreatic pseudocysts.  Br J Surg 1993; 80: 573 581.

Gupta R,  Toh S K C,  Johnson C D.  Early ERCP is an essential part of the management of all cases of acute pancreatitis.  Ann R Coll Surg Engl 1999;  81:  46-50.

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Last updated: 05 January 2008

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