Epidemiology
Etiology
Obstruction of Pancreatic Duct
Metabolic
Drugs
Definite Association with Pancreatitis
- Asparaginase (see Asparaginase, [[Asparaginase]])
- Azathioprine (see Azathioprine, [[Azathioprine]])
- Didanosine (see Didanosine, [[Didanosine]])
- Estrogen (see Estrogen, [[Estrogen]])
- Furosemide (see Furosemide, [[Furosemide]])
- Mercaptopurine (see Mercaptopurine, [[Mercaptopurine]])
- Pentamidine (see Pentamidine, [[Pentamidine]])
- Sulfonamides (see Sulfonamides, [[Sulfonamides]])
- Sulindac (Clinoril) (see Sulindac, [[Sulindac]])
- Tetracyclines (see Tetracyclines, [[Tetracyclines]])
- Thiazides (see Thiazides, [[Thiazides]])
- Valproic Acid (see Valproic Acid, [[Valproic Acid]])
Probable Association with Pancreatitis
- Cimetidine (Tagamet) (see Cimetidine, [[Cimetidine]])
- Clozapine (Clozaril) (see Clozapine, [[Clozapine]])
- Corticosteroids (see Corticosteroids, [[Corticosteroids]])
- Endoscopic Retrograde Cholangiopancreatography (ERCP) Contrast Media (see Radiographic Contrast, [[Radiographic Contrast]])
- Methyldopa (Aldomet) (see Methyldopa, [[Methyldopa]])
- Metronidazole (Flagyl) (see Metronidazole, [[Metronidazole]])
- Salicylates (see Salicylates, [[Salicylates]])
- Zalcitabine (2′-3′-dideoxycytidine, dideoxycytidine, ddC, Hivid) (see Zalcitabine, [[Zalcitabine]])
Questionable Association with Pancreatitis
- Acetaminophen (see Acetaminophen, [[Acetaminophen]])
- Cyclosporine A (see Cyclosporine A, [[Cyclosporine A]])
- Cytarabine (ARA-C) (see Cytarabine, [[Cytarabine]])
- Erythromycin (see Erythromycin, [[Erythromycin]])
- Ketoprofen (see Ketoprofen, [[Ketoprofen]])
- Metolazone (see Metolazone, [[Metolazone]])
- Octreotide (see Octreotide, [[Octreotide]])
- Roxithromycin (Biaxsig, Coroxin, Romac, Roxar, Roximycin, Roxl-150, Roxo, Roxomycin, Rulid, Rulide, Surlid, Tirabicin, Xthrocin) (see Roxithromycin, [[Roxithromycin]])
Toxin
Other
Physiology
Diagnosis
Serum Amylase (see Hyperamylasemia, [[Hyperamylasemia]])
- Time Course
- Increases within 6-12 hrs of onset of acute pancreatitis
- In uncomplicated acute pancreatitis, returns to normal within 3-5 days
- Half-Life: 10 hrs
- Due to short half-life, amylase may not be elevated in patients who present >24 hrs after onset of acute pancreatitis
- Sensitivity/Specificity for Acute Pancreatitis (Using Serum Amylase >3x Upper Limit of Normal)
- Sensitivity: 67-83%
- In alcoholic pancreatitis, serum amylase elevation to >3x upper limit of normal is not seen in 20% of cases (due to inability of pancreas to synthesize amylase)
- Specificity: 85-98%
Serum Lipase (see Serum Lipase, [[Serum Lipase]])
- Time Course
- Increases within 4-8 hrs of onset of acute pancreatitis
- Peaks at 24 hrs: makes lipase particularly useful in patients who present >24 hrs after onset of acute pancreatitis
- Returns to normal within 8-14 days
- Half-Life: 7-14 hrs
- Sensitivity/Specificity for Acute Pancreatitis
- Sensitivity: 82-100%
- Lipase is more sensitive than amylase in alcoholic pancreatitis
- Specificity: 82-100%
Serum Trypsinogen Activation Peptide (TAP)
- Trypsinogen activation peptide is a 5 amino acid peptide that is cleaved from trypsinogen (to produce active trypsin)
- Elevated in acute pancreatitis
- May be sensitive for early acute pancreatitis
- May be sensitive as a predictor of severity of acute pancreatitis
Urinary/Serum Trypsinogen-2
- May be elevated in early acute pancreatitis -> role of their measurement is currently unclear
Abdominal Ultrasound
- Less accurate than CT for the diagnosis of pancreatic necrosis
Abdominal CT
- Since pancreatic necrosis takes time to develop, CT may be normal in the first 48 hrs
- American Gastroenterological Association Recommendations
- CT should be performed after 72 hours of illness in patients with predicted severe disease
- CT within 72 hrs in patients with evidence of organ failure
- The association between contrast injection and worsening of pancreatitis is not strong -> CT is not contraindicated
Clinical Manifestations
Cardiovascular Manifestations
Gastrointestinal Manifestations
Hematologic Manifestations
- Acquired Von Willebrand Disease (see Von Willebrand Disease, [[Von Willebrand Disease]]): hyperfibrinolytic state –> VWF degradation by proteolytic enzymes (such as plasmin)
Pulmonary Manifestations
Renal Manifestations
Other Manifestations
Treatment
Address Source
- Pancreatic Duct Obstruction-Related Acute Pancreatitis: ERCP or surgery may be required to relieve obstruction
- Drug/Toxin-Related Acute Pancreatitis: cessation of drug or toxic exposure (especially in ETOH-related cases)
Analgesia
Intravenous Fluid Resuscitation
Antibiotics
Nutrition
Supportive Care
- Mechanical Ventilation: as required
Other
References
- AGA Institute technical review on acute pancreatitis. Gastroenterology. 2007;132:2022 [MEDLINE]
- Computed tomography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg. 2000;179:352 [MEDLINE]