Epidemiology

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Etiology

Obstruction of Pancreatic Duct

• Gallstone (see Cholelithiasis, [[Cholelithiasis]])
• Pancreatic Cancer (see Pancreatic Cancer, [[Pancreatic Cancer]])

Metabolic

• Hypercalcemia (see Hypercalcemia, [[Hypercalcemia]])
• Hypertriglyceridemia (see Hypertriglyceridemia, [[Hypertriglyceridemia]])

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

• Ethanol (see Ethanol, [[Ethanol]])

Other

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Physiology

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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

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Clinical Manifestations

Cardiovascular Manifestations

• Hypotension/Hypovolemia (see Hypotension, [[Hypotension]]) and Hypovolemic Shock, [[Hypovolemic Shock]])

Gastrointestinal Manifestations

• Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
• Nausea and Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

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

• Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
• Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]]): occurs in 3-17% of cases

Renal Manifestations

• Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
• Hypocalcemia (see Hypocalcemia, [[Hypocalcemia]])

Other Manifestations

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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

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Intravenous Fluid Resuscitation

• Lactated Ringers (see Lactated Ringers, [[Lactated Ringers]])
• Normal Saline (see Normal Saline, [[Normal Saline]])

Antibiotics

• Indications
  • Pancreatic Necrosis

Nutrition

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Supportive Care

• Mechanical Ventilation: as required

Other

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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]