Acute Pancreatitis
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 ]
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