Acute Pancreatitis

Epidemiology

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Etiology

Obstruction of Pancreatic Duct

Metabolic

Drugs

Definite Association with Pancreatitis

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

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

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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

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]