Acute Pancreatitis – Causes, Symptoms, Diagnosis And Treatment
Acute pancreatitis is a surgical emergency characterized by acute inflammation (with fast-evolving nature of the crisis) of the pancreas. Although it is called pancreatitis, in some cases it can occur in the absence of any inflammatory process (eg trauma, pancreatic stroke).
Normally, pancreatic enzymes do not activate until they reach the duodenum. Under certain conditions, however, these enzymes become active inside the pancreas and start to act destructively on the pancreatic cells (as digesting food). Because the pancreas is not surrounded by a well defined capsule, inflammation can spread easily and beyond. This clinical form is called edematous pancreatitis. If the inflammatory process is not stopped, it can lead to parenchyma necrosis (the main or specilized part of an organ ). In this case the pathology is known as diffuse or localized necrotizing pancreatitis. Necrosis is sometimes accompanied by bleeding and glandular dysfunction, in this case, the clinical presentation is called hemorrhagic pancreatitis.
Acute pancreatitis is a disease that occurs suddenly and usually resolves in a few days after treatment although in some rare cases can be life threatening.
The etiology is complex and varies from case to case. The disease occurs between 30 and 60 years with a maximum frequency between 35 and 45.
Etiological factors: situations that cause reflux of bile into the pancreas, causes of reflux of the duodenal juice into the pancreas ; obstruction of the pancreatic ducts, vascular accidents and injuries. The main causes are:
- Obesity, alcoholism, dietary abuses, gallstones, biliary tract infections, chronic liver disease, diabetes, duodenal ulcer, appendicitis, infectious diseases (epidemic hepatitis typhoid fever).
- Copious meals, excessive alcohol conumption, biliary colic, intense emotions, abdominal trauma
Among the etiologic factors gallstones are the main cause of acute pancreatitis. Occurs in women in 75% of cases (in which gallstones has the same frequency). Another important etiologic factor is acute or chronic alcohol ingestion. Finally, surgery on the abdomen, abdominal trauma and hyperlipidemia play crucial roles in causing acute pancreatitis.
The main process on that acute hemorrhagic pancreatitis and necrotic pancreatic pancreatitis is based is the activation of intra-glandular ferments followed by the digestion of the pancreas (autodigestion).
Lesions of the pancreas during acute pancreatitis: swelling, bleeding, necrotic areas, suppurations or gangren. Usually there are two types of lesions: edema and hemorrhagic necrosis and they represent two stages with increasing severity. Edema occurs in forms with lower severity and necrosis in more severe forms.
Typical presentation includes upper abdominal pain, nausea, vomiting and low fever. Pain, spontaneous and during palpation is generally limited to the upper abdomen first, in some severe cases pain is part of a diffuse peritoneal irritation syndrome. Sometimes the patient has no pain, but presents abdominal distension, ileus, fever and tachycardia. The pain in acute pancreatitis has a sudden onset, reaching a maximum of intensity several hours later and persists for at least 1-2 days. In patients with acute pancreatitis and biliary origin, pain can be similar to a biliary colic. Biliary colic pain persistent after treatment suggesst an acute pancreatitis. The severity of pain cause patients to be agitated and constantly change their position in order to relieve pain which is usually located in the epigastric region radiating to the left and right upper quadrant and frequently in the back injury. Abdominal pain is a major symptom but it never comes alone. Nausea and vomiting often accompany abdominal pain, constipation or diarrhea as well. Fever, present in in the first days of illness is usually accompanied by tachycardia.
- Serum amylase determination (blood) and urine; amylases are enzymes found in saliva and pancreatic juice, helping the digestion . Elevated serum amylase increase rapidly in the first 12 hours after onset and persist for 3-5 days, after which the values ??normalize. Urinary amylase increases in parallel with serum amylase
- Determination of lipase. Lipase is an enzyme that breaks down fats; hyperlipasemia appears late and may persist for up to 14 days
- Enzyme dosage (amylase and lipase) in peritoneal and pleural exudate – are considered more specific than their serum values
- Phospholipase A2 serum dosage – phospholipase A2 is an enzyme that catalyzes the hydrolysis of phospholipids but it is a difficult and expensive technique
- Determination of serum trypsin – Trypsin is an enzyme that catalyzes the transformation of peptide compounds and is a very sensitive indicator.
- CBC . Leukocytosis – increasing the number of leukocytes in the blood, leukocytosis is moderate, hemoglobin and hematocrit – early growth due to initial hemoconcentration, coagulation – early signs of DIC (disseminated intravascular coagulation)
- Liver function exploration
- Metabolic exploration – glucose, serum calcium, blood gases, blood electrolytes, fluids and electrolyte balance, increased serum urea.
- Simple abdominal radiography – intestinal transient obstruction, changes in abdominal organ positions
- Chest radiography – left atelectasis
- Abdominal ultrasound – the hallmark and early sign is the increased size of the pancreas, due to diffuse edema (fluid accumulation) and fluid collection in peritoneal cavity.
- Computed tomography (CT) – broadening the limits of the pancreas, distortion and blurred contours.
- magnetic resonance imaging (MRI) – is performed to detect the severity of acute pancreatitis
- Colangio-MRI – is invasive, can be applied to critical patients who require ventilatory support
- ERCP (endoscopic retrograde cholangiography)
Generally to assess the severity of acute pancreatitis and the onset of alcoholic pancreatitis and pancreatitis caused by other unknon causes certain criteria called the Ranson critera are applied .
The evolution is likely to be severe so as the complications that will arise such as if 3 or more of the following criteria are present on admission:
- Age over 55 years
- Glucose over 200 mg / dl
- WBC over 16000/mm
- Serum LDH over 350 units / l
- GPT over 250 units / l.
48 hours after admission, poor prognostic indicators:
- Hematocrit decreases by more than 10%
- Arterial oxygen pressure is less than 60 mmHg
- Serum urea increased by more than 5 mg / dl
- Serum calcium less than 8 mg / dl
- Base deficit above 4 mEq / l
- Fluid sequestration estimated to more than 6 liters.
Acute pancreatitis is one of the major therapeutic emergencies. Treatment is complex, individualized for eacg clinical form, etiology and evolutionary trend.
Patients with mild acute pancreatitis are admitted to the gastroenterology department, severe acute pancreatitis patients are admited directly in the intensive care unit for specialist treatment and ongoing monitoring. Therapeutic methods necessary in the first phase are associated in various combinations to achieve analgesia, treatment of shock and MOF (multiple organ failure), pathogenetic chain termination and preventing complications, especially septic complications
Analgesic drugs (relieves pain) that are indicated: procaine, sublingual buprenorphine, bupivacaine in continue epidural anesthesia. Morphine is contraindicated due to the fact that it can induce spasm. Prophylaxis and treatment of shock requires fluid therapy (crystalloid solutions), anti-hypoxia (oxygen mask is placed), and restoring ionic balance and electrolyte balance (sodium intake, potassium, calcium, sodium bicarbonate)
MOF treatment is based on restoration of the circulating blood volume to which specific therapies for organ failure are added. Glucose solutions, amino acids and fat emulsions are administered intravenously and oral diet is resumed after clinical remission, normalization of amylase and resumption of digestive tolerance.
Most patients evolve favorably under conservative treatment with complete remission in80% of cases. They only have surgical indication for removing the causes of pancreatitis (biliary, pancreatic, parathyroid causes) to prevent relapses.
Emergency operations (within 8 hours after the onset of pancreatitis, less than 5% of acute pancreatitis), namely in patients with clinical signs of acute surgical abdomen (emergency caused by damage to one or more abdominal organs as result of an injury or illness, the patient has severe pain and is often in shock) and uncertain diagnosis, unapparent or unspecified acute pancreatitis.
Delayed surgery (3-6 weeks) for the treatment of complications of acute pancreatitis. Pancreatic abscesses have vital surgery indication at the time of diagnosis. Pancreatic pseudocysts which reached the maturation stage are also resolved with surgery.