Acute

a nd C hronic P ancreatitis
Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. The
gland sometimes heals without any impairment of function or any morphologic changes; this
process is known as acute pancreatitis. Pancreatitis can also recur intermittently, contributing
to the functional and morphologic loss of the gland; recurrent attacks are referred to as chronic
pancreatitis.

The pancreas is a gland located in the upper posterior abdomen. It is an endocrine
gland producing several important hormones, including insulin, glucagon, somatostatin,
and pancreatic polypeptide which circulate in the blood. The pancreas is also a digestive organ,
secreting pancreatic juice containing digestive enzymes that assist digestion and absorption of
nutrients in the small intestine. These enzymes help to further break down
the carbohydrates, proteins, and lipids in the chyme.

Causes of acute pancreatitis
One of the most common causes of acute pancreatitis is gallstones passing into the bile duct
and temporarily lodging at the sphincter of Oddi. The risk of a stone causing pancreatitis is
inversely proportional to its size.
It is thought that acinar cell injury occurs secondary to increasing pancreatic duct pressures
caused by obstructive biliary stones at the ampulla of Vater,
Alcohol consumption also can causes acute pancreatitis. At the cellular level, ethanol leads to
intracellular accumulation of digestive enzymes and their premature activation and release. At
the ductal level, it increases the permeability of ductules, allowing enzymes to reach the
parenchyma and cause pancreatic damage. Ethanol increases the protein content of pancreatic
juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the
formation of protein plugs that block pancreatic outflow.

Medications that can cause acute pancreatitis include: Azathioprine, Thiazide, Valproic acid,
Dideoxyinosine, Sulfasalazine, Trimethoprim-sulfamethoxazole, Pentamidine, Tetracycline.
Causes of chronic pancreatitis
In more than 90 percent of the cases, chronic pancreatitis is caused by prolonged alcohol
ingestion resulting in pancreatic damage and scarring. Other causes, which account for 10
percent of cases, include: Tropical pancreatitis, Hereditary pancreatitis, Hyperparathyroidism,
Cystic Fibrosis, Pancreas Divisum.
Symptoms and signs of acute pancreatitis
The cardinal symptom of acute pancreatitis is abdominal pain, which is characteristically dull,
boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until
reaching a constant ache. Most often, it is located in the upper abdomen, usually in the
epigastric region, but it may be perceived more on the left or right side, depending on which
portion of the pancreas is involved. The pain radiates directly through the abdomen to the back.

Nausea and vomiting are often present along with accompanying anorexia. Diarrhea can also
occur. Positioning can be important, because the discomfort frequently improves with the
patient in the supine position. The duration of pain varies but typically lasts more than a day.
Fever and tachycardia are common abnormal vital signs. Per abdomen examination, abdominal
tenderness, muscular guarding, and distention are observed in most patients. Bowel sounds are
often diminished or absent because of gastric and transverse colonic ileus.

Serum amylase and lipase levels are typically elevated in acute pancreatitis. Determine alkaline
phosphatase, total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase
(ALT) levels to search for evidence of gallstone pancreatitis. An ALT level higher than 150 U/L
suggests gallstone pancreatitis and a more fulminant disease course.

Xray KUB with the patient in the upright position is primarily performed to detect free air in the
abdomen, indicating a perforated viscus, as would be the case in a penetrating, perforated
duodenal ulcer. In some cases, the inflammatory process may damage peripancreatic structures,
resulting in a colon cut-off sign, a sentinel loop, or an ileus. The presence of calcifications within
or around the pancreas may indicate chronic pancreatitis. Ultrasonography of the abdomen is
the technique of choice for detecting gallstones. MRCP and ERCP has an emerging role in the
diagnosis of suspected biliary and pancreatic duct obstruction in the setting of pancreatitis.

Medical management of mild acute pancreatitis is relatively straightforward. The patient is kept
NBM (nil by mouth), and intravenous (IV) fluid hydration is provided. Analgesics are
administered for pain relief. Antibiotics are generally not indicated.

Patients with acute pancreatitis lose a large amount of fluids to third spacing into the
retroperitoneum and intra-abdominal area. Accordingly, they require prompt IV hydration
within the first 24 hours.

IV antibiotics ( usually imipenem group) sometimes started in moderate-severe cases even
without evidence of infected necrosis.



Reference
1. Oxford Handbook of Clinical Surgery, Third Edition
2. http://emedicine.medscape.com/
3. http://my.clevelandclinic.org/