Introduction
Background
Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland.
The pancreas can sometimes heal without any impairment of function or any morphologic changes. This process is known as acute pancreatitis. It can recur intermittently, contributing to the functional and morphologic loss of the gland. Recurrent attacks are referred to as chronic pancreatitis. Both forms of pancreatitis present in the ED with acute clinical findings.
Pathophysiology
Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily. In acute pancreatitis, parenchymal edema and peripancreatic fat necrosis occur first. This process is known as acute edematous pancreatitis.
When necrosis involves the parenchyma, accompanied by hemorrhage and dysfunction of the gland, the inflammation evolves into hemorrhagic or necrotizing pancreatitis.
Pseudocysts and pancreatic abscesses can result from necrotizing pancreatitis because enzymes can be walled off by granulation tissue (ie, pseudocyst formation) or via bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic abscess formation). Ultrasonography or, preferably, CT can be used to detect both.
The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A. These cytokines may cause vasodilation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. Fat necrosis may cause hypocalcemia. Pancreatic B-cell injury may lead to hyperglycemia.
Frequency
United States
Acute pancreatitis has an incidence of approximately 40 cases per year per 100,000 adults.1
International
The incidence of acute pancreatitis ranges between 5 and 80 per 100,000 population, with the highest incidence recorded in the United States and Finland.2
Mortality/Morbidity
- Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form.
- Mild edematous pancreatitis occurs in about 80% of presentations, and the mortality rate is below 1%.
- Severe acute pancreatitis occurs in about 20% of presentations, with a mortality rate reaching 30%.3
Race
The annual incidence of acute pancreatitis in Native Americans is 4 per 100,000 population; in whites, 5.7 per 100,000 population; and in blacks, 20.7 per 100,000 population.4
Sex
No predilection exists.
Age
The risk for African Americans aged 35-64 years is 10 times higher than for any other group. African Americans are at higher risk than whites in that same age group.
Clinical
History
- The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating through, rather than around, to the back.
- Nausea and/or vomiting
- Fever
- Query the patient about recent surgery or invasive procedure (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia.
- Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis.
Physical
- Tachycardia
- Tachypnea
- Hypotension
- Fever
- Abdominal tenderness, distension, guarding, and rigidity
- Mild jaundice
- Diminished or absent bowel sounds
- Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung.
- Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia.
- Severe cases may have a Grey Turner sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis.
Causes
- The major causes are long-standing alcohol consumption and biliary stone disease.
- In developed countries, the most common cause of acute pancreatitis is alcohol abuse.
- A recent study suggests that 44% of patients have alcohol as the primary risk factor for acute or chronic pancreatitis.5
- On the cellular level, ethanol leads to intracellular accumulation of digestive enzymes and their premature activation and release.
- On the ductal level, ethanol increases the permeability of ductules, which allow enzymes to reach the parenchyma, resulting in pancreatic damage.
- Ethanol increases the protein content of the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the formation of protein plugs that block the pancreatic outflow and obstruction.
- Another major cause of acute pancreatitis is biliary stone disease (eg, cholelithiasis, choledocholithiasis). A biliary stone may lodge in the pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, leading to extravasation of enzymes into the parenchyma.
- Minor causes of acute pancreatitis
- Medications, including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, nonsteroidal anti-inflammatory drugs (NSAIDs), mercaptopurine, methyldopa, and tetracyclines
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Hypertriglyceridemia (When the triglyceride [TG] level exceeds 1000 mg/U, an episode of pancreatitis is more likely.)
- Peptic ulcer disease
- Abdominal or cardiopulmonary bypass surgery, which may insult the gland by ischemia
- Trauma to the abdomen or back, resulting in sudden compression of the gland against the spine posteriorly
- Carcinoma of the pancreas, which may lead to pancreatic outflow obstruction
- Viral infections, including mumps, coxsackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubella
- Bacterial infections, such as mycoplasma
- Intestinal parasites, such as Ascaris, which can block the pancreatic outflow
- Pancreas divisum
- Scorpion and snake bites
- Vascular factors, such as ischemia or vasculitis
- Autoimmune pancreatitis (pathogenesis unclear and is rare, with a prevalence of 0.82 per 100,000 individuals)
More on Pancreatitis |
 Overview: Pancreatitis |
| Differential Diagnoses & Workup: Pancreatitis |
| Treatment & Medication: Pancreatitis |
| Follow-up: Pancreatitis |
| References |
| Next Page » |
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Further Reading
Keywords
acute pancreatitis, chronic pancreatitis, peripancreatic fat necrosis, hemorrhagic pancreatitis, necrotizing pancreatitis, pancreatic abscesses, acute respiratory distress syndrome, ARDS, acute renal failure, hemorrhage, hypotensive shock, epigastric pain, right upper quadrant pain, biliary colic, binge alcohol consumption, alcohol abuse, Grey Turnersign, Cullen sign, biliary stone disease, cholelithiasis, choledocholithiasis, endoscopic retrograde cholangiopancreatography, ERCP, hypertriglyceridemia, pancreatic enzymes, acute edematous pancreatitis
