-IBIS-1.5.0-
tx
digestive system
pancreatitis
diagnoses

definition and etiology

definition: inflammation of the pancreas

etiology: The condition may be either acute or chronic. Common causes are biliary tract disease (about half of all patients), alcoholism (especially in chronic disease), stomach/biliary tract surgery, hypolipoproteinemia, trauma, viral and bacterial infections, especially S. typhi, streptococcus, coxsackie.

signs and symptoms

signs and symptoms:

acute:
• severe abdominal pain: may radiate to the back, flank, chest, etc.; it increases over hours and lasts until the inflammation disappears (days to weeks); the pain is worse supine and better sitting flexed forward with knees up
• nausea and vomiting
• abdominal distention
• fever of 100-102° F
• abdominal guarding and rigidity: in a third of patients
• occasional rebound tenderness, diminished or absent bowel sounds
• patient is distressed and anxious
• tachycardia, hypotension
• shock may occur
• Grey Turner's sign or Cullen's sign may appear after a couple of days: (ecchymosis on the flanks or around the umbilicus, respectively)
• abscesses are common 2-5 weeks after the attack

chronic:
• upper abdominal pain may be persistent or intermittent; it may be worse after eating, often radiates to the back and is described as aching, gnawing, burning or stabbing; it typically lasts for days or weeks.
• nausea and vomiting
• progression to insufficiency
• steatorrhea may occur when the pancreas has been severely damaged
• weight loss
• abdominal masses may be palpated

lab findings:

acute:
• serum amylase concentration begins to rise at 3-6 hr, peaks at 20-30 hours, then declines (> 500 Somogyi units/ml characteristic)
• increased urine amylase lags 6-10 hours behind serum amylase
• increased amylase/creatinine clearance ratio above 5%
• increased serum triglyceride concentration
• increased serum lipase remains elevated 14 days after amylase normalizes
• bilirubin may be increased
• blood sugar and glycosuria
• LDH over 700 u.; AST/SGOT over 250 S-F units; and/or PaO2 less than 60 mmHg indicates a poor prognosis
• hemoconcentration occurs
• X-ray of abdomen and chest
• IV cholangiography, ultrasound, CT scan
• serum Ca may decrease 1-9 days after onset; may cause tetany
• elevated WBCs

chronic:
• (+) secretin test measuring decreased pancreas exocrine function
• pancreas x-ray shows calcific pancreas (usually in patients with alcoholic history)
• abdominal ultrasound, CT scan, angiography
• may see increase in serum amylase or lipase (10%)
• glucose tolerance test mimics diabetic pattern
• steatorrhea present

course and prognosis

Most patients recover in 5-7 days in cases of mild, uncomplicated acute conditions. Mortality is about 5%. Complications include progression to chronicity, abscesses, jaundice, respiratory failure and acute renal failure. The prognosis in acute hemorrhagic or suppurative pancreatitis is very unfavorable, with a mortality rate of 50-90%. Acute pancreatitis must be treated with utmost urgency to avoid complications.

In chronic pancreatitis, the pancreatic acinar cells decrease, and the patient develops steatorrhea and creatorrhea. If islet cell destruction occurs, the patient may develop glucose intolerance and diabetes mellitus. The course is gradual and progressive. Conventional treatment includes use of pancreatic enzymes, antacids and provision of pain relief.

differential diagnosis

acute
:
• acute cholelithiasis
• perforated viscus
• acute intestinal obstruction
• mesenteric infarction
• ectopic pregnancy
• diabetic coma
• other causes of acute abdomen

chronic:
• peptic ulcer
• gastritis
• biliary tract disease
• pancreatic cancer
• malabsorption
• Crohn's disease


footnotes