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Pancreatitis
Classification and external resources K85, K86.0K86.1 ICD-10 577.0-577.1 ICD-9 167800 OMIM 24092 DiseasesDB 001144 MedlinePlus emerg/354 eMedicine D010195 MeSH Pancreatitis is an inflammation of the pancreas. It has several causes and symptoms and requires immediate medical attention. It occurs when pancreatic enzymes (especially trypsin) that digest food are activated in the pancreas instead of the small intestine. It may be acute beginning suddenly and lasting a few days, or chronicoccurring over many years.
Contents
1 Signs and symptoms 2 Causes o 2.1 Infectious causes 3 Diagnosis 4 Treatment o 4.1 Mild acute pancreatitis o 4.2 Severe acute pancreatitis 5 Prognosis 6 Complications 7 See also 8 References 9 External links
abdomen is usually tender but to a lesser degree than the pain itself. As is common in abdominal disease, bowel sounds may be reduced from reflex bowel paralysis. Fever or jaundice may be present. Chronic pancreatitis can lead to diabetes or pancreatic cancer. Unexplained weight loss may occur from a lack of pancreatic enzymes hindering digestion.
Causes
Eighty percent of cases of pancreatitis are caused by alcohol and gallstones. Gallstones are the single most common etiology of acute pancreatitis.[1] Alcohol is the single most common etiology of chronic pancreatitis.[2][3][4][5][6] Some medications are commonly associated with pancreatitis, most commonly corticosteroids such as prednisolone, but also including the HIV drugs didanosine and pentamidine, diuretics, the anticonvulsant valproic acid, the chemotherapeutic agents L-asparaginase and azathioprine, estrogen by way of increased blood triglycerides,[7] cholesterol-lowering statins[citation needed] and the antihyperglycemic agents like metformin,[8] vildagliptin,[9] sitagliptin.[10] It may be noted here that the drugs which are used to treat conditions which are themselves associated with increased events of pancreatitis may also be incidentally linked to pancreatitis. Examples include statins in dyslipidemia and gliptins in diabetes. According to the Food and Drug Administration's MedWatch Surveillance System and Published Reports Atypical, atypical antipsychotics such as clozapine, risperidone, and olanzapine can also be responsible for causing pancreatitis. [11] There is an inherited form that results in the activation of trypsinogen within the pancreas, leading to autodigestion. Involved genes may include Trypsin 1, which codes for trypsinogen, SPINK1, which codes for a trypsin inhibitor, or cystic fibrosis transmembrane conductance regulator.[12] Other common causes include trauma, mumps, autoimmune disease, scorpion stings, high blood calcium, high blood triglycerides, hypothermia, and endoscopic retrograde cholangiopancreatography (ERCP). Pancreas divisum is a common congenital malformation of the pancreas that may underlie some recurrent cases. Pregnancy can be a cause, possibly by increasing blood triglycerides. Diabetes mellitus type 2 is associated with a 2.8-fold higher risk.[13] Less common causes include pancreatic cancer, pancreatic duct stones,[14] vasculitis (inflammation of the small blood vessels in the pancreas), coxsackievirus infection, and porphyriaparticularly acute intermittent porphyria and erythropoietic protoporphyria. The mnemonic GETSMASHED is often used to remember the common causes of Pancreatitis: G - Gall stones E - Ethanol T - Trauma S - Steroids M - Mumps A - Autoimmune Pancreatitis S Scorpion Sting H - Hyperlipidaemia, Hypothermia, Hyperparathyroidism E - Endoscopic retrograde cholangiopancreatography D - Drugs commonly azathioprine, valproic acid
Infectious causes
A number of infectious agents have been recognized as causes of pancreatitis including:[15]
Viruses o Coxsackie virus o Cytomegalovirus o Hepatitis B o Herpes simplex virus o Mumps o Varicella-zoster virus Bacteria o Legionella o Leptospira o Mycoplasma o Salmonella Fungi o Aspergillus Parasites o Ascaris o Cryptosporidium o Toxoplasma
Diagnosis
Diagnosing pancreatitis requires two of the following:
Characteristic abdominal pain Blood amylase or lipase will be 4-6 times higher than the normal variations, but this will be dependent on the laboratory that is testing the blood. Abdominal ultrasound is generally performed first, which is advantageous for the diagnosis of the causes of the pancreas, for example, detecting gallstones, diagnosing alcoholic fatty liver (combined with history of alcohol consumption). They are both the main causes of pancreatitis. Abdominal ultrasound also shows an inflamed pancreas clearly. It is convenient, simple, non-invasive, and inexpensive.[16] Characteristic CT scan[17]
Amylase or lipase is frequently part of the diagnosis; lipase is generally considered a better indicator,[17][18][19][20][21][22][23] but this is disputed.[24][25] Cholecystitis, perforated peptic ulcer, bowel infarction, and diabetic ketoacidosis can mimic pancreatitis by causing similar abdominal pain and elevated enzymes.[citation needed] The diagnosis can be confirmed by ultrasound and/or CT.
Treatment
The treatment of pancreatitis is supportive and depends on severity. Morphine generally is suitable for pain control. There is a claim that morphine may constrict the sphincter of Oddi, but this is controversial. There are no clinical studies to suggest that morphine can aggravate or cause pancreatitis or cholecystitis.[26]
The treatment that is received for acute pancreatitis will depend on whether the diagnosis is for the mild form of the condition, which causes no complications, or the severe form, which can cause serious complications.
Prognosis
Severe acute pancreatitis has mortality rates around 2-9%, higher where necrosis of the pancreas has occurred.[29]
Several scoring systems are used to predict the severity of an attack of pancreatitis. They each combine demographic and laboratory data to estimate severity or probability of death. Examples include APACHE II, Ranson, and Glasgow. Apache II is available on admission; Glasgow and Ranson are simpler but cannot be determined for 48 hours.[citation needed] One form of the Glasgow criteria suggests that a case be considered severe if at least three of the following are true:[30]
Age > 55 years Blood levels: o P02 Oxygen < 60mmHg or 7.9kPa o White blood cells > 15 o Calcium < 2 mmol/L o Urea > 16 mmol/L o Lactate dehydrogenase (LDH) > 600iu/L o Aspartate transaminase (AST) > 200iu/L o Albumin < 32g/L o Glucose > 10 mmol/L
P02 Oxygen < 60mmHg or 7.9kPa Age > 55 Neutrophilia White blood cells > 15 Calcium < 2 mmol/L Renal Urea > 16 mmol/L Enzymes Lactate dehydrogenase (LDH) > 600iu/L Aspartate transaminase (AST) > 200iu/L Albumin < 32g/L Sugar Glucose > 10 mmol/L
Complications
Early complications include shock, infection, systemic inflammatory response syndrome, low blood calcium, high blood glucose, and dehydration. Blood loss, dehydration, and fluid leaking into the abdominal cavity (ascites) can lead to kidney failure. Respiratory complications are often severe. Pleural effusion is usually present. Shallow breathing from pain can lead to lung collapse. Pancreatic enzymes may attack the lungs, causing inflammation. Severe inflammation can lead to intra-abdominal hypertension and abdominal compartment syndrome, further impairing renal and respiratory function and potentially requiring management with an open abdomen (laparostomy) to relieve the pressure.[31] Late complications include recurrent pancreatitis and the development of pancreatic pseudocystscollections of pancreatic secretions that have been walled off by scar tissue. These may cause pain, become infected, rupture and bleed, block the bile duct and cause jaundice, or migrate around the abdomen. Acute necrotizing pancreatitis can lead to a pancreatic abscess, a collection of pus caused by necrosis, liquefaction, and infection. This happens in approximately
3% of cases, or almost 60% of cases involving more than two pseudocysts and gas in the pancreas.[32]