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Acute Panceratitis :- Causes, sign, Symptoms, Diagnosis, Complication, Diagnosis and Treatment of Acute Pancreatitis

Some people have more than one attack and recover completely after each, but acute pancreatitis can be a severe, life-threatening illness with many complications. About 80,000 cases occur in the United States each year; some 20 percent of them are severe. Acute pancreatitis occurs more often in men than women.

Pancreatitis may be acute or chronic. The incidence varies in different ethnic groups. Acute pancreatitis is seen infrequently as a medical or surgical emergency in India. Chronic pancreatitis accounts for a - significant proportion of malabsorption syndrome. Chronic calcific pancreatitis with secondary diabetes is seen in some endemic areas. Pancreatitis is closely associated with alcoholism and biliary tract disease. Acute pancreatitis results from autodigestion of the pancreas by its own enzymes. The inactive precursors of proteolytic enzymes are activated by regurgitated bile, viral infections, ischemia, anoxia, trauma or toxins, within the pancreas. Digestion of the tissues results in edema, hemorrhage, vascular damage, cogulation necrosis, and fat necrosis. Secondary factors like liberation of activated enzymes, bradykinin and histamine like substances into the pancreas result in vasodilation, exudation, and disseminated intravascular coagulation. These factors lead to further damage. Acute pancreatitis occurs suddenly and lasts for a short period of time and usually resolves.

Causes of Acute Panceratitis

Acute pancreatitis is usually caused by drinking too much alcohol or by gallstones. A gallstone can block the pancreatic duct, trapping digestive enzymes in the pancreas and causing pancreatitis. If alcohol use and gallstones are ruled out, other possible causes of pancreatitis should be carefully examined so that appropriate treatment-if available-can begin. Many medications, and conditions such as hyperlipidemia (high levels of fat in the blood), and hypercalcemia (high levels of calcium in the blood) may also cause pancreatitis.

1. Biliary tract disease, especially cholelithiasis in the common bile duct.

2. Trauma-blunt abdominal injuries, surgical trauma, post-ERCP reaction.

3. Alcoholic bouts.

4. Metabolic causes-hyperlipidemia, diabetes, renal failure, hypothermia.

5. Endocrine causes-hyperparathyroidism, cortico­ steroid therapy, oral contraceptives.

6. Infections-mumps, viral hepatitis, Coxsackie and echo viruses, mycoplasma.

7. Pancreatic ductal obstruction due to migration of .Ascaris lumbricoides and other causes.

8. Inflammation spreading from neighboring tissues, e.g. penetrating peptic ulcer.

9. Connective tissue diseases, e.g., systemic lupus erythematosus.

10. Drug-induced pancreatitis caused by diuretics, anti-inflammatory drugs, azathioprine, 6-mercapto­purine, I-asparaginase; isoniazid, rifampicin, tetracycline, phenfonnin.

In many cases there may be no identifiable causes and the condition occurs de novo.

Sign / Symptoms of Pancreatitis

Onset is sudden with acute upper abdominal pain which may radiate to the chest, precordium, back or lower abdomen. An alcoholic bout or heavy eating may precipitate the attack. The patient adopts a stooping posture with pressure on the abdomen to get relief. Mild jaundice may be present in a few cases. Erythematous skin nodules may form due to fat necrosis. Secondary pleural effusion may develop on the left side. Someone with acute pancreatitis often looks and feels very sick. Other symptoms may include:-

swollen and tender abdomen

nausea

vomiting

fever

rapid pulse

Severe cases may cause dehydration and low blood pressure. The heart, lungs, or kidneys may fail. If bleeding occurs in the pancreas, shock and sometimes even death follow.

Diagnosis of Pancretatis

Examination of the abdomen shows rigidity, marked tenderness, mild distention due to ileus of the intestines, and absence of peristaltic sounds. A bluish dis­coloration may be seen in the llanks (Turner's sign) or around the umbilicus (Cullen's sign) due to extravasation of blood into the abdominal wall. When present, these signs strongly suggest acute necrotising pancreatitis. Ascites may develop as a complication (pancreatic ascites).

Course and Prognosis: The acute phase subsides within a week but recurrence may occur. In general the mortality is 10-20 percent. In hemorrhagic pancreatitis with profound shock the mortality is high. Adverse factors include elderly age, severe shock, respiratory failure, fall of serum calcium below 8 mg/dl, azotemia and high fluid requirements.

Laboratory features: Serum amylase is increased early during the stage of acinar necrosis and it comes down in 3-4 days. Amylase levels may reach even 2000 Somogyi units/dl. Urinary amylase is raised initially during the illness and it remains so for 4-7 days. In acute pancreatitis the renal clearance of amylase is higher than that of creatinine. The amylase/creatinine clearance ratio (Cam/Ccr) is increased in acute pancreatitis and this is a diagnostic feature. Serum amylase levels are elevated in other conditions such as cholecystitis, intestinal infarction, perforation and obstruction, and mumps. Amylase level is increased in the ascitic fluid of pancreatic ascites.

Moderate neutrophil leukocytosis is common. Blood glucose is increased and calcium is lowered. Serum bilirubin may be transiently elevated, up to 4 mg/dl in a few cases. Electrocardiogram abnormalities such as ST-T-wave changes may develop in some cases and this may resemble myocardial ischemia.

Radiology: Calculiin the biliary and pancreatic duct systems may be seen in the plain radiograph of the abdomen. Loops of duodenum and jejunum are distended (sentinel loop) due to ileus. The inner wall of the duodenal loop may show pressure effects and widening on barium meal and hypotonic duodenography. Ultrasonography and CT scan help to asses the morphological abnormality in the pancreatico-biliary system. Endoscopic retrograde cholangiopancreato­graphy performed after subsidence of the acute phase helps to demonstrate the underlying abnormality. CT is very good imaging modality to reveal morphological changes in the pa,ncreas.

Differential diagnosis: Acute emergencies like gastric or duodenal ulcer perforation, acute cholecystitis, renal colic, hepatitis, peritonitis, acute myocardial infarction and pleurisy have to be considered in the differential diagnosis.

Complication in Acute Pancretatis

General complications: These include shock, hyperglycemia, hypertriglyceridemia, hypocalcemia, and disseminated intravascular coagulation. Infection generally supervenes on the necrotic tissue in 40-60% of cases. Acute pancreatitis can cause breathing problems. Many people develop hypoxia, which means that cells and tissues are not receiving enough oxygen. Doctors treat hypoxia by giving oxygen through a face mask. Despite receiving oxygen, some people still experience lung failure and require a ventilator.Sometimes a person cannot stop vomiting and needs to have a tube placed in the stomach to remove fluid and air. In mild cases, a person may not eat for 3 or 4 days and instead may receive fluids and pain relievers through an intravenous line.If an infection develops, the doctor may prescribe antibiotics. Surgery may be needed for extensive infections. Surgery may also be necessary to find the source of bleeding, to rule out problems that resemble pancreatitis, or to remove severely damaged pancreatic tissue. Acute pancreatitis can sometimes cause kidney failure. If your kidneys fail, you will need dialysis to help your kidneys remove wastes from your blood.

Treatment of Acute Pancritits

Treatment depends on the severity of the attack. If no kidney or lung complications occur, acute pancreatitis usually improves on its own. Treatment, in general, is designed to support vital bodily functions and prevent complications. A hospital stay will be necessary so that fluids can be replaced intravenously.

Medical management is possible if the diagnosis can be established. .Sometimes laparotomy is required to confirm the diagnosis and to exclude other fatal conditions which are correctable by surgery: If laparotomy reveals acute pancreatitis. the abdomen is closed after draining the peritoneum.'vithout any further surgical intervention to the pancreas. Surgical lesions of the biliary tract are corrected, if necessary.

If pancreatic pseudocysts occur and are considered large enough to interfere with the pancreas's healing, your doctor may drain or surgically remove them.

Unless the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may require intravenous feeding for 3 to 6 weeks while the pancreas slowly heals. This process is called total parenteral nutrition. However, for mild cases of the disease, total parenteral nutrition offers no benefit.

Before leaving the hospital, a person will be advised not to drink alcohol and not to eat large meals. After all signs of acute pancreatitis are gone, the doctor will try to decide what caused it in order to prevent future attacks. In some people, the cause of the attack is clear, but in others, more tests are needed.