This document summarizes acute and chronic pancreatitis. It covers the anatomy and physiology of the pancreas, pathophysiology, causes, symptoms, signs, diagnostic testing including labs and imaging, medical and surgical treatment options, and prognosis. The main causes of acute pancreatitis are biliary disease and alcohol use, while chronic pancreatitis is primarily caused by alcohol use long-term. Complications can include pseudocysts, abscesses, pancreatic necrosis, and pancreatic duct disruption. Treatment depends on the severity and includes pain control, antibiotics, nutritional support, enzyme replacement, and possible surgery.

1. Acute & Chronic Pancreatitis Marcos Machado, M.D. Heedong Park, M.D. November 8, 2006

2. Anatomy

3. Physiology Endocrine (20%) Islets of Langerhans Insulin (beta) Glucagon (alpha) Somatostatin (delta) Exocrine (80%) Digestive enzymes (pro-enzymes) Trypsinogen Chymotrypsinogen Controlled by Gastrin CCK Secretin

4. Pathophysiology – Acute Initiating event Injury to acinar cells impairs release of proenzymes (in zymogen granules) Premature activation of enzymes Autodigestion

5. Pathophysiology – Acute Normal Pancreatitis

6. AP: Causes – The Big Ones Biliary Tract Disease (40%) Alcohol (35%) Usually Acute on Chronic Idiopathic (10-30%) Most (70%): likely occult microlithiasis Post-ERCP (4%) Trauma (1.5%) Drugs (1.4%) Azathioprine, sulfa, sulindac, valproic acid, tetracycline, methyldopa, estrogens, lasix, corticosteroids, octreotide Poss: HCTZ, flagyl, nitrofurantoin, procainamide, cimetidine, other chemo drugs

7. AP: Other Causes – Each <1% Infection Viral (EBV, VZV, cocksackie), Bact (M. pneumo, Salmonella, Campy, TB), ascariasis Hereditary AD – mutation of trypsinogen gene, premature activation Hypercalcemia Developmental Abn Pancreas Annular pancreas, pancreas divisum, SOD dysfunction) Hypertriglyceridemia (>1000) Tumor ( obstruction of ducts) Toxin (scorpion, pesticide) Post-Op

8. Pathophysiology – Chronic Progressive inflammatory changes Chronic irreversible inflammation Fibrosis with calcification Loss of pancreatic function

9. Causes - CP Alcohol (60%) Genetic predisposition? Genetic Causes (CF, hered pancreatitis) Ductal Obstruction Trauma, pseudocysts, stones, tumors) Systemic Dz – SLE, high TG Autoimmune Idiopathic

10. Symptoms – Acute & Chronic Acute Dull, boring midepigastric, radiates to back Usually sudden onset Nausea/vomiting Chronic mid upper abd pain – chronic, intermittently severe, may rad to back Diarrhea, wt loss Steatorrhea, diabetes

11. Signs – Acute & Chronic Acute Fever (76%), tachy (65%) Abd tenderness, guarding (68%), hypoactive BS ± jaundice Severe: hemodynamic instability, hematemesis Chronic ± epigastric tender mass or fullness (pseudocyst) Advanced: malnutrition, decreased subcut fat

12. DDx – Acute & Chronic Acute Cancer (pancreatic, colon) Cholangitis Cholecystitis, Choledocholithiasis, Cholelithiasis Colonic Obstruction Ulcers IBS MI Chronic Cancer (pancreatic, ampullary) Cholangitis Cholecystitis Crohn’s Dz Chronic Gastritis Bowel perforation Mesenteric Ischemia MI PUD

13. Labs – Acute & Chronic Acute Amy/lip: 3x above Nl to be diagnostic. Lipase has longer T1/2 and is more specific Gallstone panc: ALP, Tbili, AST, ALT Ca, cholesterol, TG CBC – hemoconc-might be severe Chronic CBC, LFTs Chem Nl Amy/Lip: Nl to slightly high Compression of duct: high bili and ALP AI: high ESR, RF, ANA Adv: low serum trypsin, steatorrhea Poss: high Ca, high TG

14. Labs – cont. Other causes of elevated amylase SBO Mesenteric ischemia Tubo-ovarian dz Renal insuff Parotitis

15. Imaging When to obtain imaging uncertain diagnosis Severe disease

16. Imaging Choice U/S – most useful initial test, TOC in gallstone Sensitivity 70-80% CT abd – if severe acute pancreatitis Good for assessing complications

17. Imaging Choice ERCP, MRCP – duct obstruction MRCP is safer, noninvasive and faster than ERCP but less sensitive ERCP only if 2 ° to choledocholithiasis

18. Imaging Choice Abd xray – limited role Calcifications 30% of chronic panc Free air–perforation

19. Medical Treatment Acute Pancreatitis NPO IVF Pain relief Antibiotics If infected pancreatic necrosis Antibiotic prophylaxis in severe pancreatitis is controversial

20. Medical Treatment Chronic Pancreatitis Behavior modification Cessation of EtOH and tobacco use will help pain relief in early stages, not in late Pain control Restoration of digestion and absorption enzyme replacement ± insulin

21. Complications Pseudocyst Abscess formation Pancreatic necrosis

22. Surgical Treatment Pseudocysts Peripancreatic fluid collections for >4wks Intervention if: >7cm and rapidly expanding Symptomatic (pain, bleeding, infection)

23. Surgical Treatment Pseudocysts Percutaneous aspiration Very large fluid collections Pancreatic abcess Also responds to percut drainage

24. Surgical Treatment Pseudocysts Transpapillary drainage If pancreatic duct communicates with pseudocyst, can place stent

25. Surgical Treatment Pseudocysts Transmural enterocystostomy Endoscopic if distance between lumen and pseudocyst is <1cm

26. Surgical Treatment Pseudocysts Transmural enterocystostomy

27. Surgical Treatment Infected pancreatic necrosis Abx not enough Surgical debridement and drainage

28. Surgical Treatment Stones If evidence of biliary obstruction (jaundice, bile duct dilation), may benefit from ERCP

29. Surgical Treatment Pancreatic Duct distruption ERCP can provide dx and tx Transpapillary stent placement For distal leaks (tail of pancreas) Distal pancreatectomy

30. Surgical Treatment Pancreatic Duct distruption Proximal leaks (head of pancreas) Whipple

31. Prognosis Acute Pancreatitis Overall mortality – 15%, severe dz – 30% Ranson’s Criteria Chronic Pancreatitis Poor prognostic factors: young, smoker, cont to use EtOH, +liver cirrhosis Overall mortality 30% @ 10yrs, 55% @ 20yrs 4% risk of developing pancreatic CA @ 20yrs

32. Prognosis Ranson’s Criteria Admission >55yo, WBC>16, BG>200, LDH>350, AST>250 @ 48 hrs HCT drops 10%, BUN increases by 5, Ca < 8, pO2 <60, Base deficit>4, fluid sequestration > 6L Scoring 0-2 = minimal mortality 3-5 = 10-20% >5 = >50% mortality APACHE II scoring is best validated, but cumbersome

33. References http://www. emedicine .com http://hopkins- gi.nts.jhu.edu/pages/latin/templates/index.cfm? pg=disease4&organ=4&disease=24&lang_id=1 http://www.uptodate.com