|
|
Reza Alavi, M.D. and Jeanne Clark, M.D.
02-10-2010
- Refers to inflammation of the pancreas.
- Common etiologies of acute pancreatitis include: gallstones, alcohol, hypercalcemia, drugs, infections, trauma.
- The annual incidence of acute pancreatitis ranges from 4.9 to 35 per 100,000 population. People with type 2 diabetes have almost a three-fold greater risk of acute pancreatitis compared to those without diabetes (Vege).
- Drug- induced pancreatitis is generally extremely uncommon with diabetes medications (Balani).
- Extreme hypertriglyceridemia, >1000 mg/dl (chylomicronemia),can cause chronic pancreatitis.
- Other etiologies include cystic fibrosis, autoimmune disorders, pancreatic anomalies (e.g. pancreas divisum).
- During acute pancreatitis, one-half of patients have glucose intolerance, but few require insulin administration (Gorelick).
- In chronic pancreatitis, up to one-half have reported overt diabetes (Wakasugi), up to an incidence of 70% when pancreatic calcification is present (Gorelick).
- Overall, mortality in hospitalized patients with acute pancreatitis is ~ 10 % (range 2 - 22%). Mortality rates unaffected by diabetes status (Cavallini).
- Serum amylase rises within 6 - 12 hours of onset, usually to >3 times the upper limit of normal (more sensitive test).
- Serum lipase is a more specific test.
- Serial measurements do NOT predict prognosis or alter management.
- White blood cell count is usually elevated even in the absence of infection.
- Always check serum electrolytes, especially calcium.
- Consider toxicology screen, lipid profile, blood cultures to evaluate for secondary etiologies.
- Pancreas-dedicated CT scan with oral and iv contrast is the most important imaging test, looking for pancreatic necrosis.
- Abdominal plain films help to exclude other causes of abdominal pain such as obstruction and bowel perforation.
- Abdominal ultrasound can show a diffusely enlarged, hypoechoic pancreas and can also detect gallstones in the gallbladder.
- Upper abdominal pain
- Nausea and vomiting
- Fever and tachycardia
- Abdominal distention, epigastric tenderness and guarding
- Shallow respirations due to diaphragmatic irritation
- Vasodilatory shock in severe acute pancreatitis without sepsis
- ICU monitoring for severe pancreatitis including pancreatic necrosis, organ failure, or pleural effusion at admission; high severity of disease score (i.e. APACHE-II).
- Fluid resuscitation with 250-300cc/hr of isotonic saline for 24-48 hours if the cardiac status permits (Tenner)
- Correction of electrolyte and metabolic abnormalities.
- Supplemental oxygen to keep pulse oxygen levels above 95%
- Pain management: Meperidine usually favored over morphine because morphine increases sphincter of Oddi pressure, but no clinical evidence that morphine actually aggravates or causes pancreatitis or cholecystitis.
- Nutritional support if likely to remain fasting for >7 days. Nasojejunal tube feeding (using an elemental or semi-elemental formula) is preferred to parenteral nutrition.
- Prophylactic antibiotics to prevent pancreatic infection is NOT routinely recommended (Banks), although imipenem/meropenem may help if >30 percent pancreatic necrosis. (Villatoro)
- ERCP indicated for the clearance of bile duct stones in severe pancreatitis or cholangitis, if poor candidate for cholecystectomy, or post-cholecystectomy in those with persistent biliary obstruction.
- Surgical treatment may be required in patients with intractable pain from chronic pancreatitis.
- After necrotizing pancreatitis, high prevalence of IGT due to both loss of beta-cell function and insulin resistance.
- Perform cholecystectomy after recovery in patients with gallstone pancreatitis, within 7 days after recovery in mild pancreatitis, and 3-4 weeks after in severe necrotizing pancreatitis.
- Exocrine pancreatic insufficiency can be common in chronic pancreatitis and both type 1 and type 2 diabetes.
- Exocrine pancreatic insufficiency is treated with low-fat diet and administration of exogenous pancreatic enzymes.
- Glucose intolerance occurs frequently in chronic pancreatitis, but overt diabetes usually occurs late in the course of disease.
- Diabetes is more common with chronic calcifying disease, particularly early calcifications.
- Diabetes in patients with chronic pancreatitis usually requires insulin treatment, and has increased risk of hypoglycemia (presumably both alpha and beta cell damage).
- Although preliminary reports suggesting exenatide, sitagliptin, and sitagliptin/metformin increase the risk of drug-induced pancreatitis, the data are inconclusive at this point (Drucker).
|
|
