Acute pancreatitis

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Pancreatitis is an inflammatory process in which pancreatic enzymes auto-digest the gland. The gland sometimes heals without any impairment of function or any morphologic changes (acute pancreatitis). Pancreatitis can also be intermittent or continuous, contributing to the functional and morphologic loss of the gland (chronic pancreatitis).

Causes

  • Biliary tract disease (gallstones)
  • Alcohol abuse
  • Parasites: worm infestations e.g. ascaris
  • Blunt abdominal trauma
  • Certain medicines
    • Azathioprine
    • Sulphonamides
    • Sulindac
    • Tetracycline
    • Valproic acid
    • Didanosine
    • Methyldopa
    • Oestrogens
    • Furosemide
    • 6-Mercaptopurine
    • Pentamidine
    • 5-aminosalicylic acid compounds
    • Corticosteroids
  • Infections (e.g. mumps, HIV, hepatitis A)

Signs and symptoms

  • Constant, severe epigastric pain which:
    • Radiates towards the back
    • Worsens after meals
    • Worsens when supine and improves when patient leans forward
  • Nausea and vomiting
  • Fever
  • Jaundice
  • Tachycardia
  • Hypotension
  • Abdominal tenderness and distension
  • Diminished or absent bowel sounds
  • Dyspnoea     

Differential diagnosis

  • Peritonitis from other causes
  • Perforated peptic ulcer
  • Acute cholecystitis

Complications

  • Pancreatic pseudocysts
  • Pancreatic abscess
  • Necrotizing pancreatitis
  • Haemorrhagic pancreatitis
  • Hypovolaemic shock
  • Adult Respiratory Distress Syndrome (ARDS)

Investigations

Laboratory

  • Serum amylase - more than 3 times normal
  • Serum lipase - more than 3 times normal (more specific than amylase)
  • Liver function tests
  • Full blood count
  • E, U , Cr; serum calcium, RBG

Radiology

  • Ultrasound scan: may reveal gall stones, pancreatic pseudocysts or abscesses
  • Abdominal CT scan if available

Treatment objectives

  • Relieve pain
  • Prevent complications

Pharmacological treatment

IV fluid for resuscitation

Ringers Lactate or Normal saline IV

At least 250-400mls of fluid per hour in the first 48 hrs.

Mild to moderate pain and elevated body temperature

Paracetamol oral

1000 mg every 4-6 hours but not exceeding 4000 mg

Moderate-to-Severe Pain

Tramadol oral

Acute: 50-100 mg orally every 4-6hr when necessary; not to exceed 400 mg/day

Pethidine

Adult:

50-150 mg every 4 hours by subcutaneous injection or intramuscular injection

Caution

  • Avoid narcotic analgesics which may cause spasms of the sphincter of Oddi
  • Risks of addiction, abuse, and misuse. Reserve for patients whose pain cannot be controlled by other medicines.

For complications requiring antibiotic therapy

Ceftriaxone IV

1-2 g/day IV in single daily dose or divided q12hr for 4-7 days

PLUS

Metronidazole IV/oral 

Loading dose: 15 mg/kg IV; not to exceed 4 g/day  

Maintenance dose: 7.5 mg/kg orally every 6 hours for 7-10 days (or 2-3 weeks if severe)

Prevention

  • To stop alcohol consumption 

Referral

  • Refer patients with biliary pancreatitis to surgical care for cholecystectomy