Pancreatitis

It  is  due  to  sudden  inflammation  of  the  pancreas  due  to  pancreatic  enzymes  auto  digestion.  Common risk factors which trigger the acute episode are presence of gallstones and alcohol intake.  

Clinical presentation 

• Severe, unremitting epigastric pain, radiating to the back  
• Nausea and vomiting 
• Signs of shock may be present 
• Ileus is also common 
• Local  complications: inflammatory mass, obstructive jaundice, gastric  outlet obstruction 
• Systemic complication: sepsis, acute respiratory distress syndrome, acute renal failure  

Investigations  

• Raised serum levels for lipase and amylase greater than 3 times the upper limit of normal (ULN). Lipase is more specific and sensitive than amylase. 

And  

• Radiological (ultrasound, CT, MRI) evidence of inflamed and/or necrotizing pancreatitis. 

Treatment 

• Principles of management include supportive therapies 
• Intravascular volume expansion (colloids/crystalloid) 
• Opiate analgesia usually required (follow WHO analgesic ladder)  
• Enteral feeding, (only in absence of ileus) start within 72 hours  
• Correction of electrolytes and metabolic deficit accordingly 

Pharmacological Treatment 

B: ceftriaxone (IV) 1g 12hourly for 7days 

OR  

C: ciprofloxacin (IV) 200-400mg 12hourly for 7days 

AND  

B: metronidazole (IV) 500mg 8hourly for 7days  

OR 

S: meropenem (IV) 1g 8hourly for 7days   

Note:  

• Fever can be because of pancreatitis itself; antibiotics should be avoided before 7 days.  
  • Pancreatic necrosis: non-viable pancreatic tissue. CT-guided FNA if infection suspected.  
  • Sterile necrosis: if asymptomatic, can be managed expectantly, no role for prophylactic antibiotics. 
  • Infected necrosis: high mortality. Treat with carbapenem or metronidazole plus fluoroquinolone. 
• If stable, defer drainage to >4 weeks. If symptomatic or unstable, percutaneous drainage  and minimally invasive surgical debridement or endoscopic necrosectomy superior to open necrosectomy. ERCP + Sphincterotomy may be needed.

Chronic pancreatitis is long-term (chronic) inflammation of the pancreas that leads to permanent loss of function and morphology of the gland.  

Clinical presentation 

• Chronic upper abdominal pain associated with nausea, vomiting and loss of appetite. 
• Malabsorption diarrhoea (exocrine pancreatic insufficiency (steatorrhea)) 
• Recurrent attacks of pancreatitis weight loss
• Diabetes

Investigations  

• Radiological (Abdominal Ultrasonography/CT scan) evidence of pancreatic calcification and atrophy.

Pharmacological Treatment   

Supportive therapies with analgesics in the following order; 

A: paracetamol (PO) 1g 8hourly daily when required 

OR  

B: tramadol (PO) 50mg 12hourly when required for chronic pain relief. 

OR  

C: morphine (PO) 5-10mls 6hourly when required 

If pain unresponsive to above medications 

ADD 

A: amitriptyline (PO) 25mg nocte when required for pain control 

OR 

D: pregabalin (PO) 75mg once daily when required for pain relief 

Manage complications   

Pancreatic enzymes deficiency and steatorrhea 

S: pancreatic (PO) 1–3tablets 24hourly to supplement digestive enzyme and improve food absorption. 

Diabetes mellitus  

Refer to metabolic and endocrine disease conditions chapter 

Note: In patients with persistent or refractory pain look for a dilated pancreatic duct and intraductal calcifications. These patients may benefit from endoscopic stenting, lithotripsy, or surgical drainage (pancreatojejunostomy).