Elsevier

The Lancet

Volume 371, Issue 9607, 12–18 January 2008, Pages 143-152
The Lancet

Seminar
Acute pancreatitis

https://doi.org/10.1016/S0140-6736(08)60107-5Get rights and content

Summary

Acute pancreatitis is an inflammatory disease of the pancreas. Acute abdominal pain is the most common symptom, and increased concentrations of serum amylase and lipase confirm the diagnosis. Pancreatic injury is mild in 80% of patients, who recover without complications. The remaining patients have a severe disease with local and systemic complications. Gallstone migration into the common bile duct and alcohol abuse are the most frequent causes of pancreatitis in adults. About 15–25% of pancreatitis episodes are of unknown origin. Treatment of mild disease is supportive, but severe episodes need management by a multidisciplinary team including gastroenterologists, interventional radiologists, intensivists, and surgeons. Improved understanding of pathophysiology and better assessments of disease severity should ameliorate the management and outcome of this complex disease.

Introduction

In 1856, Claude Bernard suggested that bile reflux into the common pancreatic duct was the trigger that caused acute pancreatitis.1 Several subsequent studies led to theories fuelling the debate until 1901, when Eugene Opie proposed that gallstone migration into the common bile duct was the main cause of acute pancreatitis.2 His conclusion was based on two autopsies of young patients in whom he found a gallstone occluding the orifice of the pancreatic duct. Since then, many other causes of pancreatitis have been discovered, and here we aim to review the clinical and therapeutic aspects of acute pancreatitis.

Section snippets

Epidemiology

The incidence of acute pancreatitis has increased in the past two decades.3, 4, 5, 6 Between 1994 and 2001, the incidence of first-time attack in California increased from 33 to 44 per 100 000 adults,7 and at present acute pancreatitis accounts for more than 200 000 hospital admissions every year in the USA.8 Such increase is also seen in European countries.9 In 80% of patients, acute pancreatitis is mild and resolves without serious morbidity, but in up to 20%, acute pancreatitis is

Pathophysiology

Although controversial, most investigators believe that acute pancreatitis is caused by the unregulated activation of trypsin within pancreatic acinar cells (figure 1). Enzyme activation within the pancreas leads to the autodigestion of the gland and local inflammation. The main factors that trigger acute disease are pancreatic hyperstimulation (mainly seen in experimental models), gallstones, and alcohol abuse. Acute pancreatitis arises when intracellular protective mechanisms to prevent

Diagnosis

Acute pancreatitis is characterised by the presence of acute and constant pain in the epigastric area or the right upper quadrant.22, 23, 24 Pain might last for several days, radiate to the back, and be associated with nausea and vomiting. Physical findings depend on severity of the disease. In mild disease, abdominal palpation reveals tenderness in the upper abdomen. Exudates from pancreatic necrotic areas tracking along the falciform ligament and into the retroperitoneum can be seen in the

Diagnosis

Abdominal radiography might show localised ileus in severe pancreatitis. In a third of patients, chest radiography shows abnormalities such as elevation of one hemidiaphragm, and pleural effusions, pulmonary infiltrates or both. When abdominal ultrasound is done, bowel gases often mask focal hypoechoic areas within the pancreas.

Contrast-enhanced CT can be done after admission to confirm diagnosis of disease (87–90% sensitivity and 90–92% specificity), or after 4 days to assess local

Course and severity

Most episodes of acute pancreatitis are mild and self-limiting, needing only brief hospitalisation. However, 20% of patients develop a severe disease with local and extrapancreatic complications characterised by early development and persistence of hypovolaemia, and multiple organ dysfunction. Thus, close examination to assess early fluid losses, hypovolaemic shock, and symptoms suggestive of organ dysfunction is crucial. Assessment methods such as the sequential organ failure assessment (SOFA)

Causation

Many causes for acute pancreatitis exist, and in 75–85% of patients the cause is easily identified. In developed countries, obstruction of the common bile duct by stones (38%) and alcohol abuse (36%) are the most frequent causes of acute pancreatitis (figure 1 and panel).60

Gallstone-induced pancreatitis is caused by duct obstruction of gallstone migration. Obstruction is localised in the bile duct, the pancreatic duct, or both. Duct obstruction promotes pancreatitis by increasing ductal

Treatment

In mild forms of disease, besides the aetiological treatment (mostly for gallstone-induced pancreatitis), therapy is supportive and includes fluid resuscitation, pain relievers, oxygen administration, and antiemetics, whereas oral feeding is stopped (figure 5). By contrast, severe episodes (20% of patients) need management by a multidisciplinary team, including gastroenterologists, interventional radiologists, intensivists, and surgeons. However, despite efforts to start an appropriate

Search strategy and selection criteria

We used the PubMed database to search with the terms “acute pancreatitis” together with “complications”, “death”, “treatment”, “sphincterotomy”, “antibiotic prophylaxis”, and “enteral nutrition”. We selected citations from articles in English, German, and French from the past 5 years, but did not exclude commonly referenced and highly cited older publications. We also searched relevant citation lists in selected papers. Several review articles or book chapters were included because they

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