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
SeminarAcute pancreatitis
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
References (126)
- et al.
The epidemiology of primary acute pancreatitis in Greater Nottingham: 1969–1983
Soc Sci Med
(1988) - et al.
Timing of tumor necrosis factor antagonism is critical in determining outcome in murine lethal acute pancreatitis
Surgery
(1996) - et al.
Mechanism of increased lung injury after acute pancreatitis in IL-10 knockout mice
J Surg Res
(1998) - et al.
The role of intracellular adhesion molecule 1 and neutrophils in acute pancreatitis and pancreatitis-associated lung injury
Gastroenterology
(1999) - et al.
The role of polymorphonuclear leukocytes and oxygen-derived free radicals in experimental acute pancreatitis: mediators of local destruction and activators of inflammation
FEBS Lett
(1999) - et al.
Pancreatitis-associated lung injury: new insights
Chest
(2003) - et al.
Endoscopic sphincterotomy complications and their management: an attempt at consensus
Gastrointest Endosc
(1991) - et al.
Clinical significance of elevated serum and urine amylase levels in patients with appendicitis
Am J Surg
(1981) - et al.
What is the best biochemical test to diagnose acute pancreatitis? A prospective clinical study
Mayo Clin Proc
(1996) - et al.
Magnetic resonance imaging in the detection of pancreatitis and pancreatic neoplasms
Best Pract Res Clin Gastroenterol
(2006)
Statistical methods for quantifying the severity of clinical acute pancreatitis
J Surg Res
Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal
Am J Gastroenterol
Computed tomography severity index is an early prognostic tool for acute pancreatitis
J Am Coll Surg
Inflammatory markers of disease severity in acute pancreatitis
Clin Lab Med
Choledocholithiasis: a prospective study of common bile duct stone migration
Gastrointest Endosc
Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde cholangiopancreatography
Gastroenterology
Pancreas divisum: is it a normal anatomic variant?
Am J Surg
Causes of acute and recurrent pancreatitis. Clinical considerations and clues to diagnosis
Gastroenterol Clin North Am
Biliary sludge: the sluggish gallbladder
Dig Liver Dis
Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions
Am J Gastroenterol
Does prophylactic pancreatic stent placement reduce the risk of post ERCP acute pancreatitis? A meta-analysis of controlled trials
Gastrointest Endosc
Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla
Gastrointest Endosc
Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases
Pancreatology
Acute pancreatitis in HIV-seropositive patients: a case control study of 44 patients
Am J Med
Gallstones in pregnancy and their complications: postpartum acute pancreatitis and acute peritonitis
Eur J Intern Med
Risk factors and outcomes of pancreatitis after open heart surgery
Am J Surg
Leçons de physiologie expérimentale. Paris
Bailliere
The relation of cholelithiasis to disease of the pancreas and to fat necrosis
Johns Hopkins Hosp Bull
Acute pancreatitis: overview
Eur J Gastroenterol Hepatol
Patterns of incidence in acute pancreatitis
BMJ
Pancreatitis in Finland between 1970 and 1989
Gut
The incidence and case-fatality rates of acute biliary, alcoholic, and idiopathic pancreatitis in California, 1994–2001
Pancreas
2003 National Hospital Discharge Survey. Advance data from vital and health statistics N° 359
Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review
Pancreas
Long-term recurrence and death rates after acute pancreatitis
Scand J Gastroenterol
Prognostic usefulness of scoring systems in critically ill patients with severe acute pancreatitis
Crit Care Med
Death due to acute pancreatitis. A retrospective analysis of 405 autopsy cases
Dig Dis Sci
Morbidity and mortality in 602 patients with acute pancreatitis seen between the years 1980–1994
Z Gastroenterol
Acute pancreatitis in childhood: analysis of literature data
J Clin Gastroenterol
Pancreatitis in children
J Pediatr Gastroenterol Nutr
Acute pancreatitis: new physiopatholological concepts
Gastro Clin Biol
A clinically based classification system for acute pancreatitis
Arch Surg
Diagnosis of acute pancreatitis
Ann Chir Gynaecol
Acute abdominal pain
Med Clin North Am
Biochemical markers of acute pancreatitis
J Clin Pathol
Acute pancreatitis and normoamylasemia. Not an uncommon combination
Ann Surg
Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis
Gut
UK guidelines for the management of acute pancreatitis
Gut
Positive and etiological diagnosis of acute pancreatitis
Gatroenterol Clin Biol
Acute pancreatitis: assessment of severity with clinical and CT evaluation
Radiology
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