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Pancreatitis |
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Pancreatitis is the inflammation of the pancreas. |
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| Classification |
There are different forms of pancreatitis, which are different in causes and symptoms, and require different treatment: |
| Acute pancreatitis |
Acute pancreatitis is an acute episode of pancreatitis. |
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| Chronic pancreatitis |
Chronic pancreatitis is the "inflammation of the pancreas that is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus" |
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| Causes |
The most common cause of acute pancreatitis is gallstones. Excessive alcohol use is often cited as the second most common cause of acute pancreatitis. Less common causes include hypertriglyceridemia (but not hypercholesterolemia) and only when triglyceride values exceed 1500 mg/dl (16 mmol/L), hypercalcemia, viral infection (e.g. mumps), trauma (to the abdomen or elsewhere in the body) including post-ERCP (i.e. Endoscopic Retrograde Cholangiopancreatography), vasculitis (i.e. inflammation of the small blood vessels within the pancreas), and autoimmune pancreatitis. Pregnancy can also cause pancreatitis, but in some cases the development of pancreatitis is probably just a reflection of the hypertriglyceridemia which often occurs in pregnant women. Pancreas divisum, a common congenital malformation of the pancreas may underlie some cases of recurrent pancreatitis.
The known porphyrinogenicity of many drugs, hormones, alcohol, chemicals and the association of porphyrias with autoimmune disorders and gallstones do not exclude the diagnosis of heme disorders when these explanations are used. A primary medical disorder, including an underlying undetected inborn error in metabolism, supersedes a secondary medical complication or explanation.
It is worth noting that pancreatic cancer is seldom the cause of pancreatitis. |
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Symptoms and signs |
Severe upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis. Nausea and vomiting (emesis) are prominent symptoms. Findings on the physical exam will vary according to the severity of the pancreatitis, and whether or not it is associated with significant internal bleeding. The blood pressure may be high (when pain is prominent) or low (if internal bleeding or dehydration has occurred). Typically, both the heart and respiratory rates are elevated. Abdominal tenderness is usually found but may be less severe than expected given the patient's degree of abdominal pain. Bowel sounds may be reduced as a reflection of the reflex bowel paralysis (i.e. ileus) that may accompany any abdominal catastrophe. |
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Diagnosis |
| Laboratory tests |
Most frequently, measurement is made of amylase and/or lipase, and often one, or both, are elevated in cases of pancreatitis
Conditions other than pancreatitis may lead to rises in these enzymes and, further, that those conditions may also cause pain that resembles that of pancreatitis (e.g. cholecystitis, perforated ulcer, bowel infarction (i.e. dead bowel as a result of poor blood supply), and even diabetic ketoacidosis. |
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| Imaging |
Ultrasound and CT scanning of the abdomen can be used to confirm the diagnosis of pancreatitis. |
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Complications |
| Acute (early) complications of pancreatitis include |
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shock, |
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hypocalcemia (low blood calcium), |
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high blood glucose, |
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dehydration, and kidney failure (resulting from inadequate blood volume which, in turn, may result from a combination of fluid loss from vomiting, internal bleeding, or oozing of fluid from the circulation into the abdominal cavity in response to the pancreas inflammation, a phenomenon known as Third Spacing). |
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Respiratory complications are frequent and are major contributors to the mortality of pancreatitis. Some degree of pleural effusion is almost ubiquitous in pancreatitis. Some or all of the lungs may collapse (atelectasis) as a result of the shallow breathing which occurs because of the abdominal pain. Pneumonitis may occur as a result of pancreatic enzymes directly damaging the lung, or simply as a final common pathway response to any major insult to the body (i.e. ARDS or Acute Respiratory Distress Syndrome). |
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Likewise, SIRS (Systemic inflammatory response syndrome) may ensue. |
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Infection of the inflamed pancreatic bed can occur at any time during the course of the disease. In fact, in cases of severe hemorrhagic pancreatitis, antibiotics should be given prophylactically. |
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| Late complications |
Late complications include recurrent pancreatitis and the development of pancreatic pseudocysts. A pancreatic pseudocyst is essentially a collection of pancreatic secretions which has been walled off by scar and inflammatory tissue. Pseudocysts may cause pain, may become infected, may rupture and hemorrhage, may press on and block structures such as the bile duct, thereby leading to jaundice, and may even migrate around the abdomen. |
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Treatment |
The treatment of pancreatitis will, of course, depend on the severity of the pancreatitis itself. Still, general principles apply and include |
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1. provision of pain relief. |
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2. provision of adequate replacement fluids and salts (intravenously), |
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3. limitation of oral intake (with dietary fat restriction the most important point)NG tube feeding is the preferred method to avoid pancreatic stimulation and possible infection complications caused by bowel flora. |
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4. monitoring and assessment for, and treatment of, the various complications listed above. |
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When necrotizing pancreatitis ensues and the patient shows signs of infection it is imperative to start antibiotics. These patients may require surgery/repeated surgeries, some patients may need prolonged hospital stay & can it be saved even after intensive medical &/or surgical managements. |
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