Necrotizing Pancreatitis
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Acute pancreatitis (AP) is a sudden
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
of the
pancreas The pancreas (plural pancreases, or pancreata) is an Organ (anatomy), organ of the Digestion, digestive system and endocrine system of vertebrates. In humans, it is located in the abdominal cavity, abdomen behind the stomach and functions as a ...
. Causes include a
gallstone A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of ...
impacted in the
common bile duct The common bile duct (also bile duct) is a part of the biliary tract. It is formed by the union of the common hepatic duct and cystic duct. It ends by uniting with the pancreatic duct to form the ampulla of Vater (hepatopancreatic ampulla). ...
or the
pancreatic duct The pancreatic duct or duct of Wirsung (also, the major pancreatic duct due to the existence of an accessory pancreatic duct) is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancre ...
, heavy
alcohol use Alcohol, sometimes referred to by the chemical name ethanol, is the active ingredient in alcoholic drinks such as beer, wine, and distilled spirits (hard liquor). Alcohol is a central nervous system (CNS) depressant, decreasing electrical ac ...
,
systemic disease A systemic disease is one that affects a number of Organ (anatomy), organs and Tissue (biology), tissues, or affects the Human body, body as a whole. It differs from a localized disease, which is a disease affecting only part of the body (e.g., ...
,
trauma Trauma most often refers to: *Psychological trauma, in psychology and psychiatric medicine, refers to severe mental and emotional injury caused by distressing events *Traumatic injury, sudden physical injury caused by an external force, which doe ...
, elevated calcium levels,
hypertriglyceridemia Hypertriglyceridemia is the presence of high amounts of triglycerides in the blood. Triglycerides are the most abundant fatty molecule in most organisms. Hypertriglyceridemia occurs in various physiologic conditions and in various diseases, and ...
(with triglycerides usually being very elevated, over 1000 mg/dL), certain medications, hereditary causes and, in children,
mumps MUMPS ("Massachusetts General Hospital Utility Multi-Programming System"), or M, is an imperative, high-level programming language with an integrated transaction processing key–value database. It was originally developed at Massachusetts Gen ...
. Acute pancreatitis may be a single event, it may be recurrent, or it may progress to
chronic pancreatitis Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent p ...
and/or
pancreatic failure Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types, acute pancreatitis and chronic pancr ...
(the term pancreatic dysfunction includes cases of acute or chronic pancreatitis where the pancreas is measurably damaged, even if it has not failed). In all cases of acute pancreatitis, early
intravenous fluid Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutr ...
hydration and early enteral (nutrition delivered to the gut, either by mouth or via a
feeding tube A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral f ...
) feeding are associated with lower mortality and complications. Mild cases are usually successfully treated with conservative measures such as hospitalization with intravenous fluid infusion, pain control, and early enteral feeding. If a person is not able to tolerate feeding by mouth, feeding via nasogastric or nasojejunal tubes are frequently used which provide nutrition directly to the stomach or intestines respectively. Severe cases often require admission to an
intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive care medicine. An inten ...
. Severe pancreatitis, which by definition includes organ damage other than the pancreas, is associated with a mortality rate of 20%. The condition is characterized by the pancreas secreting active enzymes such as
trypsin Trypsin is an enzyme in the first section of the small intestine that starts the digestion of protein molecules by cutting long chains of amino acids into smaller pieces. It is a serine protease from the PA clan superfamily, found in the dig ...
,
chymotrypsin Chymotrypsin (, chymotrypsins A and B, alpha-chymar ophth, avazyme, chymar, chymotest, enzeon, quimar, quimotrase, alpha-chymar, alpha-chymotrypsin A, alpha-chymotrypsin) is a digestive enzyme component of pancreatic juice acting in the duodenu ...
and
carboxypeptidase A carboxypeptidase ( EC number 3.4.16 - 3.4.18) is a protease enzyme that hydrolyzes (cleaves) a peptide bond at the carboxy-terminal (C-terminal) end of a protein or peptide. This is in contrast to an aminopeptidases, which cleave peptide b ...
, instead of their inactive forms, leading to auto-digestion of the pancreas. Calcium helps to convert trypsinogen to the active trypsin, thus elevated calcium (of any cause) is a potential cause of pancreatitis. Damage to the pancreatic ducts can occur as a result of this. Long term complications include
type 3c diabetes Type 3c diabetes (also known as pancreatogenic diabetes) is diabetes that comes secondary to pancreatic diseases, involving the exocrine and digestive functions of the pancreas. It also occurs following surgical removal of the pancreas. Around 5†...
(pancreatogenic diabetes), in which the pancreas is unable to secrete enough insulin due to structural damage. 35% develop
exocrine pancreatic insufficiency Exocrine pancreatic insufficiency (EPI) is the inability to properly digest food due to a lack or reduction of digestive enzymes made by the pancreas. EPI can occur in humans and is prevalent in many conditions such as cystic fibrosis, Shwach ...
in which the pancreas is unable to secrete digestive enzymes due to structural damage, leading to malabsorption.


Signs and symptoms


Common

Common symptoms of acute pancreatitis include abdominal pain, nausea, vomiting, and low to moderate grade fever. The abdominal pain is the most common symptom and it is usually described as being in the left upper quadrant, epigastric area or around the umbilicus, with radiation throughout the abdomen, or to the chest or back. The abdominal pain initially may worsen with eating or drinking but may become constant as the disease progresses. Less common symptoms include
hiccups A hiccup (scientific name singultus, from Latin for "sob, hiccup"; also spelled hiccough) is an involuntary contraction ( myoclonic jerk) of the diaphragm that may repeat several times per minute. The hiccup is an involuntary action involvi ...
, abdominal bloating and indigestion. Although these are common symptoms, frequently they are not all present; and epigastric pain may be the only symptom. Grey-Turner's sign (hemorrhagic discoloration of the flanks) or
Cullen's sign Cullen's sign, also known as umbilical black eye, is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is named for gynecologist Thomas Stephen Cullen (1869–1953), who first described the sign in ruptured ...
(hemorrhagic discoloration of the umbilicus) are associated with severe disease. However both signs are rare (occurring in less than 1% of cases of acute pancreatitis) and are not specific nor sensitive for diagnosis of acute pancreatitis.
Pleural effusions A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilo ...
(fluid in the lung cavity) may occur in up to 34% of people with acute pancreatitis and are associated with a poor prognosis. The Mayo-Robson's sign (pain while pressing at the top of the angle lateral to the
erector spinae muscles The erector spinae ( ) or spinal erectors is a set of muscles that straighten and rotate the back. The spinal erectors work together with the glutes ( gluteus maximus, gluteus medius and gluteus minimus) to maintain stable posture standing or ...
and below the left 12th rib (left
costovertebral angle The costovertebral angle () is the acute angle formed on either side of the human back between the twelfth rib and the vertebral column. The kidney lies directly below this area, so is the place where, with percussion (), pain is elicited when th ...
(CVA)) is also associated with acute pancreatitis.


Complications

Complications of acute pancreatitis may occur. Necrotic pancreatitis occurs when inflammation of the pancreas progresses to cell death. Acute fluid collections may form adjacent to the pancreas or necrotic collections (discrete areas of dead tissue) may also form adjacent to or within the pancreas. These may progress to
pancreatic pseudocyst A pancreatic pseudocyst is a circumscribed collection of fluid rich in pancreatic enzymes, blood, and non-necrotic tissue, typically located in the lesser sac of the abdomen. Pancreatic pseudocysts are usually complications of pancreatitis, alt ...
s and walled off areas of dead tissue which may persist for longer than 4 weeks. Both can become secondarily infected. Other complications include
gastric outlet obstruction Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that ha ...
splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, blood clot of the splenic vein, superior mesenteric vein and portal veins, duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis, pancreatic ascites, or pleural effusion. Systemic complications include
acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin co ...
(ARDS),
multiple organ dysfunction syndrome Multiple organ dysfunction syndrome (MODS) is altered organ function in an acutely ill patient requiring immediate medical intervention. There are different stages of organ dysfunction for certain different organs, both in acute and in chronic ...
,
disseminated intravascular coagulation Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking Microvessel, small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems ...
(DIC),
hypocalcemia Hypocalcemia is a medical condition characterized by low calcium levels in the blood serum. The normal range of blood calcium is typically between 2.1–2.6  mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L), while levels less than 2.1  ...
(from fat saponification),
hyperglycemia Hyperglycemia is a condition where unusually high amount of glucose is present in blood. It is defined as blood glucose level exceeding 6.9 mmol/L (125 mg/dL) after fasting for 8 hours or 10 mmol/L (180 mg/dL) 2 hours after eating. Blood gluc ...
and insulin dependent diabetes mellitus (from pancreatic insulin-producing
beta cell Beta cells (β-cells) are specialized endocrine cells located within the pancreatic islets of Langerhans responsible for the production and release of insulin and amylin. Constituting ~50–70% of cells in human islets, beta cells play a vi ...
damage), and
malabsorption Malabsorption is a state arising from abnormality in absorption of food nutrients across the gastrointestinal (GI) tract. Impairment can be of single or multiple nutrients depending on the abnormality. This may lead to malnutrition and a varie ...
due to exocrine failure. Tobacco use, recurrent episodes of acute pancreatitis, pancreatic tissue death, alcoholic pancreatitis are all risk factors for developing chronic pancreatitis.


Causes


Most common

* Biliary pancreatitis due to gallstones or constriction of
ampulla of Vater The ampulla of Vater, hepatopancreatic ampulla or hepatopancreatic duct is the common duct that is usually formed by a union of the common bile duct and the pancreatic duct within the wall of the duodenum. This common duct usually features a di ...
in 40% of cases *
Alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
in 30% of cases * Idiopathic in 15–25% of cases * Metabolic disorders:
hereditary pancreatitis Hereditary pancreatitis (HP) is an inflammation of the pancreas due to genetic causes. It was first described in 1952 by Comfort and Steinberg but it was not until 1996 that Whitcomb ''et al'' isolated the first responsible mutation in the trypsino ...
,
hypercalcemia Hypercalcemia, also spelled hypercalcaemia, is a high calcium (Ca2+) level in the blood serum. The normal range for total calcium is 2.1–2.6 mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L), with levels greater than 2.6 mmol/L def ...
, elevated triglycerides,
malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...
* May occur after instrumentation of the pancreatic duct or its opening to the duodenum (ampula of Vater) in procedures such as an endoscopic ultrasound or
endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior ...
(ERCP). The risk after EUS is less than 1% and the risk after ERCP is 5-10%. * Abdominal trauma * Penetrating ulcers *
Carcinoma Carcinoma is a malignancy that develops from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesoder ...
of the
head of pancreas The pancreas (plural pancreases, or pancreata) is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrin ...
, and other
cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...
* Drugs:
acetaminophen Paracetamol, or acetaminophen, is a non-opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain. It is a widely available over-the-counter drug sold under various brand names, including Tylenol and Panadol. Parac ...
with or without
codeine Codeine is an opiate and prodrug of morphine mainly used to treat pain, coughing, and diarrhea. It is also commonly used as a recreational drug. It is found naturally in the sap of the opium poppy, ''Papaver somniferum''. It is typically use ...
,
amiodarone Amiodarone is an antiarrhythmic medication used to treat and prevent a number of types of cardiac dysrhythmias. This includes ventricular tachycardia, ventricular fibrillation, and wide complex tachycardia, atrial fibrillation, and paroxys ...
,
azathioprine Azathioprine, sold under the brand name Imuran, among others, is an immunosuppressive medication. It is used for the treatment of rheumatoid arthritis, granulomatosis with polyangiitis, Crohn's disease, ulcerative colitis, and systemic lupus er ...
,
carbamazepine Carbamazepine, sold under the brand name Tegretol among others, is an anticonvulsant medication used in the treatment of epilepsy and neuropathic pain. It is used as an adjunctive treatment in schizophrenia along with other medications and as ...
,
cimetidine Cimetidine, sold under the brand name Tagamet among others, is a histamine H2 receptor antagonist that inhibits stomach acid production. It is mainly used in the treatment of heartburn and peptic ulcers. With the development of proton pump ...
,
cisplatin Cisplatin is a chemical compound with chemical formula, formula ''cis''-. It is a coordination complex of platinum that is used as a chemotherapy medication used to treat a number of cancers. These include testicular cancer, ovarian cancer, c ...
,
clomiphene Clomifene, also known as clomiphene, is a medication used to treat infertility in women who anovulation, do not ovulate, including those with polycystic ovary syndrome. It is taken by mouth. Common side effects include pelvic pain and hot f ...
,
enalapril Enalapril, sold under the brand name Vasotec among others, is an ACE inhibitor medication used to treat high blood pressure, diabetic kidney disease, and heart failure. For heart failure, it is generally used with a diuretic, such as furosem ...
, estrogen containing products or hormones,
furosemide Furosemide, sold under the brand name Lasix among others, is a loop diuretic medication used to treat edema due to heart failure, liver scarring, or kidney disease. Furosemide may also be used for the treatment of high blood pressure. It can ...
,
isoniazid Isoniazid, also known as isonicotinic acid hydrazide (INH), is an antibiotic used for the treatment of tuberculosis. For active tuberculosis, it is often used together with rifampicin, pyrazinamide, and either streptomycin or ethambutol. F ...
,
metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...
,
methyldopa Methyldopa, also known as α-methyl-L-DOPA and sold under the brand name Aldomet among others, is a medication used for high blood pressure. It is one of the preferred treatments for high blood pressure in pregnancy. For other types of high blo ...
,
pravastatin Pravastatin, sold under the brand name Pravachol among others, is a statin medication, used for preventing cardiovascular disease in those at high risk and treating abnormal lipids. It is suggested to be used together with diet changes, exerc ...
,
valproic acid Valproate (valproic acid, VPA, sodium valproate, and valproate semisodium forms) are medications primarily used to treat epilepsy and bipolar disorder and prevent migraine headaches. They are useful for the prevention of seizures in those with ...
* Infections:
mumps MUMPS ("Massachusetts General Hospital Utility Multi-Programming System"), or M, is an imperative, high-level programming language with an integrated transaction processing key–value database. It was originally developed at Massachusetts Gen ...
, viral hepatitis,
coxsackie B virus Coxsackie B is a group of six serotypes of coxsackievirus (CVB1-CVB6), a pathogenic enterovirus, that trigger illnesses ranging from a mild febrile rash to full-fledged pericarditis and myocarditis ( coxsackievirus-induced cardiomyopathy). The ...
,
cytomegalovirus ''Cytomegalovirus'' (CMV) (from ''cyto-'' 'cell' via Greek - 'container' + 'big, megalo-' + -''virus'' via Latin 'poison') is a genus of viruses in the order '' Herpesvirales'', in the family '' Herpesviridae'', in the subfamily '' Betaherp ...
, ''
Mycoplasma pneumoniae ''Mycoplasma pneumoniae'' is a species of very small-cell bacteria that lack a cell wall, in the class Mollicutes. ''M. pneumoniae'' is a human pathogen that causes the disease Mycoplasma pneumonia, a form of atypical bacterial pneumonia related ...
'', ''
Ascaris ''Ascaris'' is a nematode genus of parasitic worms known as the "small intestinal roundworms". One species, ''Ascaris lumbricoides'', affects humans and causes the disease ascariasis. Another species, ''Ascaris suum'', typically infects pigs. O ...
'' * Structural abnormalities:
pancreas divisum Pancreas divisum is a congenital anomaly in the anatomy of the ducts of the pancreas in which a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts. Most individuals with pancreas divisum remain witho ...
, pancreatic masses or cysts that block the ducts. *
Radiotherapy Radiation therapy or radiotherapy (RT, RTx, or XRT) is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle ...
*
Autoimmune pancreatitis Autoimmune Pancreatitis (AIP) is an increasingly recognized type of chronic pancreatitis that can be difficult to distinguish from pancreatic carcinoma but which responds to treatment with corticosteroids, particularly prednisone. Although auto ...
* Severe
hypertriglyceridemia Hypertriglyceridemia is the presence of high amounts of triglycerides in the blood. Triglycerides are the most abundant fatty molecule in most organisms. Hypertriglyceridemia occurs in various physiologic conditions and in various diseases, and ...


Less common

* Scorpion venom * Chinese liver fluke *
Ischemia Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems ...
from
bypass surgery Bypass surgery refers to a class of surgery involving rerouting a tubular body part. Types include: * Vascular bypass surgery such as coronary artery bypass surgery, a heart operation, in which the internal thoracic artery and great saphanous v ...
* Heart valve surgery *
Fat necrosis Fat necrosis is necrosis affecting fat tissue (adipose tissue). The term is well-established in medical terminology despite not denoting a specific pattern of necrosis. Fat necrosis may result from various injuries to adipose tissue, including: p ...
*
Pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
*
Infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
s other than mumps, including
varicella zoster Varicella zoster virus (VZV), also known as human herpesvirus 3 (HHV-3, HHV3), is one of nine known herpes viruses that can infect humans. It causes chickenpox (varicella) commonly affecting children and young adults, and shingles (herpes zos ...
* Hyperparathyroidism *
Cystic fibrosis Cystic fibrosis (CF) is a genetic disorder inherited in an autosomal recessive manner that impairs the normal clearance of Sputum, mucus from the lungs, which facilitates the colonization and infection of the lungs by bacteria, notably ''Staphy ...
*
Anorexia Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
or
bulimia Bulimia nervosa, also known simply as bulimia, is an eating disorder characterized by binge eating (eating large quantities of food in a short period of time, often feeling out of control) followed by compensatory behaviors, such as self-induc ...


Pathology


Pathogenesis

Acute pancreatitis occurs when there is abnormal activation of digestive enzymes within the pancreas. This occurs through inappropriate activation of inactive enzyme precursors called
zymogens In biochemistry, a zymogen (), also called a proenzyme (), is an inactive precursor of an enzyme. A zymogen requires a biochemical change (such as a hydrolysis reaction revealing the active site, or changing the configuration to reveal the activ ...
(or proenzymes) inside the pancreas, most notably
trypsinogen Trypsinogen () is the precursor form (or zymogen) of trypsin, a digestive enzyme. It is produced by the pancreas and found in pancreatic juice, along with amylase, lipase, and chymotrypsinogen. It is cleaved to its active form, trypsin, by e ...
. Normally, trypsinogen is converted to its active form (
trypsin Trypsin is an enzyme in the first section of the small intestine that starts the digestion of protein molecules by cutting long chains of amino acids into smaller pieces. It is a serine protease from the PA clan superfamily, found in the dig ...
) in the first part of the small intestine (
duodenum The duodenum is the first section of the small intestine in most vertebrates, including mammals, reptiles, and birds. In mammals, it may be the principal site for iron absorption. The duodenum precedes the jejunum and ileum and is the shortest p ...
), where the enzyme assists in the digestion of proteins. During an episode of acute pancreatitis, trypsinogen comes into contact with lysosomal enzymes (specifically
cathepsin Cathepsins (Ancient Greek ''kata-'' "down" and ''hepsein'' "boil"; abbreviated CTS) are proteases (enzymes that degrade proteins) found in all animals as well as other organisms. There are approximately a dozen members of this family, which are d ...
), which activate trypsinogen to trypsin. The active form trypsin then leads to further activation of other molecules of trypsinogen. The activation of these digestive enzymes lead to inflammation, edema, vascular injury, and even cellular death. The death of pancreatic cells occurs via two main mechanisms:
apoptosis Apoptosis (from ) is a form of programmed cell death that occurs in multicellular organisms and in some eukaryotic, single-celled microorganisms such as yeast. Biochemistry, Biochemical events lead to characteristic cell changes (Morphology (biol ...
, which is physiologically controlled, and
necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...
, which is less organized and more damaging. The balance between these two mechanisms of cellular death is mediated by
caspases Caspases (cysteine-aspartic proteases, cysteine aspartases or cysteine-dependent aspartate-directed proteases) are a family of protease enzymes playing essential roles in programmed cell death. They are named caspases due to their specific cystei ...
which regulate apoptosis and have important anti-necrosis functions during pancreatitis: preventing trypsinogen activation, preventing ATP depletion through inhibiting polyADP-ribose polymerase, and by inhibiting the inhibitors of apoptosis (IAPs). If, however, the caspases are depleted due to either chronic ethanol exposure or through a severe insult then necrosis can predominate.


Pathophysiology

The two types of acute pancreatitis are mild and severe, which are defined based on whether the predominant response to cell injury is inflammation (mild) or necrosis (severe). In mild pancreatitis, there is inflammation and edema of the pancreas. In severe pancreatitis, there is necrosis of the pancreas, and nearby organs may become injured. As part of the initial injury there is an extensive inflammatory response due to pancreatic cells synthesizing and secreting inflammatory mediators: primarily
TNF-alpha Tumor necrosis factor (TNF), formerly known as TNF-α, is a chemical messenger produced by the immune system that induces inflammation. TNF is produced primarily by activated macrophages, and induces inflammation by binding to its receptors o ...
and IL-1. A hallmark of acute pancreatitis is a manifestation of the inflammatory response, namely the recruitment of neutrophils to the pancreas. The inflammatory response leads to the secondary manifestations of pancreatitis: hypovolemia from capillary permeability, acute respiratory distress syndrome, disseminated intravascular coagulations, renal failure, cardiovascular failure, and gastrointestinal hemorrhage.


Histopathology

The acute pancreatitis (acute hemorrhagic pancreatic necrosis) is characterized by acute inflammation and necrosis of pancreas
parenchyma upright=1.6, Lung parenchyma showing damage due to large subpleural bullae. Parenchyma () is the bulk of functional substance in an animal organ such as the brain or lungs, or a structure such as a tumour. In zoology, it is the tissue that ...
, focal enzymic necrosis of pancreatic fat and vessel necrosis (
hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...
). These are produced by intrapancreatic activation of pancreatic enzymes. Lipase activation produces the necrosis of fat tissue in pancreatic
interstitium In anatomy, the interstitium is a contiguous fluid-filled space existing between a structural barrier, such as a cell membrane or the skin, and internal structures, such as organs, including muscles and the circulatory system. The fluid in this s ...
and peripancreatic spaces as well as vessel damage. Necrotic fat cells appear as shadows, contours of cells, lacking the nucleus, pink, finely granular cytoplasm. It is possible to find calcium precipitates (). Digestion of vascular walls results in thrombosis and hemorrhage. Inflammatory infiltrate is rich in
neutrophils Neutrophils are a type of phagocytic white blood cell and part of innate immunity. More specifically, they form the most abundant type of granulocytes and make up 40% to 70% of all white blood cells in humans. Their functions vary in different ...
. Due to the pancreas lacking a capsule, the inflammation and necrosis can extend to include fascial layers in the immediate vicinity of the pancreas.


Diagnosis

Acute pancreatitis is diagnosed using
clinical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and even ...
and
physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...
findings supporting the diagnosis with imaging and pancreatic enzymes (amylase and lipase). The Revised Atlanta Classification requires two out of three of the following findings for the diagnosis: abdominal pain consistent with pancreatitis, elevated amylase or lipase levels greater than 3 times the upper limit of normal, and imaging consistent with acute pancreatitis. Additional labs may be used to identify organ failure for prognostic purposes or to guide fluid resuscitation rate. If the lipase level is about 2.5 to 3 times that of amylase, it is an indication of pancreatitis due to alcohol. Serum lipase is more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis, and is the preferred test in the diagnosis. Most, but not all individual studies support favor the diagnostic utility of lipase. In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase. Another study found that the amylase could add diagnostic value to the lipase, but only if the results of the two tests were combined with a discriminant function equation. Reduced lipase clearance due to kidney disease, gastrointestinal or hepatobiliary cancers, pancreatic enzyme hypersecretion, critical illness including due to neurosurgical causes have been shown to increase serum lipase and may complicate the diagnosis of acute pancreatitis.


Differential diagnosis

The differential diagnosis includes: * Perforated
peptic ulcer Peptic ulcer disease is when the inner part of the stomach's gastric mucosa (lining of the stomach), the first part of the small intestine, or sometimes the lower esophagus, gets damaged. An ulcer in the stomach is called a gastric ulcer, while ...
*
Biliary colic Biliary colic, also known as symptomatic cholelithiasis, a gallbladder attack or gallstone attack, is when a colic (sudden pain) occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of t ...
* Acute
cholecystitis Cholecystitis is inflammation of the gallbladder. Symptoms include Right upper quadrant (abdomen), right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede ...
*
Pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...
*
Pleuritic Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other sy ...
pain *
Myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...


Computed tomography

Regarding the need for
computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
, practice guidelines state: CT is an important common initial assessment tool for acute pancreatitis. Imaging is indicated during the initial presentation if: * the diagnosis of acute pancreatitis is uncertain * there is abdominal distension and tenderness, fever >102 F (38,9 C), or leukocytosis * there is a Ranson score > 3 or APACHE score > 8 * there is no improvement after 72 hours of conservative medical therapy * there has been an acute change in status: fever, pain, or shock CT is recommended as a delayed assessment tool in the following situations: * acute change in status * to determine therapeutic response after surgery or interventional radiologic procedure * before discharge in patients with severe acute pancreatitis Abdominal CT should not be performed before the first 12 hours of onset of symptoms as early CT (<12 hours) may result in equivocal or normal findings. CT findings can be classified into the following categories for easy recall: * Intrapancreatic – diffuse or segmental enlargement, edema, gas bubbles, pancreatic pseudocysts and phlegmons/abscesses (which present 4 to 6 wks after initial onset) * Peripancreatic / extrapancreatic – irregular pancreatic outline, obliterated peripancreatic fat, retroperitoneal edema, fluid in the lessar sac, fluid in the left anterior pararenal space * Locoregional – Gerota's fascia sign (thickening of inflamed Gerota's fascia, which becomes visible), pancreatic ascites, pleural effusion (seen on basal cuts of the pleural cavity), adynamic ileus, etc. The principal value of CT imaging to the treating clinician is the capacity to identify devitalized areas of the pancreas which have become necrotic due to ischaemia. Pancreatic necrosis can be reliably identified by intravenous contrast-enhanced CT imaging, and is of value if infection occurs and surgical or percutaneous debridement is indicated.


Magnetic resonance imaging

While
computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
is considered the gold standard in diagnostic imaging for acute pancreatitis,
magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...
(MRI) has become increasingly valuable as a tool for the visualization of the pancreas, particularly of pancreatic fluid collections and necrotized debris. Additional utility of MRI includes its indication for imaging of patients with an allergy to CT's contrast material, and an overall greater sensitivity to hemorrhage, vascular complications, pseudoaneurysms, and venous thrombosis. Another advantage of MRI is its utilization of
magnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique. It uses magnetic resonance imaging to visualize the biliary and pancreatic ducts non-invasively. This procedure can be used to determine whether gallstones are lod ...
(MRCP) sequences. MRCP provides useful information regarding the etiology of acute pancreatitis, i.e., the presence of tiny biliary stones (
choledocholithiasis Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD) (thus '' choledocho-'' + '' lithiasis''). This condition can cause jaundice and liver cell damage. Treatments include choledocho ...
or
cholelithiasis A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of ...
) and duct anomalies. Clinical trials indicate that MRCP can be as effective a diagnostic tool for acute pancreatitis with biliary etiology as
endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior ...
, but with the benefits of being less invasive and causing fewer complications.


Ultrasound

Ultrasound is less preferred as a diagnostic test for acute pancreatitis, but it may be used in select cases.
Abdominal ultrasonography Abdominal ultrasonography (also called abdominal ultrasound imaging or abdominal sonography) is a form of medical ultrasonography (medical application of ultrasound technology) to visualise abdominal anatomical structures. It uses transmission a ...
may be obtained if there is concern of a gallstone blocking the pancreatic duct leading to pancreatitis.


Treatment

Early enteral (nutrition given directly to the gut, either by mouth or via feeding tube) nutrition and aggressive intravenous fluid hydration are indicated in all forms and severities of acute pancreatitis and are associated with lower mortality and complications.


Fluid replacement

The specific rate of intravenous fluid replacement in acute pancreatitis is not well established but some experts recommend an initial fluid infusion rate of 5-10 mL of IV fluids per kilogram of body weight per hour and adjusting the rate to meet physiologic parameters such as heart rate,
mean arterial pressure In medicine, the mean arterial pressure (MAP) is an average calculated blood pressure in an individual during a single cardiac cycle. Although methods of estimating MAP vary, a common calculation is to take one-third of the pulse pressure (the d ...
, urine output and
hematocrit The hematocrit () (Ht or HCT), also known by several other names, is the volume percentage (vol%) of red blood cells (RBCs) in blood, measured as part of a blood test. The measurement depends on the number and size of red blood cells. It is nor ...
. Isotonic crystalloid solutions (such as
lactated ringers Ringer's lactate solution (RL), also known as sodium lactate solution, Lactated Ringer's (LR), and Hartmann's solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replaci ...
) are preferred over
normal saline Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By intravenous therapy, inje ...
for fluid resuscitation and are associated with a lower risk of developing
systemic inflammatory response syndrome In immunology, systemic inflammatory response syndrome (SIRS) is an inflammation, inflammatory state affecting the whole body. It is the body's Immune response, response to an infectious or noninfectious Insult (medical), insult. Although the ...
(SIRS). In the initial stages (within the first 12 to 24 hours) of acute pancreatitis, fluid replacement has been associated with a reduction in morbidity and mortality.


Pain control

Abdominal pain is often the predominant symptom in patients with acute pancreatitis and should be treated with analgesics. Opioids are safe and effective at providing pain control in patients with acute pancreatitis. Adequate pain control requires the use of intravenous opiates, usually in the form of a patient-controlled analgesia pump.
Hydromorphone Hydromorphone, also known as dihydromorphinone, and sold under the brand name Dilaudid among others, is a morphinan opioid used to treat moderate to severe pain. Typically, long-term use is only recommended for pain due to cancer. It may b ...
or
fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
(intravenous) may be used for pain relief in acute pancreatitis. Fentanyl is being increasingly used due to its better safety profile, especially in renal impairment. As with other opiates, fentanyl can depress respiratory function. It can be given both as a bolus as well as constant infusion.
Meperidine Pethidine, also known as meperidine and sold under the brand name Demerol among others, is a fully synthetic opioid pain medication of the phenylpiperidine class. Synthesized in 1938 as a potential anticholinergic agent by the German chemist Ot ...
has been historically favored over
morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...
because of the belief that morphine caused an increase in
sphincter of Oddi The sphincter of Oddi (SO) (also hepatopancreatic sphincter or Glisson's sphincter), is a sphincter, a muscular valve that, in humans and some animals, controls the flow of bile and pancreatic juice out of the gallbladder and pancreas respective ...
pressure. However, no clinical studies suggest that morphine can aggravate or cause pancreatitis or cholecystitis. In addition, meperidine has a short half-life and repeated doses can lead to accumulation of the metabolite normeperidine, which causes neuromuscular side effects and, rarely, seizures.


Nutritional support

Acute pancreatitis is a catabolic state and with hemodynamic instability or fluid shifts or edema there may be reduced intravascular perfusion to the gut. This reduction in gut perfusion increases the risk of gut necrosis with bacterial translocation with the subsequent risk of sepsis or secondary infections. Enteral nutrition gives one needed caloric intake as well as enhances intestinal motility and blood flow to the gut, reducing these risks. Enteral nutrition (as compared to
parenteral nutrition Parenteral nutrition (PN), or intravenous feeding, is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding entities or standard ph ...
, in which nutrients are given via intravenous infusion) is associated with reduced mortality, reduced risk of multi-organ failure and systemic infection in those with acute pancreatitis. In patients with acute pancreatitis, the
American Gastroenterological Association The American Gastroenterological Association (AGA) is a medical association of gastroenterologists. Approximately 16,000 scientists and physicians are members of the organization. Overview The American Gastroenterological Association is a prof ...
(AGA) recommends early oral nutrition, within 24 hours, rather than keeping the patient fasting (or nil by mouth). And in those unable to feed orally, the AGA recommends enteral nutrition (via a nasogastric or nasojejunal tube) rather than parenteral nutrition.


Antibiotics

Up to 20 percent of people with acute pancreatitis develop an infection outside the pancreas such as
bloodstream infections Bloodstream infections (BSIs) are infections of blood caused by blood-borne pathogens. The detection of microbes in the blood (most commonly accomplished by blood cultures) is always abnormal. A bloodstream infection is different from sepsis, w ...
,
pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...
, or
urinary tract infections A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra ( urethritis) while upper urinary tract infections affect the kidney (pye ...
. These infections are associated with an increase in mortality. Fluid collections around the pancreas or areas within the pancreas that experience tissue death (necrosis) may also become secondarily infected requiring the use of antibiotics. When an infection is suspected, antibiotics should be started while the source of the infection is being determined. However, if cultures are negative and no source of infection is identified, antibiotics should be discontinued. Preventative antibiotics are not recommended in people with acute pancreatitis, regardless of the type (interstitial or necrotizing) or disease severity (mild, moderately severe, or severe)


Endoscopic retrograde cholangiopancreatography

In 30% of those with acute pancreatitis, no cause is identified.
Endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior ...
(ERCP) with empirical biliary sphincterotomy has an equal chance of causing complications and treating the underlying cause, therefore, is not recommended for treating acute pancreatitis. If a gallstone is detected, ERCP, performed within 24 to 72 hours of presentation with successful removal of the stone, is known to reduce morbidity and mortality. The indications for early ERCP are: * Clinical deterioration or lack of improvement after 24 hours * Detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on abdominal CT The risks of ERCP are that it may worsen pancreatitis, it may introduce an infection to otherwise sterile pancreatitis, and bleeding.


Surgery

In those with mild acute pancreatitis due to gallstones,
cholecystectomy Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed i ...
(removal of the gallbladder) is recommended in the hospital and is associated with a reduced risk of pancreatitis recurrence. In those with gallstone pancreatitis who have severe disease, including the presence of peripancreatic fluid collections, cholecystectomy should be delayed as the fluid collections around the pancreas make surgery technically difficult. The peri-pancreatic fluids also carry a risk of becoming secondarily infected with surgery. Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria * Gas bubbles on CT scan (present in 20 to 50% of infected necrosis) * Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas. Surgical options for infected necrosis include: * Minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen * Conventional management – necrosectomy with simple drainage * Closed management – necrosectomy with closed continuous postoperative lavage * Open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)


Other measures

* Pancreatic enzyme inhibitors are proven not to work. * The use of
octreotide Octreotide, sold under the brand name Sandostatin among others, is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone. It was ...
has been shown not to improve outcomes.


Classification by severity: prognostic scoring systems

Acute pancreatitis patients recover in majority of cases. Some may develop abscess, pseudocyst or duodenal obstruction. About 20% of the acute pancreatitis are severe with a mortality of about 20%. Acute pancreatitis can be further divided into mild and severe pancreatitis. Several clinical scoring tools have been developed to determine prognostic information and may guide certain areas of clinical management, such as need for ICU admission. Two such scoring systems are the Ranson criteria and
APACHE II APACHE II ("Acute Physiology and Chronic Health Evaluation II") is a severity-of-disease classification system, one of several ICU scoring systems. It is applied within 24 hours of admission of a patient to an intensive care unit (ICU): an in ...
(Acute Physiology and Chronic Health Evaluation) indices. Most, but not all studies report that the Apache score may be more accurate. In the negative study of the APACHE-II, the APACHE-II 24-hour score was used rather than the 48-hour score. Some experts recommend using the APACHE II score as well as a serum hematocrit level early during the admission as prognostic indicators.


Ranson score

The Ranson score is used to predict the severity of acute pancreatitis. They were introduced in 1974.


At admission

* age in years > 55 years * white blood cell count > 16000 cells/mm3 * blood glucose > 11.1 mmol/L (> 200 mg/dL) * serum AST > 250 IU/L * serum LDH > 350 IU/L


At 48 hours

* Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) * Hematocrit fall >10% * Oxygen (hypoxemia PO2 < 60 mmHg) * BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration * Base deficit (negative base excess) > 4 mEq/L * Sequestration of fluids > 6 L The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:


Alternative Ranson score

Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT) Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality


APACHE II score

"Acute Physiology And Chronic Health Evaluation" (
APACHE II APACHE II ("Acute Physiology and Chronic Health Evaluation II") is a severity-of-disease classification system, one of several ICU scoring systems. It is applied within 24 hours of admission of a patient to an intensive care unit (ICU): an in ...
) score > 8 points predicts 11% to 18% mortality * Hemorrhagic peritoneal fluid *
Obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...
* Indicators of organ failure *
Hypotension Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...
(SBP <90 mmHG) or
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...
> 130 beat/min * PO2 <60 mmHg *
Oliguria Oliguria or hypouresis is the low output of urine specifically more than 80 ml/day but less than 400ml/day. The decreased output of urine may be a sign of dehydration, kidney failure, hypovolemic shock, hyperosmolar Hyperglycemic Nonketotic Syndro ...
(<50 mL/h) or increasing
BUN A bun is a type of bread that is round and small enough that it can generally be eaten hand-held. Whether a bun is considered sweetened or unsweetened differs between countries: it is considered sweetened in the United Kingdom, a savory bread in ...
and
creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an impor ...
* Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>


Balthazar score

Developed in the early 1990s by Emil J. Balthazar ''et al.'', the Computed Tomography Severity Index (CTSI) is a grading system used to determine the severity of acute pancreatitis. The numerical CTSI has a maximum of ten points, and is the sum of the Balthazar grade points and pancreatic necrosis grade points: Balthazar grade Necrosis score CTSI's staging of acute pancreatitis severity has been shown by a number of studies to provide more accurate assessment than APACHE II, Ranson, and
C-reactive protein C-reactive protein (CRP) is an annular (ring-shaped) pentameric protein found in blood plasma, whose circulating concentrations rise in response to inflammation. It is an acute-phase protein of hepatic origin that increases following interleukin ...
(CRP) level. However, a few studies indicate that CTSI is not significantly associated with the prognosis of hospitalization in patients with pancreatic necrosis, nor is it an accurate predictor of AP severity.


Glasgow score

The Glasgow score is valid for both gallstone and alcohol induced pancreatitis, whereas the Ranson score is only for alcohol induced pancreatitis. If a patient scores 3 or more it indicates severe pancreatitis and the patient should be considered for transfer to ITU. It is scored through the mnemonic, PANCREAS: * P – PaO2 <8kPa * A – Age >55-years-old * N – Neutrophilia: WCC >15x10(9)/L * C – Calcium <2 mmol/L * R – Renal function: Urea >16 mmol/L * E – Enzymes: LDH >600iu/L; AST >200iu/L * A – Albumin <32g/L (serum) * S – Sugar: blood glucose >10 mmol/L


BISAP score

Predicts mortality risk in pancreatitis with fewer variables than Ranson's criteria. Data should be taken from the first 24 hours of the patient's evaluation. * BUN >25 mg/dL (8.9 mmol/L) * Abnormal mental status with a Glasgow coma score <15 * Evidence of SIRS (systemic inflammatory response syndrome) * Patient age >60 years old * Imaging study reveals pleural effusion Patients with a score of zero had a mortality of less than one percent, whereas patients with a score of five had a mortality rate of 22 percent. In the validation cohort, the BISAP score had similar test performance characteristics for predicting mortality as the APACHE II score. As is a problem with many of the other scoring systems, the BISAP has not been validated for predicting outcomes such as length of hospital stay, need for ICU care, or need for intervention.


Epidemiology

The worldwide incidence of acute pancreatitis has increasing from 1961 to 2016 with an average annual percentage increase of 3%, the increased incidence was seen in North America and Europe. The incidence of acute pancreatitis in the United States is 110-140 cases per 100,000 people. In the United States the most common causes include gallstones, which are responsible for 21-33% of cases, followed by alcohol (16-27%) and elevated triglycerides (2-5%).


See also

*
Canine pancreatitis Pancreatitis is a common condition in cats and dogs. Pancreatitis is inflammation of the pancreas that can occur in two very different forms. Acute pancreatitis is sudden, while chronic pancreatitis is characterized by recurring or persistent for ...
*
Chronic pancreatitis Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent p ...


References


External links

* Banks et al. Modified Marshall scoring syste
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Pathology Atlas
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