PANCREATITIS

Pancreatitis is inflammation of the pancreas. It may be:

• Acute pancreatitis – sudden inflammation that may resolve completely.
• Chronic pancreatitis – long-standing inflammation causing permanent structural damage and loss of pancreatic function.

Anatomy & Functions of the Pancreas

The pancreas lies behind the stomach and has:

• Head
• Neck
• Body
• Tail

Functions

Exocrine:

• Produces digestive enzymes such as amylase, lipase and proteases.
• Releases bicarbonate to neutralize gastric acid.

Endocrine:

• Produces insulin → lowers blood glucose.
• Produces glucagon → raises blood glucose.

ACUTE PANCREATITIS

Acute pancreatitis is an acute inflammatory process of the pancreas, ranging from mild self-limiting disease to severe disease with pancreatic necrosis and multiorgan failure.

Common Causes

Remember GET SMASHED:

• G – Gallstones
• E – Ethanol (alcohol)
• T – Trauma
• S – Steroids
• M – Mumps
• A – Autoimmune
• S – Scorpion sting
• H – Hypercalcaemia / Hyperlipidaemia
• E – ERCP
• D – Drugs

Other causes include:

• Pancreatic tumors
• Genetic causes
• Infections
• Idiopathic pancreatitis

Pathophysiology

Normally, pancreatic digestive enzymes are activated in the intestine.

In acute pancreatitis:

Trigger → premature activation of pancreatic enzymes → autodigestion of pancreatic tissue → inflammation → edema → tissue necrosis

This inflammatory response may cause:

• Fluid loss
• Hypotension
• Systemic inflammatory response
• Acute kidney injury
• Respiratory failure
• Multiorgan failure

Clinical Features

Classical symptoms

Severe upper abdominal pain is the main symptom.

Pain is typically:

• Epigastric
• Severe and persistent
• May radiate to the back
• Often associated with nausea and vomiting
• May be worse after eating

Signs

• Epigastric tenderness
• Abdominal distension
• Tachycardia
• Fever
• Dehydration
• Hypotension in severe cases
• Reduced bowel sounds/ileus

Important signs in severe pancreatitis

• Cullen sign – periumbilical bruising.

  • Grey-Turner sign – flank bruising.

These suggest severe hemorrhagic pancreatitis but are uncommon.

Diagnosis generally requires 2 of 3:

1. Typical abdominal pain.
2. Serum lipase or amylase ≥3 times the upper limit of normal.
3. Imaging findings consistent with acute pancreatitis.

Investigations

Blood tests

• Serum lipase
• Serum amylase
• FBC
• Urea and electrolytes
• Creatinine
• Blood glucose
• Calcium
• Liver function tests
• Triglycerides
• CRP

Imaging

• Abdominal ultrasound → especially useful for gallstones.
• CT abdomen → useful when diagnosis is uncertain or complications/severe disease are suspected.
• MRI/MRCP may be useful in selected cases.

Management of Acute Pancreatitis

Initial management

ABCDE approach if seriously ill.

A. Fluid resuscitation

• Give appropriate IV fluids, especially in patients with hypovolaemia.
• Monitor urine output, blood pressure, heart rate and renal function.

B. Pain control

• Adequate analgesia.
• Opioids may be required for severe pain.

C. Nutrition

• Early oral feeding is preferred when tolerated in mild acute pancreatitis.
• Enteral feeding is preferred over parenteral nutrition when oral feeding is not possible in more severe disease.

D. Treat the cause

Examples:

• Gallstone pancreatitis → assess for biliary intervention/cholecystectomy.
• Hypertriglyceridaemia → manage triglycerides.
• Drug-induced pancreatitis → discontinue offending drug where appropriate.
• Alcohol-related pancreatitis → alcohol cessation support.

E. Antibiotics

Routine prophylactic antibiotics are NOT recommended for uncomplicated acute pancreatitis or sterile pancreatic necrosis.

Antibiotics are used when there is a confirmed or strongly suspected infection, such as infected pancreatic necrosis or another bacterial infection.

Complications of Acute Pancreatitis

Local complications

• Pancreatic pseudocyst
• Pancreatic necrosis
• Infected pancreatic necrosis
• Pancreatic abscess
• Walled-off necrosis
• Ascites
• Splenic/portal vein thrombosis

Systemic complications

• Shock
• Acute kidney injury
• ARDS
• DIC
• Electrolyte abnormalities
• Hyperglycaemia
• Multiorgan failure

CHRONIC PANCREATITIS

Chronic pancreatitis is a progressive inflammatory and fibrotic disease of the pancreas, resulting in irreversible structural damage and loss of exocrine and endocrine function.

Causes

• Long-term alcohol use
• Smoking
• Genetic disorders
• Autoimmune pancreatitis
• Recurrent acute pancreatitis
• Obstruction of the pancreatic duct
• Idiopathic causes

Clinical Features of Chronic Pancreatitis

• Recurrent or persistent epigastric pain
• Pain radiating to the back
• Weight loss
• Nausea and vomiting
• Malabsorption
• Steatorrhoea – bulky, pale, oily, foul-smelling stools
• Diabetes mellitus
• Nutritional deficiencies

Investigations

• FBC and biochemical tests
• Blood glucose/HbA1c
• Faecal elastase → assesses pancreatic exocrine function
• Abdominal ultrasound
• CT abdomen
• MRI/MRCP
• Endoscopic ultrasound in selected cases

Management of Chronic Pancreatitis

Lifestyle

• Stop alcohol
• Stop smoking
• Small, frequent meals
• Nutritional support

Medications

• Analgesics for pain
• Pancreatic enzyme replacement therapy (PERT) for exocrine insufficiency
• Fat-soluble vitamin supplementation when deficient
• Diabetes management

Procedures

May be required for:

• Persistent severe pain
• Pancreatic duct obstruction
• Biliary obstruction
• Pseudocysts
• Other complications

Acute vs Chronic Pancreatitis

Exam Points 

• Most common causes of acute pancreatitis: gallstones and alcohol.
• Most useful enzyme: serum lipase.
• Diagnosis usually requires 2 of 3 criteria.
• Pain is classically epigastric and radiates to the back.
• Cullen sign: periumbilical bruising.
• Grey-Turner sign: flank bruising.
• Early management focuses on fluids, analgesia, monitoring and early nutrition.
• Routine prophylactic antibiotics are not recommended.
• Chronic pancreatitis causes exocrine and endocrine insufficiency.
• Steatorrhoea + weight loss suggest pancreatic exocrine insufficiency.
• Chronic pancreatitis increases the risk of pancreatic cancer.

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