Pancreatitis
LIFE-THREATENING DISORDERPancreatitis, inflammation of the pancreas, occurs in acute and chronic forms. With pancreatitis, the enzymes that the pancreas normally excretes digest pancreatic tissue (autodigestion). Acute pancreatitis can range from mild self-limiting episodes of abdominal discomfort to severe systemic illness associated with fluid sequestration, metabolic disorder, hypotension, sepsis, and death. Life-threatening illness is associated with pancreatic hemorrhage or necrosis in about 10% of patients.
In 90% of patients with acute pancreatitis, the disease occurs as a mild, self-limiting illness and requires only simple supportive care. In the remaining 10% of patients, the disease can evolve into a severe form with significant complications, a lengthy duration, and a significant mortality rate. Complications include heart and kidney failure and adult respiratory distress syndrome.
Causes
The most common causes of pancreatitis are biliary tract disease and alcoholism; however, it can also result from pancreatic cancer, trauma, or certain drugs, such as glucocorticoids, sulfonamides, chlorothiazide, azathioprine,
excessive use of acetaminophen, and hormonal contraceptives.
excessive use of acetaminophen, and hormonal contraceptives.
This disease may also develop as a complication of peptic ulcer, mumps, or hypothermia. Rarer causes are stenosis or obstruction of the sphincter of Oddi, hypercalcemia, duodenal obstruction, hyperlipemia, ischemia from vasculitis or vascular disease, viral infections, mycoplasmal pneumonia, scorpion venom, and pregnancy. The disease may also be familial or idiopathic.
Age AlertIn children, pancreatitis may coincide with abdominal trauma, cystic fibrosis, hemolytic uremic syndrome, Kawasaki disease, mumps, Reye’s syndrome, viral illness, or medications the child may be taking.
Pancreatitis may also develop in a patient after surgery. This occurrence has the highest morbidity and mortality. Whatever the cause, complications from acute pancreatitis are possible.
Clinical TipDetermining the cause of pancreatitis is useful for managing and predicting complications.
Signs and symptoms
In many patients, the first and only symptom of mild pancreatitis is steady epigastric pain centered close to the umbilicus. Examination of the abdomen reveals muscle guarding or tenderness. If there’s seepage of bloody exudate from the pancreas, periumbilical bruising (Cullen’s sign) and bruising of the flanks (Turner’s syndrome) may occur. The pain usually begins as a gradually increasing midepigastric pain reaching its maximum intensity several hours after the beginning of the illness. With pancreatitis resulting from alcohol ingestion, the pain begins 12 to 48 hours after an episode of binge drinking. Nausea and vomiting commonly accompany the abdominal pain. However, a severe attack causes extreme pain, persistent vomiting, abdominal rigidity, diminished bowel activity (suggesting peritonitis), right or left pleural effusion, or elevation of the left half of the diaphragm.
Severe pancreatitis may produce extreme malaise and restlessness, mottled skin, tachycardia, and diaphoresis. Hypotension, hypovolemia, hypoperfusion, sepsis, and shock may ensue. Pulmonary complications, secondary pancreatic infections (such as pancreatic abscess or infected pancreatic necrosis) and, later, pancreatic pseudocyst may also occur. The proximity of the inflamed pancreas to the bowel may cause ileus. Renal failure may occur because of severe hypovolemia.
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