Definition
Pancreatitis is an inflammatory condition of the exocrine pancreas that results from injury to the acinar cells. It may be acute or chronic. A pancreatic pseudocyst is a persisting accumulation of inflammatory fluid, usually in the lesser sac. It is called a pseudocyst because it does not have an epithelial lining. Necrotizing pancreatitis is a severe form of pancreatitis with one or more diffuse or focal areas of non-viable pancreatic parenchyma. Chronic pancreatitis is a continuing inflammation of the pancreas leading to an atrophic pancreas, chronic abdominal pain and impaired endocrine/exocine function.
- Most pancreatitis (>80%) is mild and spontaneously resolves.
- All patients should have a cause sought by imaging and the severity assessed by recognized criteria.
- A normal or mildly elevated serum amylase does not exclude pancreatitis.
- Severe or complicated pancreatitis may worsen rapidly and require ICU support.
- Surgery has little place other than to treat severe complications.
Aetiology
- Gallstones and alcohol account for 95% of cases of acute pancreatitis.
- Other causes include: drugs, idiopathic, hypercalcaemia, hyperlipidaemia, congenital structural abnormalities, viral infections, hypothermia and trauma.
Pathology
Acute
- Mild injury: acinar (exocrine) cell damage with enzymatic spillage, inflammatory cascade activation and localized oedema. Local exudate may also lead to increased serum levels of pancreatic enzymes (amylase, lipase, colipase).
- Moderate injury: increasing local inflammation leads to intrapancreatic bleeding, fluid collections and spreading local oedema involving the mesentery and retroperitoneum. Activation of the systemic inflammatory response leads to progressive involvement of other organs.
- Severe injury: progressive pancreatic destruction leads to necrosis, profound localized bleeding and fluid collections around the pancreas. Spread to local structures and the peritoneal cavity may result in mesenteric infarction, peritonitis and intra-abdominal fat ‘saponification’.
Chronic
Recurrent episodes of acute inflammation lead to progressive destruction of acinar cells with healing by fibrosis. Incidental islet cell damage may lead to endocrine gland failure.
Clinical Features
- Mild/moderate pancreatitis: constant upper abdominal pain radiating to back, nausea, vomiting, pyrexia, tachycardia ± jaundice.
- Severe/necrotizing pancreatitis: severe upper abdominal pain, signs of hypovolaemic shock, respiratory and renal impairment, silent abdomen, retroperitoneal bleeding with flank and umbilical bruising (Grey Turner’s and Cullen’s signs).
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