5 to 40 per 100,000 with overall mortality of 1.5 per 100,000; severe forms, however, can have a mortality >30%.
- Alcohol (men)
- Biliary (women): ultrasound, endoscopic ultrasound (before ERCP)
- Trauma (abdominal, surgical, post-ERCP)
- Metabolic (hypertriglyceridemia, uremia, hypothermia, hypercalcemia)
- Infections (EBV, mumps, HIV, HBV, mycoplasma, Campylobacter, Legionella)
- Drugs (steroids, sulfonamides, azathioprine, NSAIDs, diuretics, didanosine, etc.)
- Autoimmune (PAN, SLE, TTP)
- Toxins (methanol, organophosphates, scorpion venom)
- Pancreatic tumors
Inappropriate activation of trypsin leads to activation of protease activated receptor-2 (PAR2) and activation of other pancreatic enzymes. It results in out of proportion inflammation of pancreas leading to a SIRS-like response.
Abdominal pain + lipase >3 times normal is sufficient for diagnosis.
Negative type-2 trypsinogen in urine (stick) virtually eliminates Dx of pancreatitis.
- Clinical features:
- Abdominal pain typically radiating to the back
- Nausea, vomiting
- Abdominal distension
- Cullen's sign (hemorrhagic discoloration of the umbilicus)
- Grey-Turner's sign (hemorrhagic discoloration of the flanks)
- Laboratory findings:
- Increased serum amylase >3 times upper limit of normal (returns to normal in 2–4 days)
- Increased serum lipase (more sensitive and specific, remains elevated 10–14 days)
- Increased CRP (more frequent association with pancreatic necrosis, 24- to 48-hour latency period)
- IL-6, procalcitonin, and polymorphonuclear elastase could be used
- Radiologic findings:
- X-ray: duodenal ileus, sentinel loop sign, colon cutoff sign, pleural effusion (especially left side)
- Ultrasonography: more sensitive to identify gallstones, biliary ducts. Difficult to assess pancreas. Endoscopic ultrasound of use when other modalities fail or cannot be used to assess biliary disease and guide therapy
- CT scan: contrast-enhanced CT gold standard to diagnose pancreatitis. Useful to assess necrosis, abscess, fluid collections, hemorrhage. Indicated if dilemma in diagnosis/complications. Recommended to delay until 48–72 hours or repeat at this time if initial obtained on presentation. Not of much use if disease mild. Carries risk of contrast nephropathy
- MRI: useful when CT contraindicated
- Pancreatitis deemed severe if local complications (necrosis, abscess, pseudocyst) or organ failure
- Multiple classifications and criteria are available to assess severity
- Ranson's criteria (Table 215-1) have the disadvantage of requiring 48 hours to assess and cannot help at-risk patients in initial assessment
- The 2004 International Consensus Guidelines to assess severe acute pancreatitis on presentation (Table 215-2) are also helpful
- Balthazar's classification (Table 215-3) assesses pancreatic necrosis based on CT criteria
Table 215-1 Ranson's Criteria
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Table 215-1 Ranson's Criteria
- On admission
- Age >55 years
- Blood glucose >200 mg/dL
- WBC >16,000/mm3
- LDH >350 IU/L
- AST >250U/L
- At 48 h
- Serum Ca <8 mg/dL
- PaO2 <60 mm Hg
- Base deficit >4 mEq/L
- ↑ BUN ≥5 mg/dL
- ↓ Hct ≥10%
- Fluid sequestration >6 L
- 0–2 → 5%
- 3–4 → 20%
- 5–6 → 40%
- 7–8 → 100%
Table 215-2 Risk Factors for Severe Acute Pancreatitis
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