Pancreatitis, Acute

Key Features

Essentials of Diagnosis

• Epigastric abdominal pain radiating to the back

• Nausea and vomiting

• Elevated serum amylase and lipase

• Evidence of pancreatic inflammation by CT or ultrasound

General Considerations

• Causes of pancreatic obstruction

  • Stones

  • Choledochal cyst

  • Tumors of the duodenum

  • Pancreas divisum

  • Ascariasis

• Acute pancreatitis has been seen following treatment with

  • Sulfasalazine

  • Thiazides

  • Valproic acid

  • Azathioprine

  • Mercaptopurine

  • Asparaginase

  • Antiretroviral drugs (especially didanosine)

  • High-dose corticosteroids

• May also occur

  • In cystic fibrosis, systemic lupus erythematosus, α₁-antitrypsin deficiency, diabetes mellitus, Crohn disease, glycogen storage disease type I, hyperlipidemia types I and V, hyperparathyroidism, Henoch-Schönlein purpura, Reye syndrome, organic acidopathies, Kawasaki disease, or chronic kidney disease

  • During rapid refeeding in cases of malnutrition

  • Following spinal fusion surgery

  • In families

• Alcohol-induced pancreatitis should be considered in the teenage patient

Clinical Findings

Symptoms and Signs

• Acute onset of persistent (hours to days), moderate to severe upper abdominal and midabdominal pain occasionally referred to the back, frequently associated with vomiting or nausea; these classic symptoms are less common is infants and younger children

• Abdomen is tender, but not rigid, and bowel sounds are diminished, suggesting peritoneal irritation

• Abdominal distention is common in infants and younger children

• Jaundice is unusual

• Ascites may be noted

• Left-sided pleural effusion is present in some patients

• Periumbilical and flank bruising indicate hemorrhagic pancreatitis

Differential Diagnosis

• Gastritis

• Peptic ulcer disease

• Duodenal ulcer

• Hepatitis

• Liver abscess

• Cholelithiasis

• Cholecystitis

• Choledocholithiasis

• Acute gastroenteritis or atypical appendicitis

• Pneumonia

• Volvulus

• Intussusception

• Nonaccidental trauma

Diagnosis

Laboratory Findings

• Elevated serum amylase or lipase (more than three times normal) is key finding

  • Elevated serum lipase persists longer than serum amylase

  • Because amylase or lipase may not be elevated in infants younger than 6 months, elevated immunoreactive trypsinogen may be more sensitive

• Pancreatic lipase can help differentiate nonpancreatic causes (eg, salivary, intestinal, or tuboovarian) of serum amylase elevation

• Leukocytosis, hyperglycemia (serum glucose > 300 mg/dL), hypocalcemia, falling hematocrit, rising blood urea nitrogen, hypoxemia, and acidosis may all occur in severe cases and imply a poor prognosis

Imaging

• Plain radiographic films of the abdomen may show a localized ileus (sentinel loop)

• Ultrasonography

  • Used to assess for biliary tract disease leading to pancreatitis

  • Can show decreased echodensity of the pancreas in comparison with the left lobe of the liver

  • Pancreas is often difficult to visualize due to overlying gas

• CT scanning

  • Visualizes pancreas more consistently

  • Better for detecting pancreatic phlegmon, pseudocyst, necrosis, or abscess formation

• The computed tomography severity index (CTSI) is useful in identifying patients at increased risk for serious complications

Diagnostic Procedures

• ERCP or MRCP may be useful in

  • Confirming patency of the main pancreatic duct in cases of ...