Pancreatitis

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Pancreatitis

• Pancreatitis is a potentially serious disorder characterized by inflammation of the pancreas that may cause autodigestion of the organ by its own enzymes. This disease has two manifestations: acute pancreatitis and chronic pancreatitis (patho 912)
  

Acute Pancreatitis

• Acute pancreatitis is the result of an inflammatory process involving the pancreas caused by the release of activated pancreatic enzymes. In addition to the pancreas, this disorder can also affect surrounding organs, as well as cause a systemic reaction. This form of pancreatitis is generally brief in duration, milder in symptom presentation, and reversible. However, while this form of the disease resolves both clinically and histologically, approximately 15% of patients with acute pancreatitis will develop chronic pancreatitis (patho 912, merck 128).
• Acute pancreatitis may present as mild or severe. Milder forms of acute pancreatitis involve only the interstitium of the pancreas, which accounts for 80% of all cases, and has a temperate presentation with fewer complications. However, severe forms involve necrosis of the pancreatic tissue, which occurs in 20% of cases, and results in increased complications and mortality (patho 912, merck 128).

Chronic Pancreatitis

• Chronic pancreatitis develops from chronic inflammation of the pancreas that results in irreversible and progressive histologic changes. This includes fibrosis and ductal strictures, which destroy the pancreas directly, as well as decreased endocrine and exocrine functions, which can negatively affect other body systems. Unlike acute pancreatitis, this form of the disease is characterized by recurrent or persistent symptoms (patho 914 and 912, merck 128).

Prevalence

Acute Pancreatitis

• There are an estimated 50,000 to 80,000 cases in the United States each year, and 210,000 hospitalizations as a result. Of these, 80% are mild in nature, while 20% are necrotizing and severe, and approximately 2,000 patients die each year from associated complications. In addition, men are affected more frequently than women (foundation, cleveland, nddic).

Chronic Pancreatitis

• Worldwide, there are approximately 1.6 to 23 cases per 100,000 each year. In the United States alone chronic pancreatitis results in over 122,000 outpatient visits and 56,000 hospitalizations each year. Chronic pancreatitis also has a higher prevalence in men than women, and often develops between the ages of 30 and 40. This disease is rare in children (nddic, cleveland).

Characteristics/Clinical Presentation

Acute Pancreatitis

Mild Pancreatitis

• The primary symptom of acute pancreatitis is abrupt abdominal pain in the mediepigatsrium, often involving the entire upper abdomen that increases in intensity for several hours and cast last from days to more than a week. In addition, approximately 50% of patients with acute pancreatitis experience radiating pain in the back and, though rare, some patients may first experience pain in the lower abdomen. While characteristically continuous and boring in nature overall, pain may initially present as mild, dull, and nonspecific, but may increase to profound, sharp, and severe pain in conjunction with systemic symptoms, and result in shock, coma, or death. In addition, onset of pain is typically sudden when secondary to gallstones, but progresses over several days when derived from alcohol consumption. Specific movements can also affect pain; sitting upright and leaning forward may reduce pain, while coughing, vigorous activity, walking, lying supine, and deep breathing may intensify it. Furthermore, pain may be triggered or exacerbated by eating fatty foods or consuming alcohol. Along with pain, the disease also tends to cause nausea, anorexia, and vomiting in 90% of people with pancreatitis (patho 913, dd 139).
• Patients also display marked changes in appearance resulting from changes in bodily functions. Generally patients appear acutely ill and sweaty and report feelings of malaise, while about 20% experience upper abdominal distention attributable to gastric distention or displacement of the stomach by a pancreatic inflammatory mass. Grey Turner’s sign and/or Cullen’s sign, or a bluish discoloration to the flanks and umbilicus, may also be noted and are indicative of severe hemorrhagic pancreatitis, while other patients present with jaundice. Vital signs are also affected, with the heart rate increasing to 100-140 beats/min, a shallow and rapid breathing pattern, and an interim high or low blood pressure with significant postural hypotension. Temperature may remain normal initially, but rise to 100° - 101° F, and sensation may also be diminished (merck 129, dd 392).
• Palpation reveals apparent abdominal tenderness, typically in the upper quadrants. While there may be mild tenderness in the lower abdomen, the rectum is not sore and the stool is devoid of blood. Along with tenderness, the upper abdominal muscles may be rigid; however, this is rare in the lower abdominal region. In rare cases, severe peritoneal irritation can lead to a rigid and board-like abdomen. Furthermore, auscultation of bowel sounds may reveal hypoactivity, and general muscle weakness may be noted (merck 129).

Severe Pancreatitis

• In addition to these symptoms, a small percentage of cases develop into severe pancreatitis, which can have serious complications. Severe pancreatitis includes the aforementioned signs and symptoms, as well as a systemic inflammatory process with shock, multiorgan failure, and/or local complications. Symptoms of severe pancreatitis development include tachycardia, hypoxia, tachypnea, and changes in mental status (patho 913, merck 128).
• Complications that may occur with severe forms of this disease include pancreatic fluid-filled collections (57% of cases), pseudocysts, and necrosis. Fluid-filled collections can enlarge and increase pain, and both the fluid-filled collections and necrotic areas can become infected, resulting in pain, leukocytosis, fever, hypotension, and hypovolemia. Ascites and pleural effusions are also possible, but rare, complications (patho 913).

Chronic Pancreatitis

• Like acute pancreatitis, the central problem arising from chronic pancreatitis is abdominal pain, although 10 to 15% of patients have no pain and present with malabsorption. This pain is typically located in the epigastric and left upper quadrant with referral into the upper left lumbar region, and is frequently associated with nausea, vomiting, anorexia, constipation, flatulence, and weight loss. When the head of the pancreas is primarily affected, pain typically manifests in the T5-T9 regions; however, when the tail of the pancreas is involved pain tends to be referred to the left shoulder due to its innervation by C3-5. Pain is made worse with eating, and relieved by bringing the knees to the chest or bending forward. However, the frequency and severity of the pain may vary, with some patients experiencing acute attacks lasting only a few hours that become more chronic in nature lasting as long as two weeks and increasingly frequent over time, while others have continuous pain that gradually becomes more intense in due course. Patients with alcohol-related pancreatitis often experience pain 12 to 48 hours after imbibing large quantities of alcohol, while those with gallstone-associated pancreatitis have pain after consuming a large meal. This severe and chronic pain frequently leads to an abuse of opioids, decreased appetite, weight loss, and decreased quality of life, and is also the main reason surgery is performed in people with this disease (patho 915-916, merck 132, dd 139).
• Along with chronic pain, the destruction of pancreatic tissue and the consequential loss of pancreatic function often result in diarrhea and steatorrhea. Steatorrhea, or bulky, oily, and foul-smelling stools, occurs in late stages of the disease when the majority of the ancinar cells have been destroyed and less than 10% of normal lipase levels is being produced, resulting in fat maldigestion. Poor digestions leads to malnutrition due to the excretion of fat in the stool, and can cause patients to lose weight, despite normal appetites and eating habits. Other complications that may arise include the development of large pseudocysts, bleeding from pseudoaneurysms, splenic vein thrombosis, and fistula formation (patho 915-916. nddic).
• Diabetes mellitus may also develop in later stages of the disease, especially if the pancreas has been surgically removed. Because both beta cells, which produce insulin, and alpha-cells, which produce glucagon, are destroyed, this can result in severe hypoglycemia with the use of insulin for an extended length of time (patho 915).

Associated Co-morbidities

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Causes

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Systemic Involvement

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