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Pancreatitis - Causes, Symptoms and Treatments

Pancreatitis, inflammation of the pancreas, Occurs in acute and chronic forms. In this disease, the enzymes normally excreted by the pancreas 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. In 85% to 90% of patients with pancreatitis, the disease subsides with conventional treatment. Chronic pancreatitis is persistent inflammation that produces irreversible changes in the structure and function of the pancreas. It sometimes follows acute pancreatitis. Two sets of criteria are used to determine the patient's prognosis. These are the Ranson/Imrie criteria and Acute Physiology and Chronic Health Evaluation (APACHE ). Patients with any two criteria have a mortality rate of 20% to 30%. Life-threatening illness is associated with pancreatic hemorrhage or necrosis in about 10% of patients.

Causes of Pancreatitis:

The most common causes of pancreatitis are biliary tract disease and alcoholism, but it can also result from pancreatic carcinoma, trauma, or certain drugs, such as glucocorticoids, sulfonamides, chlorothiazide, and azathioprine.

This disease also may 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. It may also be familial or idiopathic.

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.

Signs and symptoms of Pancreatitis:

In many patients, the first and only symptom of mild pancreatitis is steady epigastric pain centered close to the umbilicus. The pain usually begins as a gradually increasing mid-epigastric pain reaching its maximum intensity several hours after the beginning of the illness. In pancreatitis resulting from alcohol ingestion, the pain commences 12 to 48 hours after an episode of binge drinking. Nausea and vomiting generally 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 left hemidiaphragm elevation.

Severe pancreatitis may produce extreme malaise and restlessness, mottled skin, tachycardia, and diaphoresis. Hypotension, hypovolemia, hypoperfusion, sepsis, and shock may ensue. Pulmonary complications and secondary pancreatic infections such as pancreatic abscess or infected pancreatic necrosis, and later, pancreatic pseudocyst, may also occur. Proximity of the inflamed pancreas to the bowel may cause ileus. Renal failure may occur as a result of severe hypovolemia.

If pancreatitis damages the islets of Langerhans, complications may include diabetes mellitus and enzyme deficiency. Fulminant pancreatitis causes massive hemorrhage and total destruction of the pancreas, resulting in diabetic acidosis, shock, or coma.

Diagnosis for Pancreatitis:

Clinical presentation along with combined laboratory and radiographic findings form the basis for diagnosis. A careful patient history (especially for alcoholism) and physical examination are the first steps in diagnosis, but the retroperitoneal position of the pancreas makes physical assessment difficult.

Dramatically elevated serum amylase levels-frequently over 500 U/L-confirm pancreatitis and rule out perforated peptic ulcer, acute cholecystitis, appendicitis, and bowel infarction or obstruction. Persistent elevation of serum amylase levels may indicate pancreatic necrosis, pseudocyst, or abscess.

Similarly dramatic elevations of amylase are also found in urine, ascites, or pleural fluid. Characteristically, amylase levels return to normal 48 hours after onset of pancreatitis, despite continuing symptoms. Supportive laboratory values include:

. increased serum lipase levels - which rise more slowly than serum amylase

. white blood cell counts-ranging from 8,000 to 20,000/ul, with increased polymorphonuclear leukocytes

. elevated glucose levels-as high as 500 to 900 mg/dl, indicating hyperglycemia.

Other tests that may be used to diagnose pancreatitis include:

. abdominal X-rays-show dilation of the small or large bowel or calcification of the pancreas

. chest X-rays-show left-sided pleural effusion

. abdominal computed tomography scan with contrast-most sensitive noninvasive test used to confirm the diagnosis of pancreatitis.

Treatment of Pancreatitis:

The goal of therapy is to maintain circulation and fluid volume. Treatment measures must also relieve pain and decrease pancreatic secretions. In 90% of patients with acute pancreatitis, the disease occurs as a mild self-limiting illness and requires simple supportive care alone. In the remaining 10% of patients, the disease can evolve into a severe form of acute pancreatitis with significant complications, a lengthy duration of illness, and a significant mortality rate.

Special considerations of Pancreatitis:

Acute pancreatitis is a life-threatening emergency. Provide meticulous supportive care and continuous monitoring of vital systems.

  • Monitor vital signs and pulmonary artery pressure closely.
  • Monitor fluid intake and output, and electrolyte levels.
  • Assess for crackles, bronchi, decreased breath sounds, or respiratory failure.
  • Observe for signs of calcium deficiency-tetany, cramps, carpopedal spasm, and seizures.
  • Administer analgesics, as needed, to relieve the patient's pain and anxiety
  • Observe for adverse reactions to antibiotics: nephrotoxicity with aminoglycosides; pseudomembranous enterocolitis with clindamycin; and blood dyscrasias with chloramphenicol.
  • Monitor for complications due to hyperalimentation, such as sepsis, hypokalemia, overhydration, and metabolic acidosis.
  • Observe for fever, cardiac inegularities, changes in arterial blood gas measurements, and deep respirations (signs of sepsis).

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