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Tuesday, March 11, 2008

Pancreatitis, Acute and Chronic

The pancreas is a large gland in the abdomen located behind the stomach and next to the upper part of the small intestine called the duodenum. It has two primary functions. First, the pancreas facilitates the digestion of carbohydrates, proteins and fat by the secretion of very powerful digestive enzymes into the small intestine. Second, the pancreas releases two hormones, insulin and glucagon, into the bloodstream. These hormones are involved in blood glucose metabolism.

Pancreatitis is a rare disease in which the pancreas becomes inflamed. Pancreatic damage occurs when the digestive enzymes are activated and begin attacking the pancreas. In very severe cases, pancreatitis can result in bleeding into the gland itself; serious tissue damage, infection and fluid collections may occur. Severe pancreatitis can result in damage to other vital organs such as the heart, lung and kidneys.

There are two forms of pancreatitis: acute and chronic. The acute form occurs suddenly and may result in life-threatening complications; however the majority of patients (80 percent) recover completely. Chronic pancreatitis is usually the result of longstanding damage to the pancreas from alcohol ingestion. Chronic pancreatitis is primarily marked by severe pain and loss of pancreatic function.

Causes

In about 80 percent of the cases, acute pancreatitis is caused by gallstones and alcohol ingestion (see list below). Other causes are usually due to medications and, very rarely, infections, trauma or surgery of the abdomen. In about 10 percent of the cases, the cause is unknown (idiopathic).
  • Gallstones 45%
  • Alcohol 35%
  • Idiopathic 10%
  • Other 10%
  • Medications
    • Azathioprine
    • Thiazide
    • Valproic acid
    • Dideoxyinosine
    • Sulfasalazine
    • Trimethoprim-sulfamethoxazole
    • Pentamidine
    • Tetracycline

Trauma

  • Postoperative
  • Hyperlipidemia
  • Hypercalcemia
  • Infectious Agents
    • Mumps
    • Coxsackie B virus
    • Cytomegalovirus (CMV)
    • Candida
    • HIV
    • Salmonella
    • Shigella
    • E. coli
    • Legionella
    • Leptospirosis
  • Ductal obstruction
Chronic Pancreatitis Histology
In more than 90 percent of the cases, chronic pancreatitis is caused by prolonged alcohol ingestion resulting in pancreatic damage and scarring (see below list). In a small percentage of the cases, the cause is unknown and, very rarely, patients can have chronic pancreatitis that tends to run in families (hereditary pancreatitis).

  • Alcohol 70%
  • Idiopathic 20%
  • Other 10%
    • Tropical pancreatitis
    • Hereditary pancreatitis
    • Hyperparathyroidism
    • Cystic Fibrosis
    • Pancreas Divisum

Risk Factors
Acute pancreatitis occurs in patients with a history of gallstone disease or heavy alcohol consumption. Chronic pancreatitis primarily occurs in patients between 30 and 40 years of age with longstanding alcohol ingestion. Chronic pancreatitis is also more common in men than women.

Symptoms

Most patient with acute pancreatitis have upper abdominal pain that travels through the back. Patients may describe this as a “piercing sensation” aggravated by eating. The abdomen may be swollen and very tender. Patients also may have associated nausea, vomiting, and fever, and increased heart rate.

Chronic pancreatitis has three primary symptoms: pain, malabsorption of food leading to weight loss or diarrhea, and diabetes. The pain of chronic pancreatitis is usually constant in nature and radiates to the back, and in some patients may be disabling. The weight loss is usually due to the patient’s inability to secrete pancreatic enzymes to break down foods so nutrients are not absorbed normally. Finally, diabetes may develop if the insulin-producing cells in the pancreas are damaged.

Diagnosis
Acute pancreatitis is suspected when a patient has symptoms and has risk factors such as alcohol ingestion or gallstone disease. Measuring levels of amylase and lipase in the blood helps diagnose pancreatitis. High levels of these two digestive enzymes in the blood are strongly suggestive of acute pancreatitis. As the patient recovers, the digestive enzyme levels will decrease to normal.

Chronic pancreatitis generally is suspected when the patient has symptoms and risk factors such as heavy alcohol ingestion. Diagnosis can be difficult but aided by a number of new techniques, including pancreatic function tests and x-ray imaging of the pancreas gland with a CT scan or retrograde pancreatography (ERCP).

Treatment
Acute pancreatitis is primarily treated with supportive management in the hospital. Generally, intravenous fluids and pain medication are given. In up to 20 percent of patients, the pancreatitis can be severe. The patient may need to be placed in the intensive care unit because of damage that has occurred to other vital organs such as the heart, lungs or kidneys. Some cases of severe pancreatitis require surgery to remove irreversibly damaged parts of the gland.

Chronic pancreatitis can be challenging to treat. Physicians will try to relieve pain and improve nutritional and metabolic problems that result from pancreatic function loss. Patients are generally given pancreatic enzymes and insulin to supplement what is not being secreted or released by the pancreas. In some instances, blockage of the pancreatic duct would require a surgical drainage procedure

Via: http://cms.clevelandclinic.org

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