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Acute pancreatitis 

Acute pancreatitis

Chapter:
Acute pancreatitis
Author(s):

R. Carter

and C.J. McKay

DOI:
10.1093/med/9780199204854.003.152401_update_001

Update:

This chapter has been very substantially updated, in particular with regard to grading of disease severity, and indications for and techniques of surgical intervention.

Updated on 28 Nov 2012. The previous version of this content can be found here.
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date: 30 March 2017

Acute pancreatitis affects 300 to 600 new patients per million population per year and is most commonly caused by gallstones or alcohol, but there are many other causes and associations. Careful imaging reveals that most so-called idiopathic acute pancreatitis is due to small (1–3 mm diameter) gallstones. Diagnosis is made by a combination of a typical presentation (upper abdominal pain and vomiting) in conjunction with raised serum amylase (> × 3 upper limit of normal) and/or lipase (> × 2 upper limit of normal). Several acute abdominal emergencies can mimic acute pancreatitis and may be associated with a raised serum amylase. These include perforated peptic ulcer (particularly perforated posterior gastric ulcer) and acute mesenteric ischaemia. In equivocal cases, a CT scan is indicated in order to exclude other causes and confirm the diagnosis.

Initial management is with (1) analgesia, (2) ensuring adequate oxygenation, (3) the early restoration of circulating volume through intravenous fluid administration. The revision of the Atlanta classification separates patients clinically into (1) mild—with early resolution without complications, (2) moderate—local complications without organ failure, and (3) severe—complications associated with organ failure.

Mild acute pancreatitis responds to analgesia and intravenous fluids, and patients rarely need to be in hospital beyond a few days. If gallstones have been identified, then cholecystectomy (or endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy where clinically appropriate) should be performed during the same admission, or at least within 2 to 4 weeks to prevent recurrent attacks. Severe acute pancreatitis carries a high mortality (up to 20%). Management in the early stages is centred on organ support (respiratory, circulatory, and renal failure). Later management involves surgical or radiological intervention for sepsis, usually within a specialist pancreatic unit.

With regard to some specific aspects of management: (1) There is no indication for an NG tube or starvation. In patients with a prolonged illness nutrition support will be required—enteral feeding is associated with fewer risks and side effects than total parenteral nutrition. (2) Antibiotics should not be given until and unless a specific indication arises; there is no benefit to early initiation of prophylactic antibiotics. (3) ERCP—occasionally cholangitis (abdominal pain, jaundice, and fever) may be associated with hyperamylasaemia, in which case urgent biliary decompression at ERCP is indicated. In the absence of cholangitis or jaundice, the evidence to support early ERCP is weak. (4) There are no pharmacological agents that benefit any form of acute pancreatitis. (5) The case for decompressive laparotomy for abdominal compartment syndrome remains unproven.

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