Acute pancreatitis is a severe condition in which the pancreas suddenly becomes inflamed. Presenting with severe epigastric pain that radiates to the back due to the position of the pancreas high up in the abdomen and the fact it is retroperitoneal. It occurs when there is abnormal activation of enzymes within the pancreas. One of the roles of the pancreas is to produce pre-enzymes (enzymes that are not yet active) in order to help with the digestion of food. One such pre-enzyme is called trypsinogen which is then converted to trypsin in the duodenum where it functions to digest proteins. During acute pancreatitis this pre-enzyme becomes activated within the pancreas itself, due to coming into contact with lysosomal enzymes which activate it. Once activated trypsin can lead to further activation of trypsinogen. The activation of these digestive enzymes leads to inflammation within the pancreas, this can result in death of pancreatic tissue.
The causes for pancreatitis can be remembered through the pneumonic – I GET SMASHED:
I – idiopathic
G – gallstones
E – ethanol
T – trauma
S – steroids
M – mumps
A – autoimmune
S – scorpion stings
H – hyperlipidaemia/hypercalcaemia/hyperparathyroidism
E – ERCP (a procedure to look into the biliary tree)
D – drugs
With gallstones, alcohol and trauma being the most common causes of acute pancreatitis.
Most trusts use the blood test of amylase to determine if a patient has pancreatitis as it can present in a similar way to other conditions with its unspecific features. There are some signs that are more specific to pancreatitis however they signify severe disease, such as Grey-Turner’s sign which is haemorrhagic discolouration of the flanks and Cullen’s sign which again is haemorrhagic discolouration by this time around the umbilicus (belly button). Drastically raised amylase is a marker for pancreatitis however the degree at which it is elevated does not predict the severity, another criteria is used for this, called the modified Glasgow score. This can be easily remembered using the pneumonic PANCREAS:
P – PaO2 (level of oxygen within the arteries, so an arterial blood gas sample needs to be taken) <8KPa
A – age >55years
N – neutrophils > 15x10^9/L
C – calcium <2mmol/L
R – renal function, urea >16mmol/L
E – enzymes, LDH >600iU/L/AST >2000iU/L
A – albumin <32g/L
S – sugar, glucose >10mmol/L
A score of greater than or equal to 3 indicates likely severe pancreatitis even if the patient appears well, this needs to be treated urgently and ITU informed, to prevent multiorgan failure which is a fatal complication of pancreatitis.
Initial treatment of such patients is through fluid resuscitation, pain control, nutritional and supportive measures. Aggressive fluid replacement is initiated when pancreatitis is suspected as if given within the first 24 hours has been associated with a reduction in morbidity and mortality. The main stay of treatment is to treat the cause. Most commonly it is due to a gallstone stuck in the biliopancreatic duct. Therefore, removal of this stone is required usually via ERCP.