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Pancreatitis

Overview
  • Pancreatitis: Inflammation of the pancreas. Commonly due to alcohol or gallstones.
  • Characterised by autodigestion of pancreatic tissue by its enzymes, resulting in necrosis.

What are the most common causes of pancreatitis?

  • Gallstones
  • Alcohol
  • Medications (e.g., azathioprine, thiazide diuretics).
  • Trauma.
  • Metabolic disorders (e.g., hypercalcaemia).
  • Viral infections (e.g., mumps).
Types
  • Acute Pancreatitis (AP): Sudden inflammation, which often resolves with treatment.
  • Chronic Pancreatitis (CP): Persistent inflammation, causing irreversible damage.
Clinical Presentation
  • Abdominal pain: Severe epigastric pain, often radiating to the back.
  • Commonly accompanied by vomiting.
  • Examination may show epigastric tenderness, ileus, and a low-grade fever.
  • Rare signs include periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign).
  • Rarely, ischaemic (Purtscher) retinopathy may occur, leading to temporary or permanent blindness.
Investigations
  • Serum amylase: Elevated in about 75% of patients; typically >3 times the upper limit of normal. However, its level does not correlate with severity. Specificity for pancreatitis is around 90%.
  • Other conditions causing raised amylase include pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, and diabetic ketoacidosis.
  • Serum lipase: More sensitive and specific than amylase. Useful for late presentations (>24 hours) due to its longer half-life.
  • Imaging: Diagnosis can be confirmed without imaging if there’s characteristic pain and amylase/lipase is >3 times the normal level. However, early ultrasound is crucial to determine the cause, especially for gallstones/biliary obstruction. Other options include contrast-enhanced CT.
Scoring Systems
  • Used to identify severe cases: Ranson score, Glasgow score, APACHE II, etc.
  • Indicators of severe pancreatitis include: age >55 years, hypocalcaemia, hyperglycaemia, hypoxia, neutrophilia, and elevated LDH & AST. Note: amylase level is not of prognostic value.

What are some complications of pancreatitis?

  • Pseudocyst: Fluid-filled cyst-like cavities.
  • Haemorrhage or infection.
  • Organ failure, especially respiratory.
  • Chronic pancreatitis can lead to malabsorption and diabetes.
Treatment
  • Supportive care: Fluid resuscitation, pain relief.
  • Nutritional support: Initial fasting followed by a low-fat diet.
  • Alcohol cessation, if alcohol-induced.
  • Addressing the underlying cause, e.g., gallstone removal.
  • Surgery for severe cases or complications.
Prognosis
  • Most cases of acute pancreatitis recover completely.
  • Chronic cases can lead to lasting damage and need long-term management.

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